Profession and Place: Contesting Professional Boundaries at the Margins

There is considerable concern regarding the adequacy of rural health services in New Zealand, with much attention having been paid to issues of recruitment and retention of rural general practitioners. Rhetoric of 'crisis' is often utilised to raise political awareness of the problematic, but in fact, rural general practitioner recruitment and retention has been documented for about a hundred years. For about the same length of time nurses have been providing primary health care services in rural and remote places, often working alone. Using the notion of nurses as a 'stop-gap' in the provision of rural primary health care until problems with recruitment and retention of rural general practitioners are addressed, is a rhetorical device that facilitates the under analysis of the role nurses play and the contribution that they make. The longstanding practice of rural primary care nursing in its various guises over the last century challenges the notion of nursing as a stop-gap.Any investigation of health care in the contemporary moment needs to take account of the influence of biomedical dominance, an increasingly litigious mentality in relation to health care, a shifting focus towards primary rather than secondary health care, and the positioning and re-positioning of health professionals within the neo-liberal state. The very existence of nurses working as the first point of contact in the health care system, with success over time in so far as they do not provoke undue litigation, and appear to deliver an appropriate service must raise questions about who can claim the right to be a primary health care provider. Based on qualitative research conducted in New Zealand and the Western Isles with rural primary care nurses and Family Health Nurses respectively, this thesis explores the ways that nurses construct flexible generalist professional identities that challenge traditional inter and intra-professional boundaries. In the New Zealand case, rural primary care nurses negotiate the boundaries between nursing and medicine, those within nursing itself, and also those between nursing a paramedic work. Nurses perform this boundary work by negotiating self-governing 'appropriate' and 'safe' professional identities. In the Western Isles case, the introduction of the newly developed role of Family Health Nurse serves to highlight the problematic nature of inserting an ostensibly generalist nursing role beyond the rural