Journal of Research in Nursing 18(8) 720–731 ! The Author(s) 2012 Using an emic and etic Reprints and permissions: sagepub.co.uk/journalsPermissions.nav ethnographic technique in a DOI: 10.1177/1744987111434190 grounded theory study of jrn.sagepub.com information use by practice nurses in New Zealand

Karen J. Hoare University of Auckland, New Zealand

Stephen Buetow University of Auckland, New Zealand

Jane Mills James Cook University, Australia

Karen Francis Charles Sturt University, Australia

Abstract This paper draws lessons from the use of an emic–etic ethnographical technique in a grounded theory study of how New Zealand practice nurses use information. The technique was used to heighten theoretical sensitivity in this study. As a nurse practitioner, I (the lead author) could not step out of my emic perspective to provide an etic perspective of my own general practice. From my emic embodied subjectivity I constructed my work environment to fit with best practice. Conversely, in four other general practices, my lack of personal connection protected an etic sense of disembodiment. New insights into mental models guiding the emic and etic roles of are suggested. Emic and etic perspectives, along with embodied and disembodied feelings, are not binary opposites but rather sit along a philosophical continuum. Their position on this continuum depends on the role and relationships of the researcher(s) in the social and cultural context of the area of inquiry.

Corresponding author: Karen J. Hoare, Department of General Practice and Primary Health Care and School of Nursing, University of Auckland, Private Bag 92 019, Auckland 1142, New Zealand. Email: [email protected] Hoare et al. 721

Keywords emic and etic, embodied and disembodied, grounded theory, theoretical sensitivity, practice nurses, New Zealand

Introduction The emic–etic distinction has been assumed to underpin the ethnographic technique of making observations and generating field notes. This paper describes the mental models guiding the research practice decisions of the lead author (KH). I am a researcher (novice grounded theorist) and work part-time as a nurse practitioner in a teaching general practice in Auckland, New Zealand. Nurse practitioners in this country are expert nurses with a particular scope of practice. Their professional qualification is registrable with the regulating authority separate to that of a registered nurse and it entails preparation at an advanced level academically and clinically (Nursing Council of New Zealand, 2009). As the data-generation phase of my study evolved, I struggled to assume the etic role of ‘silently’ observing my own general practice. I readily adopted an emic position of critical ethnographer, changing the work environment I shared with my colleagues to adopt best practice guidelines. In contrast, as I gathered data in other general practice environments I easily adopted what I perceived as an etic perspective, because I entered these settings feeling no sense of ownership or close relationship with the participants and workplaces. According to Greene (2007) there is scant empirical work on the influence of such mental models on research practice decisions. Conscious articulation of how they influence inquiry can make a study more thoughtful, intentional and reflective, enhancing its knowledge claims. Articulating my feelings about my ability to take an etic or emic stance as an instrument of research lends transparency to the research process. Documenting how I managed these feelings provides insights for others into the acquisition of theoretical sensitivity. I developed this sensitivity with respect to information use by practice nurses in general practice in New Zealand, and will use it to direct future theoretical sampling. Although the ethnographic technique was used by the originators of grounded theory – Glaser and Strauss – in their seminal work Awareness of Dying (1965), there is a dearth of literature describing the process of enhancing theoretical sensitivity. Therefore, this paper aims to draw on my field experience in order to discuss mental models and draw lessons that guided my data collection and enhanced my theoretical sensitivity in the first part of a grounded theory study. Ethnographic technique in grounded theory studies focuses on emerging theories and theory-driven data collection using and field notations. This form of data collection differs from conventional , which describe all that can be observed in a given setting regardless of its theoretical relevance (Hood, 2007). In addition, as a constructivist grounded theorist, I became aware of my inscripted body as an instrument of data collection and sought to examine the philosophies underpinning my role at different stages of the research.

