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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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    What is the potential of distance education for learning and practice development in critical care nursing in the South Island of New Zealand? : a thesis presented in partial fulfilment of the requirements for the degree of Master of Education in Adult Education at Massey University
    (Massey University, 2003) Hardcastle, Jane
    This thesis explores the potential of distance approaches to teaching and learning in post registration nursing education within the context of critical care nursing practice. The thesis specifically considers the appropriateness of distance education within the population of critical care nurses in the South Island of New Zealand. The geographical distribution of critical care services and subsequent population distribution of practising critical care nurses within the South Island has resulted in a demand for post registration education from relatively small yet distinct groups of nurses spanning a substantial land area (150,461 Km2). National shortages of experienced and qualified critical care nurses, and consensus regarding the necessity for post registration education for specialist practice have been recognised throughout the Western World (Ball 1992, Charlton, Machin and Clough 2000, Cutler 2000, Johnston 2002). Yet nurses in the South Island of New Zealand have limited provision or access to critical care education programmes (Hardcastle 2003). The thesis therefore presents a pertinent and timely exploration into the potential of distance approaches to educational provision for an area of specialist practice that is currently unable to consistently meet health care demands. The thesis uses descriptive and interpretive research (previously conducted by the author), and relevant literature in order to provide a comprehensive exploration of the study context and consider the research question. The thesis aims to enhance understanding of the specific population in terms of educational provision and demand, and the meaning of 'effective' education for critical care nursing practice. Subsequent examination of the potential of distance education within this context will more clearly indicate whether distance approaches could be compatible with concepts of effective education. The outcome of which will be useful in order to determine educational strategies that may positively influence the future of education for critical care nursing practice within the South Island of New Zealand.
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    A process evaluation of a shared leadership model in an intensive care unit : a thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Nursing at Massey University
    (Massey University, 2001) Turner, Clare Lynette Eden
    Shared leadership has been touted in the United States and United Kingdom as a model of staff management that fosters active involvement of staff, in this case nurses as experienced professionals, in patient management. This study uses process evaluation for the examination of a shared leadership model in an intensive care environment following a period of significant change and restructuring. The model was based on the shared leadership literature (porter-O'Grady, 1992) which focuses on clinical practice as a key accountability and on decentralised clinical leadership at the point of service. The model aligned with the skill acquisition framework used by the employer organisation called the Professional Development Programme (PDP). This programme aims at enhancing the development of expertise in clinical practice and supports the principles of shared leadership. This research study was undertaken to evaluate the process of implementation of the model and to discover whether there is evidence nurse involvement in the management of patient care. The results are based on the responses of 104 registered nurse respondents (56%) working in the intensive care unit of a specialised hospital. Documentation was also examined for evidence of nursing input into indirect patient management process development. The results indicate that nurses are becoming more settled in their working environment and feel more confident in their ability to provide an active role in the management of their patients within a multidisciplinary team.
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    The use of knowledge of respiratory physiology in critical care nurses' clinical decision-making : a thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Nursing at Massey University
    (Massey University, 2005) Pirret, Alison Margaret
    The knowledge and experience of expert nurses has long been recognised as contributing to early identification of patient problems, early intervention and an improved patient outcome. The present study sought to answer the research question, following completion of a critical care specialty practice programme, do nurses use knowledge of respiratory physiology in their clinical decision-making? An evaluation methodology using a managerial perspective was used to compare the use of knowledge of respiratory physiology in critical care nurses' clinical decision-making with the respiratory physiology recommended in the New Zealand Standards for Critical Care Nursing Education (Critical Care Nurses' Section, 2000). Using intensity sampling, 27 nurses who had completed a critical care specialty practice programme and who were currently working in the critical care units of two tertiary hospitals in a large metropolitan city within New Zealand were selected. Quantitative and qualitative methods were used to collect data. Data analysis was completed using descriptive statistics, correlations and identification of common terms and themes. The results showed that following completion of a critical care programme, critical care nurses demonstrated a low to medium level of knowledge of respiratory physiology in their clinical decision-making. In the total group, no statistically significant associations were found between the use of knowledge of respiratory physiology in clinical decision-making and age, experience, academic level, use of guidelines and protocols, standards and integrated care pathways, conference attendance, reading of journals and accessing the World Wide Web for literature. Qualitative analysis identified factors contributing to the low to medium use of knowledge as being nurses' high reliance on intuitive knowledge, lack of in-depth discussion of respiratory concepts in critical care programmes, lack of opportunity in the clinical practice environment to discuss respiratory physiology and lack of collaborative practice. The study identified the need for more collaborative practice and for clinical nurse educators firstly, to have a closer relationship with the critical care programme providers to ensure adequate theoretical content and secondly, to work with nurses in the clinical setting.
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    Optimising the human experience : the lived world of nursing the families of people who die in intensive care : a thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Nursing at Massey University
    (Massey University, 1997) Andrew, Catherine
    Intensive Care nurses share some of the most precious and poignant moments with people who have family members dying in ICU. This study explores the lifeworld of seven ICU nurses who describe their experiences working with these families. Data was gathered using unstructured, indepth, face-to-face interviews. These were tape-recorded and transcribed. The study uses a phenomenological approach informed by Heidegger and hermeneutics. Van Manen's methodological suggestions are followed to shape and focus the study, and provide guidelines for analysis of the data and the writing of the report. The findings reveal that ICU nurses recognise that this is a particularly tragic and difficult time in peoples' lives. The nurses are aware that the last hours or days with a dying relative may be vividly remembered for years to come. During this time nurses seek to optimise the human experience of the family members by making the time as positive, or best, as possible. This is achieved through strategies such as Being There, Supporting, Sharing, Involving, Interpreting and Advocating. These strategies are enabled by three domains: Nurse as Person, Nurse as Practitioner and Nurse as Colleague which describe a wider context to working effectively with families rather than merely looking at direct interactions between the nurse and the family. Optimising the Human Experience is proposed as the central essence or phenomenon of nursing the families of people who die in ICU.
