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    Hydration status in older adult patients and the relationship to factors affecting the access and intake of fluid : a thesis presented in partial fulfillment of the requirements for the degree of Masters of Science in Nutrition and Dietetics at Massey University
    (Massey University, 2019) Smithers, Alexandra
    Objectives: To assess fluid intake and access among hospitalised patients ≥65 or ≥55 years and to compare total fluid intake with the patient’s hydration status as determined by serum osmolality. Methods: Eligible patients, aged were recruited from Northshore and Waitakere hospitals within the Waitemata DHB in NZ. Socio-­‐demographic characteristics were collected using an electronic questionnaire. The patients’ fluid intake was measured using the interactive FIAT, which enabled patients to select any beverage or high fluid food (e.g. jelly, custard, soup) that they had consumed from the hospital, onsite cafeteria, and vending machines. The patients were able to indicate how much they had consumed using a visual representation of the product filled at various volumes for guidance. The patients’ access to fluid and potential barriers to them meeting their fluid requirements was assessed using the FAST on an electronic device. Serum osmolality, sodium, potassium, haematocrit and creatinine were determined as indicators of hydration status and collected within 24 hours of the FIAT and FAST. Results: The study sample (n=54) included 23 (43%) men and 31 (57% women) with a mean age of 82.5±8.10 years. The FIAT identified that the majority of patients did not meet their fluid recommendations (n=46, 90%) and that half (n=27) had a low fluid intake of less than 1.6L/day. The FAST identified that of those patients with low fluid intake 16 (59%) struggled to open fluid containers and 10 (37%) sought assistance with opening. Patients who struggled to open fluids had a higher mean serum osmolality than those who didn’t struggle (297±6.88mOsm/kg versus 291±7.80mOsm/kg, P=0.009). Half of the patients were impending dehydration (n=15, 33%) or were dehydrated (n=9, 20%). Conclusions: Low fluid intake appeared to contribute to dehydration. Early assessment of fluid intake and hydration status is critical to prevent dehydration in older hospitalised patients. It is recommended that health care staff ensure all patients are able to open the provided fluids. Adequate hydration status may aid in the patients recovery, reducing their length of stay and thus the cost of their treatment.
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    The barriers to surgical patients' oral intake in the acute hospital setting : a thesis presented in partial fulfilment of the requirements for the degree of Master of Science in Nutrition and Dietetics, Massey University, Albany, New Zealand
    (Massey University, 2018) Stone, Olivia
    Background: Hospital patients worldwide often do not eat all of their meals, resulting in suboptimal food intakes. These patients are more likely to experience numerous undesirable health outcomes as a consequence of not meeting their nutritional requirements. Aim: To investigate the barriers to surgical patients’ oral intake in an acute hospital setting in New Zealand (NZ). Objectives: To conduct a pilot study to test the usability of the validated Patient Mealtime and Nutrition Care Survey (PMNCS) in a NZ setting, and to adapt the PMNCS to include the most relevant barriers to oral intake in NZ. Further, to conduct a feasibility study to test the effectiveness of the NZ-PMNCS independently, and paired with patient meal observations to confirm the effectiveness of the tool. Methods/Design: A single-centre cross-sectional study conducted at North Shore Hospital, NZ. A sample of 100 surgical in-patients participated in the pilot study and 65 patients in the feasibility study. Results: The most frequently reported barriers were food brought into the hospital by visitors (81.5%) and a loss of appetite (70.8%). Six barrier domains