Theoretical sensitivity In grounded theory studies, theoretical sensitivity is a key concept that refers to the ability to recognise, in the data, elements relevant to an evolving theory. Ethnography can enhance 722 Journal of Research in Nursing 18(8) theoretical sensitivity through sustained observation of, and participation in, a given group. Charmaz (2006) suggests that the extent to which ethnographers move from passive observation to full participation depends on the study. A grounded theory ethnography gives ‘priority to the studied phenomena or process – rather than the setting itself’ (Charmaz, 2006). Birks and Mills (2011) state that theoretical sensitivity has three important characteristics: it reflects the sum of personal, professional and experiential history; it can be enhanced by various techniques, tools and strategies; and it increases as the study progresses. I expected to raise my own theoretical sensitivity to guide my observation and questioning of my own and other nurses’ use of information in different general practice settings. Having investigated the development of practice nursing in New Zealand and having noticed the negligible literature published about this professional group, I had assumed that information use was an area of nursing not well developed in this country. As a nurse practitioner with the scope of providing care for children and young people, I was unfamiliar with the specifics of information use in practice nursing.

Grounded theory In the late 1960s Barney Glaser and Anselm Strauss created a new research methodology that they called grounded theory. Their collaborative studies of how terminal patients dealt with the knowledge that they were dying, and the reactions of hospital staff, resulted in them devising a new way of analysing qualitative data. In an era of positivism, their new inductive methodology was ground breaking. Charmaz (2006) suggests their discovery was widely acclaimed in research circles and made qualitative research respectable. Evolution of grounded theory over the decades has resulted in its movement along a methodological spiral, from post positivism to constructivism (Mills et al., 2006), with more recent scholarship by Charmaz moving it into the social construction paradigm (Charmaz, 2008). Glaser and Strauss (1967) in their original text described theories emerging from the data, but Charmaz contends this position and states that theories cannot emerge from data in an objective manner, rather the researcher co-constructs theories with the research participants. The researcher stands within the research process, not as an objective observer outside of it. Glaser and Strauss’ original research adopted ethnographic methods that combined observation and interview.

Ethnography Ethnography is one of the oldest and most distinct forms of qualitative investigation (Quimby, 2006), with historically anthropologists spending time in exotic locations living with an alien . By immersing themselves into daily life, writing field notes and conducting interviews, their objective was to introduce the Western world to alternative (Lambert and McKevitt, 2002). The information they collected was transcribed into rich descriptive accounts, typically monographical in style. Alongside anthropologists, sociologists have studied small communities in cities for almost a century, with many of these studies originating in, or being inspired by, the Chicago School of Sociology. Key scholars who fashioned the School were Robert Park and Ernest Burgess. Between 1917 and 1942 they trained students who went on to write a series of famous ethnographies (Deegan, 2001) that attempt to see the world through the Hoare et al. 723 changing eyes of those under investigation. During a similar time period, British Social originated with the work of Bronislaw Malinowski and his seminal publication, Argonauts of the Western Pacific: An Account of Native Enterprise and Adventure in the Archipelagoes of Melanesian New Guinea (Malinowski, 1922). Although anthropological fieldwork was not new, Malinowski spent an unusually long period of time living with the people of the Trobriands so that he could portray the emic perspective of a participant observer.

Emic and etic perspectives The concepts of emic and etic derive from a distinction in between phonemics, which comprises the examination of sounds used within a particular language, and , which is the explanation of universal traits that transcend particular languages (Tripp-Reimer, 1984). In ethnography, a similar difference between intrinsic and extrinsic features characterises the distinction between emic and etic perspectives. Emic analysis portrays features of a particular culture from inside the group. An unmet need for this analysis was described by Malinowski, whose functional theory added three new perspectives to . Firstly, he moved away from historical and evolutionist descriptions of ‘natives’ (a term used in his era) to explain in the present the function of social practices in relation to biological and psychological needs. Secondly, he challenged conventional analytical categories, in particular those describing cultural practices from diverse without contextualising them, an approach used by James Fraser and earlier anthropologists. Thirdly, Malinowski encouraged ethnographers to understand societies from the native’s [sic] perspective. The etic perspective had been used by Malinowski’s predecessors. It consists of observing and reporting behaviour without the viewpoint of those within the cultural group. An etic analysis applies universal features to discuss observed cultural practices, such as the preparation of food, with little information analysed about the original social context ascribed to the data generated (Tripp-Reimer, 1984). This activity therefore resembles phonetics in its examination of universal traits. Western biomedicine has been viewed as an etic classification system that pools the analysis of data from individual clients to estimate population averages. However, evidence-based health care now emphasises that the health care professional needs to use clinical expertise to integrate research evidence with the clinical state and circumstances of the client, and their values and preferences in the health care encounter (Buetow and Adams, 2006). This development moves evidence- based health care towards a more integrated etic–emic system. The terms ‘emic’ and ‘etic’ were not used in ethnography until the 1950s, Malinowski having first defined the emic perspective in his functional theory without using the word.