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    The role of New Zealand intensive care nurses in ventilation management : a thesis submitted in partial fulfilment of the requirements for the degree of Master of Philosophy in Nursing at Massey University, Wellington, New Zealand
    (Massey University, 2015) Henderwood, Mark
    Introduction: Previous research about the role of nurses in ventilation management suggests that it is a largely collaborative endeavour between doctors and nurses. These studies, however, are based on the views of nurse managers representing staff as a collective, rather than individual nurses answering from their perspective. Further, previous research only begins to account for the role of automation in ventilation management. Aim: This study describes the role of the New Zealand intensive care nurse in ventilation management and the use of automated ventilator modes. Method: A self-reported online survey using a non-probability sample of intensive care nurses who are members of the New Zealand College of Critical Care Nurses was used (n=204). Data were analysed using quantitative methods to describe and compare with international data. Results: The sample (n=204) had a range of intensive care unit (ICU) experience (0-42years) and 136 (69.7%) had completed a post-graduate critical care specialty qualification. Participants worked in various sized units (2-26 beds). Nurse to patient ratios were 1:1 for intubated patients. Ventilation management protocols were available for 136 (66.7%) participants; however, the effect of protocol availability on clinical practice was insignificant. Nurses in this study had lower perceived autonomy (p=0.0006) and more perceived influence (p=0.028) in decision-making than their managers reported previously. Consistent with previous research, nurses collaborate with medical staff in fundamental decisions and largely act independently in titrating ventilator settings. New Zealand ICUs have high nurse to patient ratios compared to their European counterparts. While New Zealand ICU nurses have similar reported levels of independent decision-making in oxygen and PEEP titration, they have less independence in adjusting the six other ventilator settings. As in Europe, the most common automated ventilation modes used in New Zealand ICUs are ASVTM and SmartCareTM. Discussion: As automated modes independently titrate ventilator settings, the ventilator itself increasingly participates in a role largely identified as the nurses’ domain. The study concludes that it is timely for nurses to re-evaluate their role in ventilation management. Rather than focus on the titration of ventilator settings, nurses could strengthen their contribution in the collaboration of fundamental decisions.
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    Making a difference : the lived world of nursing practice in an acute care setting : a thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Nursing at Massey University
    (Massey University, 1989) Paterson, Bronwyn
    This study examines the practice world of twenty two registered nurses working in medical and surgical wards of an acute general hospital in New Zealand. It is argued that nursing practice is a complex, context-specific, activity and needs to be studied using methods that do not assume an objective, context-free reality. The work of Patricia Benner (1984) guided this study which utilised a qualitative research approach to enter the lived world of nursing practice. Through descriptions of work days and a sharing of clinical exemplars, an understanding of the broader context of nursing practice was gained, areas of skilled performance in nursing emerged, and the meaning of making a difference for the nurses in the study examined. The central role of mutual advice and support in facilitating significant incidents in practice was apparent. An examination of the types of experiences which challenge current practice and change it in some way provided insight into the importance of experience in developing clinical expertise and the vital role of local knowledge in facilitating practice. Nursing practice emerged as crucial to patient welfare and safety in the acute care setting.
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    Implementing a Critical Care Outreach Team : what difference has it made for nurses? : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Nursing at Massey University, Albany, New Zealand
    (Massey University, 2011) Davies, Kathryn Erin
    The aim of this study is to describe the implementation of Critical Care Outreach (CCO) and to understand what difference implementing a Critical Care Outreach Team (CCOT) has made to ward nurses in a secondary level general hospital in New Zealand. A CCOT was established at the study hospital in 2006. The aim was to implement an early warning score, to provide education and to share appropriate intensive care skills from CCOT nurses on the wards. Additionally, patients discharged from the Intensive Care Unit were to be followed up. The difference this made to ward nurses in this hospital was unclear. International studies had reported suboptimal patient care on acute wards and the emergence of CCOTs. Research was warranted to gain an understanding of the impact of the service on ward nurses. The methodology chosen for the study was case study, and was underpinned by Change Management Theory and elements of whole system reform (Fullan, 2010). Fullan’s (2007) Change Management Theory of a three phased approach to change management, initiation, implementation and institutionalisation was selected for the study. Data was collected from a nursing focus group, three interviews, and District Health Board documents related to the CCOT. Interviews and nursing focus group data were analysed by thematic analysis and documents analysed by subject. Implementing the CCOT facilitated the shift of late recognition/late intervention of patients to early recognition/early intervention. An area of whole hospital reform occurred. The use of an early warning score promoted more timely patient review, communication between nurses and doctors, improved observation frequency and an environment of objectivity developed. Nurses benefited from education, were empowered to escalate patient concerns, improved their assessment and specific clinical skills, and reported that they were supported by the CCOT. The CCOT has had a positive effect on the early recognition and early intervention of the physiologically unstable patient. The challenge to New Zealand nursing now is to continue to build on the evidence from this study that CCOT has a beneficial impact on ward nurses. The challenge to the District Health Board is to preserve CCOT to ensure that nurses are supported and late recognition/late intervention is truly a phenomenon of the past.