were explored revealing significant findings for: younger (<65 years) compared to older (≥65 years) age associated with more hunger domain barriers (1.47 ± 0.81 versus 0.90 ± 0.67, P=0.003); longer (>5 days) versus shorter (≤5 days) length of stay associated with more food quality domain barriers (1.20 ± 1.26 versus 0.40 ± 0.81, P=0.003). Comparing the NZ-PMNCS and meal observation results showed that patients consuming ≤½ of their meals more frequently reported inability to make informed menu choices (50.0%)(P=0.027) and that consumption of their prescribed nutritional supplements affected their food intake negatively (50%)(P=0.001). Conclusion: Compared to earlier studies using previous versions of the PMNCS, the NZ-PMNCS captured similar results in the NZ hospital setting. Key issues identified include a younger age being associated with experiencing more hunger domain barriers, and patients consuming less food experienced difficulty choosing menu options and found prescribed nutritional supplements interfered with their food intake. The NZ-PMNCS was practical to use and feasible in identifying barriers to food intake. These findings could contribute to changing practices to improve hospital food intake. Keywords: barriers, oral intake, foodservice, surgical patients, hospital
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    A multicase study of a prolonged critical illness in the Intensive Care Unit : patient, family and nurses' trajectories : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing, Massey University, Palmerston North, New Zealand
    (Massey University, 2017) Minton, Claire Maree
    A critical illness necessitating admission to an Intensive Care Unit (ICU) is a profoundly stressful event for patients and families. It is important nurses understand these experiences, to provide appropriate care. For most patients admitted to an ICU in New Zealand their stay is of short duration. However, as a consequence of advances in life-sustaining therapies a new group of patients has emerged. This cohort survives their initial critical illness but become dependent on live-saving interventions for a prolonged period, necessitating a protracted ICU stay. This purpose of this study was to explore the experiences of the patient, their family and healthcare professionals during the trajectory of a prolonged critical illness in an ICU. A qualitative instrumental multicase study approach was used, informed by the Chronic Illness Trajectory Framework. Data collection involved six linked cases (patient, family and clinicians) in four ICUs over a two-year period utilising observations, conversations, interviews and document analysis. Longitudinal data analysis revealed four sub-phases in the trajectory of a prolonged critical illness. These sub-phases were determined by the patients’ physiological condition, with each sub-phase also representing different psychosocial needs. The patients’ physiologically debilitated state made them prone to complications and added to the complexity of their illness trajectory. Families’ trajectory, dominated by uncertainty, were informed by the patients’ trajectory. Families worked hard to relieve the uncertainty by looking for signs of improvement. As their trajectory progressed the ‘wear and tear’ of prolonged uncertainty became more evident. Nurses’ work was informed by the patients’ trajectory, with different sub-phases representing different challenges. During the mid-phase, distress related to the uncertainty about positive patient outcomes and the suffering some patients endured. During the emerging with a failed body sub-phase, nurses were challenged to meet all patients’ needs due to their overwhelming work priorities. The identification of the specific sub-phases of a prolonged critical illness trajectory can result in interventions being targeted to each sub-phase to improve outcomes and experiences. Research and education can also be targeted to each sub-phase to explore specific issues and problems to continue to advance this body of knowledge.