Entering the field Assessing how practice nurses in New Zealand understand and apply information in practice is not well described in the literature. The study’s main aim was to construct an understanding of how practice nurses in New Zealand use information to inform their work. As defined by New Zealand’s Expert Advisory Group on Primary Health Care Nursing (Ministry of Health, 2003), practice nurses are ‘Registered nurses with knowledge and expertise in primary health care practice’. 724 Journal of Research in Nursing 18(8)

Before embarking on my study, I (the lead author) thought I would be able to bring both an emic and etic perspective to the data collection by bracketing my emic sense of self as a nurse practitioner in order to become a participant observer within my own general practice (Ahern, 1999). Participant observation is flexible, allowing for many combinations and permutations of data collection in the research setting (Carnevale et al., 2008). Burgess (1984) described participant observation as employing four levels of involvement: participant, participant-as-observer, observer-as-participant and observer. Ethnographers generally move among these levels but most data are collected when the researcher is in the role of participant-as-observer or observer-as-participant (Roper and Shapira, 2000). Within the four other general practices I sought merely to observe the practice environment while I was interviewing the practice nurses. I believed I could complement my emic knowledge of my own general practice by also adopting an etic perspective that transcends the role of clinician and assumes the research role of participant-as-observer. However, within my own general practice, conflict in the two roles of emic and etic ethnographer arose when I observed situations in my research role that I felt required action for change in my nurse practitioner role. Traditionally, ethnographers have described the situations they encounter. They do not seek to make changes through emancipating the research participants or influencing the social contexts under study (Nyanzi et al., 2007). Although I achieved this objective and used ethnography to raise theoretical sensitivity (Glaser, 1978), I could not allow misinformation I had discovered about drug doses to remain advertised, or the lack of information regarding treatment of meningococcal septicaemia to go unnoticed. As a nurse leader in my own general practice I could not step out of my clinical role and therefore become a silent observer. I felt an ethical, legal and workplace obligation to ensure that best practice was evident. Self-observation and observation of my colleagues heightened my theoretical sensitivity and gave me avenues to pursue with research participants from four other general practices. I felt distanced from these participants and tried to assume an etic position. This distance reflected a lack of connection with these people and their settings and a felt need to remain an instrument for data collection. However, should an occasion have occurred where actual or possibly harmful practice was observed, professional accountability would have required me to intervene. Defining the two categories of emic and etic appeared to introduce bipolar constructs with the emic or ‘insider’ perspective constituting one pole and the etic or ‘outsider’ the other. These constructs fitted the categorical perspective of ancient Greek philosophers. The insider or ‘emic’ view has one set of characteristics pertaining to a specific culture, while the ‘etic’ perspective may refer to a collection of different cultures. Bonner and Tolhurst (2002) discuss the advantages and disadvantages of being ‘insider’ and ‘outsider’ nurse researchers, but make no reference to underpinning philosophical assumptions of these two constructs. I questioned the constructs of emic and etic as I grappled with being integral to one culture but not the other. Within the two roles were also vague areas that were not clearly emic or etic, such as the shared knowledge and familiarity (between myself and the participants) brought about by the same patient management system used by all five practices. By acknowledging that the emic and etic positions were qualities of a continuum along which I could move throughout the research experience, I felt that my philosophical positions changed at various stages. Epidemiologists have similarly challenged categorical constructs of disease, such as hypertension or hypercholesterolaemia (Schuster et al., 1998; Jackson et al., 2005; Hoare et al. 725

Vickers et al., 2008), while health services researchers have suggested seeing quality of care as a continuum (Buetow and Adams, 2006).

Reflections on assuming an emic and etic role The following reflections draw on my field notes and memo writing when I first assumed an etic perspective of my own general practice. My field notes documented the following.

Stepping out of the role of clinician I observed my own general practice environment. Initial thoughts about information use included the availability and prominence of types of information; files on shelves, books, guidelines; and materials from ProCare (the primary care provider network) describing funding allocations for general practitioners (GPs). ‘‘Crib sheets’’ were taped to office walls. In one room the dosage of paracetamol for children based on their weight was too large for babies less than three months old. A management plan for childhood collapse did not have guidelines for treating suspected meningococcal disease. For three hours I observed the display board which had pockets containing information for patients to access. During the time of observation, despite a steady stream of patients coming in and out of the waiting room, no-one accessed any of the information sheets.

Casual conversations with staff elicited pertinent remarks. ‘I ask the doctor’ was the initial response of one nurse when questioned about how she accessed information on which to base her patient care. ‘I observed a doctor using the spacer and inhaler’ was the response of another nurse when questioned about her knowledge concerning treatment of a wheezy child. I found it a struggle to remain a silent observer when the GP registrar asked ‘Where’s the azithromycin?’ while the reception was busy and buzzing, and I was in the role of researcher in my own general practice. As a partner in the practice, I felt I was expected to furnish the answer but it was not until later in the tea room that I felt compelled and sufficiently comfortable to ask the GP registrar and three nurses, ‘Have you seen the best tests BPAC book with chlamydia testing as the feature article?’ I then felt that I was compromising my etic role by entering the conversation in order to guide my co-workers towards the best source of information. This problem was repeated when the practice manager asked everyone in the tea room ‘Have you completed the online smoking cessation training for Cornerstone (a standardised national quality programme for general practices)?’ I responded in a setting where relationships were congenial; conversations were ‘loose’ in flitting from professional to social. After the best tests conversation a nurse and the GP registrar discussed Indian cooking and left for the local Indian store to buy spices. I then had more avenues to pursue with my research participants: Cornerstone is all about information. Positive, friendly relationships in the team aided in disseminating information. With research participants from other practices, I had categories to pursue, including role models, sources of information, relationships and Cornerstone. My theoretical sensitivity to information use had increased, specifically recognising the value of role models and Cornerstone, the national quality programme for general practice.

Memo writing One characteristic of grounded theory methodology is memo writing to enhance data exploration as the researcher becomes immersed in the stories told by the research 726 Journal of Research in Nursing 18(8) participants (Birks et al., 2007). I wrote the following memo to illustrate my heightened state of reflexivity brought about by the study.

I am a participant in this study ...I consciously think about how information is used. I retrieved the dermatologist’s eczema guidelines and shared them with the team. I realised when I wrote this memo that I could only function in my own general practice as a nurse practitioner and researcher in the emic role, constructing and changing the world I was observing and interacting in. I could not stand back and be a participant observer providing an etic perspective. In contrast, as I interviewed my first research participant from a different general practice I became conscious that my role as researcher was uppermost. I did not feel the need to share information sources or comment on the social context of the environment in the same way that I had in my own general practice. I adopted the etic perspective when entering these practices to interview research participants. I had therefore created my own binary opposition ‘inside’ the general practice where I had dual roles as researcher and nurse practitioner versus ‘outside’ in other general practices where my role was that of researcher.