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    An investigation of nutrition risk among hospitalised adults of advanced age admitted to the AT&R wards at North Shore and Waitakere Hospitals : a thesis presented in partial fulfilment of the requirements for the degree of Master of Science in Nutrition and Dietetics at Massey University, Albany, New Zealand
    (Massey University, 2015) Popman, Amy
    Background: In line with the global trend of an ageing population, the number and proportion of New Zealanders aged 65 years and older is increasing. Those of advanced age (85 years and older) make up the fastest-growing demographic group within the aging population. In coming years it is projected almost a quarter of older adults in New Zealand will be aged 85 years and older. Advanced age adults are at an increased risk of poor nutrition status. Optimising nutritional wellbeing in advanced age is important as nutrition risk has been associated with longer hospital admissions, loss of independence due to disability and the need for a higher level of care. Aim: The aim of this study was to establish the prevalence of nutrition risk among adults of advanced age (85 years and older) recently admitted to the Admission, Treatment and Rehabilitation (AT&R) wards at North Shore and Waitakere Hospitals. Method: Participants were recruited into this cross-sectional study within five days of admission to the AT&R wards at North Shore and Waitakere Hospitals. Sociodemographic and health characteristics were established using an interviewer administered questionnaire. Anthropometric measures including body mass, muscle mass, and muscle strength were also taken. Nutrition risk was assessed using a validated screening tool, the Mini Nutritional Assessment-Short Form (MNA-SF). The validated 10-item Eating Assessment Tool was used to assess dysphagia risk and the validated Montreal Cognitive Assessment was used to determine level of cognition. Data were analysed using descriptive statistics. Pearson Chi-Square and Fisher’s Exact tests were used to examine differences between MNA-SF nutrition status groups. A p-value<0.05 was considered statistically significant. Results: Of the 88 participants, 43.2% were at high risk of malnutrition and 28.4% were malnourished. The majority of malnourished participants were widowed (64.0%), received the pension as their only source of income (76.0%), were taking more than five medications (76.0%), wore dentures (64%), had below normal cognitive function (92.3%), received regular support services (72.0%), and required daily help (76.0%). Participants who were malnourished were significantly more likely to be at risk of dysphagia (52.0%, p=0.015,). The MNA-SF score was positively correlated with body mass index (r=0.484, p<0.001); grip strength in the dominant hand (r=0.250, p=0.026), and negatively correlated with dysphagia risk score (r=-0.383, p<0.001). Conclusion: Nutrition risk and malnutrition is highly prevalent among hospitalised adults of advanced age. Ensuring routine nutrition screening is carried out on admission to an AT&R ward is an important first step to identify those at nutrition risk. These findings also highlight the importance of screening for dysphagia risk alongside nutrition risk among advanced age adults. Screening on admission to hospital can help to identify those in need of further assessment and can help to shape the interventions to improve nutrition status.
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    Constructing and managing patient death : a narrative inquiry : a thesis presented in partial fulfilment for the requirement for the degree of Masters of Science in Psychology (endorsed in Health Psychology) at Massey University, Albany, Auckland, New Zealand
    (Massey University, 2015) Steyn, Wilmie-Minette
    This research inquiry has sought to explore how medical consultants construct and manage patient death. Previous research in this area has focused on the influence of patient death on nurses and medical students or on family members. However no research could be found that specifically investigated what the influence of patient death was on medical consultants nor on how medical consultants constructed and managed patient death. This thesis aims to break new ground by examining this topic. Twelve consultants across six different specialities: Emergency medicine, Anaesthetics, Intensive care, General surgery, Internal medicine and Paediatrics; volunteered to be interviewed for this research project. Interviews were recorded, transcribed and then analysed using narrative inquiry in order to gain insights into the influence of patient death on consultants and also how they understand and manage patient death. Findings are discussed in two parts. The first part focuses specifically on the values that consultants hold and how these values underpin their particular identity as consultants. The research shows that consultants value being responsible, having support from others, being rational decision-makers, being good communicators, however they also value keeping their emotions compartmentalised until they felt it appropriate to display them. Consultants used these values to build the identity of a good doctor as one who is ethical and compassionate. Furthermore, consultants used these values to help them project the protagonist position they held within their narratives. The second part explores how consultants construct and manage patient death; both in a broad sense and with reference to specific cases. These findings indicated that consultants consider death not only as a relentless force without discriminatory power, but also as a natural process. Viewing death in these ways allowed consultants to construct death in two ways, depending on whether the death was due to an acute or chronic condition. For patients who died in acute circumstances, the consultants constructed death as a lost battle. For patients who died following long term illness, death was constructed as a merciful end. The case examples emphasized that these two distinct constructions of death allow consultants to manage patient death. They were able to resolve their own internal conflicts of feeling that they should be able to save all patients versus the reality that it is not possible to save everyone. This research contributes to the limited research in this area and fills a gap in the literature by specifically looking at consultants, a group that has not previously been considered.