Theoretical framework I was guided in my research by the work of Charmaz, a student of Glaser and Strauss. (Glaser and Strauss, 1967). The dominant meta-theory of scientific discovery at the time of Glaser and Strauss’s original research was positivism (Charmaz, 2006). Logical positivists believe the empirical world is independent of the observer and causal explanations exist in a quantifiable world. Positivist researchers of the mid-20th century conducted research to prove or disprove existing theories; their work rarely led to theory construction. Descartes (1596–1650) hypothesised that the world was separated into two distinct substances: res extensa, a material world that included the body, and res cogitans, the mind. This mind–body dualism underpins positivism and, along with Galileo’s early work, hailed the beginning of modernism (Deary, 2005). In contrast, postmodern sociological discourse has centred on how the body is inscribed with meaning, for example through fitness, beauty, diet, gesture and posture. The meaning of body inscription is that a body serves as signifier in a particular time and place in the same way that a text or film is read and seen by others and can be re-written. The inscripted body is not the organic body but the composition of self with the social world. Fox (1993) describes this inscripted body as constituted through the collision of desire (belonging to the physical world) and the social arena (cultural discourse of the physical world). Deleuze and Guattari consider desire a positive force, ‘a material and positive investment of libido in a person or thing: the body’s will-to-power’ (Fox, 1993). The term ‘will-to-power’ is based on the philosophy of Nietzsche and refers to an active process of ‘becoming’ rather than being reactive or passive. Deleuze and Guattari used the term Body-without-Organs (BwO) to describe the non-organic political body, which is constantly in flux with an inscription that is never static. The BwO cannot be known in the same way as the organic body. Such postmodern writing eradicates the dualism of mind–body differentiation, where the explanation of inscription would involve a double process (Fox, 1993). In dualism, the physical body exhibits demeanour and behaviours and the mind is attributed with beliefs, taste, judgements and choices made by the person as a rational human actor. Postmodern embodiment suggests that inscription is not ‘read’ by the self but that it ‘is’ subjectively the Hoare et al. 727 self. Fox uses the example of a person newly diagnosed with an incurable illness. The sense of self of this person is challenged and she or he responds with patterns of behaviour, new demeanours or bodily strategies that may be read or misread by others (Fox, 1993). My body was inscribed as a nurse practitioner in my own general practice. My demeanour and behaviours were maintained even when in the role of researcher. As a constructivist grounded theorist, Charmaz (Mills et al., 2006) postulates that researchers are part of the process of generating data. They do not stand apart from it as do those who subscribe to dualism. Charmaz integrates a more frankly discursive approach to grounded theory methodology to help uncover the socio-linguistic processes contributing to the construction of meaning (Yardley, 1997). Discursive researchers believe they influence all data. No data are neutral, as the researcher frames questions, chooses participants and interacts with the participants to produce texts to analyse. Social constructivism is aligned with constructionism; the basic premise of social construction is to question and critique what we know about the world. Constructionists do not claim that propositions and arguments are true, objective or grounded in empiricism (Gergen, 2009). Rather their ideas are tied together through the use of language, are culturally and historically bound and are subjectively rational within a given milieu. In my emic role, I questioned my knowledge about drug doses for paracetamol for infants. Based on empirical research on this topic, I changed the environment in my own general practice. Similarly, based on current research about meningococcal septicaemia, I changed the environment to ensure that information was available about this disease in every consulting room. Providing a framework that does more than acknowledge the way researchers shape data collection, post- centralises the body and embodiment. Interactive qualitative data gathering consists of embodied exchanges involving continual interplay, which not only affects the research processes but also shapes the embodied subjectivity of the researcher and researched (Burns, 2006). The interview interaction does not exist neutrally outside of the body and consideration must be made of how the interviewer’s embodied subjectivity interacts with the respondent to continuously construct and re-construct meanings and bodies. Weiss (1999) states that the experience of being embodied is never a private affair, and always already mediated by our continual interactions with other bodies. As an embodied researcher I had been unable to maintain a silent role when the GP registrar and nurses were discussing azithromycin. I had felt the need to share new ‘best practice’ information and join in the conversation. The theory of embodiment, described by French philosopher Deleuze and psychoanalyst Guattari (Fox, 2002), is pertinent to my experience within my own general practice. Fox analysed Deleuze and Guattari’s theory and suggested that Anglophone sociology ignores the relationship between body, self and social world. Deleuze and Guattari formulated a new way to think about self – the body–self ‘confluence’ (Fox, 2002). This theory of body–self points to the way a body has the capacity to construct itself and the world around it while at the same time maintaining a biophysical and social world that determines the body’s subjectivity. I had felt able to observe information use and construct a change in my own general practice, as a fully engaged embodied subject whilst in the emic role of ethnographer. However, in the four other environments where I interviewed practice nurses in the etic role, the sense of embodiment or body–self confluence felt different and distanced due to the different social worlds I was experiencing. My bodily inscription there was that of a researcher asking questions as opposed to a nurse practitioner providing care. 728 Journal of Research in Nursing 18(8)

Discussion This paper has examined ethnographic technique as a strategy to heighten theoretical sensitivity and so direct theoretical sampling in a grounded theory study. I have explicitly portrayed mental models I adopted in assuming two roles in the research process, that of emic and etic ethnographer. By engaging with philosophical discourses on the holistic role of the researcher as an instrument of data collection, I felt able to move seamlessly between emic and etic positions when changing the setting of my research. I found it easier to interview participants from other general practices, as I did not want to intervene and change conditions in their environment as I had done in my own. My mental model in their practices’ was that of disembodiment. This sense of distance was, I felt, reminiscent of Cartesian dualism. However, Fox (2002) suggests that neither a [disembodied] passive subject nor an essentialist self (meaning an actively engaged subject) can fully understand the social and psychological character of health and, by association, health settings. I could not reduce my physicality to an absent presence (Burns, 2006) as participant observer and maintain a sense of being disembodied within my own general practice, where I felt part of the fabric and subjectively embodied. These feelings of connection reflected my roles within a new centre of primary care research training facility for nursing and medical students and as a provider of high-quality health care. My role as clinician and researcher in general practice is unusual in New Zealand. Internationally, few nurses have been able to combine a clinical career with serious research (Finch, 2009). Role conflict and role ambiguity have been reasons cited for causing difficulty in a dual role (Latter et al., 2009). In addition, I would suggest inflexible adoption of mental models may be untenable when conducting research in one’s own clinical environment. Attempting to evolve grounded theory methodology to do justice to the insights of postmodern theory, Clarke (2003) has integrated social worlds/arenas/frameworks with grounded theory to produce a new conceptual infrastructure entitled situational analyses. Such analyses deeply situate the research ‘individually, collectively, social organisationally and institutionally, temporally, geographically, materially, symbolically, visually and discursively’. Greene (2007: 59) also suggests that rather than taking one philosophical position, the inquiry purpose and research problem should determine the design and methods of a study. There are:

...contested spaces in which philosophy, perspective and practice encounters one another – and either join together in a reciprocal, respectful, and mutually beneficial conversation or walk right by without noticing one another – or pretending not to notice.

Conclusion Ethnographic technique is a useful method for heightening theoretical sensitivity in grounded theory studies. We suggest that the emic and etic approaches of ethnography and underpinning philosophical assumptions should not be viewed as binary oppositions, but placed on a continuum and acknowledged within the research experience. The categories of emic and etic at times merge into each other in a transition zone, creating vagueness. Epidemiologists and medical sociologists have also challenged the categorical model. It is the role of researchers to identify their philosophical position and how it may change at the different stages of the research. Acknowledging that researchers may potentially move along Hoare et al. 729 a continuum between emic and etic positions within a research study may make the knowledge that they and their participants generate more thoughtful, intentional and reflective.

Key points for policy, practice and/or research . Emic and etic constructs align with ‘insider’ and ‘outsider’ perspectives of ethnographic technique. . Ethnographic techniques have a long tradition in grounded theory studies; in this study they were used to increase theoretical sensitivity to guide theoretical sampling. . This paper draws lessons from explicating mental models guiding the emic and etic roles in ethnography. . Emic and etic perspectives, along with embodied and disembodied feelings, can sit along a philosophical continuum within the same research study.

Declaration of conflicting interest None declared.

Funding This research received no specific grant from any funding agency in the public, commercial or not-for- profit sectors.

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Karen J. Hoare is a lecturer at the University of Auckland and works as a Nurse Practitioner for children and young people in a general practice in South Auckland. Her research interests include use of information by practice nurses, the topic of her PhD, and child health. She is currently a student at Monash University in Australia. She is a director of Development Direct, an international company and charity that aims to share health and education information between the developed and developing world to alleviate poverty and ill health. She leads the child health network of the College of Nurses Aotearoa.

Stephen Buetow is an Associate Professor and Acting Head in the Department of General Practice and Primary Health Care. He is also a member of the Centre for Brain Research, having conducted and published research on Parkinson’s disease. Most recently, he has conducted qualitative research on the meaning and significance of companion animals to people with Parkinson’s. He is a highly experienced researcher who has published two books and over 100 peer-reviewed papers, and he has supervised five PhD students to completion. He coordinates a postgraduate course on research methods in health.

Dr Jane Mills is employed a Senior Lecturer/Deputy Head of School Cairns Campus. She has a community nursing background, working for seven years in rural Tasmania as a rural nurse, team leader and manager. Her research to date has focused on rural nurses’ experiences of mentoring, general practice nursing and nursing in remote or isolated areas. Her areas of expertise are rural remote nursing, primary health care, workforce support, evidence-based practice, grounded theory and action research.

Professor Karen Francis is recognised nationally and internationally for her contribution to the development of rural nursing as a specialist discipline. She held the position of President Hoare et al. 731 of Australian Rural Nurses and Midwives (now the Faculty of Rural Nursing and Midwifery, Royal College of Nursing Australia) for a period of seven years, a contribution that was recognised in 2008 when she received the President’s award for outstanding service. She is currently head of the School of Nursing, Midwifery and Indigenous Health at Charles Sturt University in Wagga Wagga.