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    Exploring solutions : addressing non-urgent emergency department presentations : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing, Massey University, Albany, New Zealand
    (Massey University, 2025-07-30) Alderson, Amber
    Background: The Emergency Department (ED) plays a crucial role in delivering healthcare, focusing on the rapid assessment and treatment of serious illnesses or injuries, often providing life-saving resuscitation and stabilisation. However, EDs face increasing pressure from rising patient volumes, increased acuity and limited resources. This growing demand highlights the need for innovative strategies to optimise ED operations and improve patient outcomes. Patients presenting to the ED with non-urgent concerns need to be managed through more appropriate pathways. Aim: This study aims to analyse the characteristics of non-urgent ED presentations and propose a novel care pathway to address the healthcare needs of this patient group effectively. Methods: A mixed-methods approach was employed, combining qualitative and quantitative data. Five focus groups with healthcare professionals provided qualitative insights into non-urgent presentations. A quantitative patient database review spanning eight years (65,000-90,000 annual ED presentations) was conducted to identify trends and inform the new pathway development. The stage-gate process was used to guide the development and refinement of the proposed care pathway, ensuring systematic evaluation and iteration at each stage based on stakeholder feedback and data insights. Findings: Analysis revealed a priority non-urgent patient group defined by specific criteria: ‘walk-ins’ to the ED, self-referred, Australasian Triage Scale (ATS) four or five, not redirected to urgent care and presenting within six months of a prior ED visit. These individuals predominantly resided in high-deprivation areas, were aged 20–69 years, had low-acuity diagnoses and high ED attrition rates. Using these findings, the Coordination, Assessment, Treatment and Community Hauora (CATCH) model was developed. This pathway integrates ED based nurse practitioners undertaking assessment and treatment alongside patient navigators who empower patients and connect them with appropriate healthcare services. Unlike the conventional ED model, grounded in critical care and triage principles, the CATCH model is tailored to address non-urgent care needs. Conclusion: This research identifies a distinct non-urgent patient group presenting to the ED and introduces a targeted care pathway leveraging nurse practitioners and patient navigators. Future studies could implement the CATCH model to evaluate its real-world effectiveness in improving care and reducing ED demand.
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    Respiratory Support of Adults in the Emergency Department : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University, [Auckland], New Zealand
    (Massey University, 2024-11) O'Donnell, Jane Frances
    Introduction: Adult emergency department (ED) patients frequently require respiratory support (RS), yet limited research on RS, particularly nasal high-flow (NHF) therapy, is available in this setting. This doctoral research aimed to analyse the nature of ED-based RS and its impact on adult patient outcomes, focusing on NHF therapy. Grounded in an evidence-based practice (EBP) framework, this research proposes to bridge a theory-practice gap and inform NHF clinical decision-making in the ED. Methodology: This thesis was informed by a positivist philosophical paradigm and methodology underpinned by an EBP theoretical framework. The research approach was quantitative, the research strategy was non-experimental, the design was multi-method, and the time horizon was cross-sectional, using two methods. The two methods were a systematic review (SR) with meta-analysis (MA) and a point prevalence study (PPS). Each method was conducted in parallel and as per the multi-method design, and the results were integrated to form the thesis findings and answer the research questions. Results: In the first method, the SR provided five MAs involving 18 ED RCTs reporting on 1874 participants. A 45% reduction in escalation relative risk (RR) was seen for NHF vs conventional oxygen therapy (COT) (RR 0.55; 95% CI, 0.33 to 0.92; p = 0.02), with no difference in mortality or adverse event risk. For NHF vs non-invasive ventilation (NIV), NHF increased escalation risk by 81% (RR 1.81; 95% CI, 1.19 to 2.75; p < 0.01). Mortality risk was not different for NHF vs NIV. In the second method, the PPS characterised 76 patients receiving RS from a total of 898 ED-presenting patients. The PPS was underpowered and unable to support its planned inferential analyses. The mean age of the participants was 67.38 years (SD ± 17.4); 52% (n = 40) were male, 48.6% (n = 37) had greater than three comorbidities, and 44% (n = 34) had primary respiratory diagnoses. By ethnicity, the Indigenous New Zealand Māori were overrepresented in the data (n = 18, 23%). Of those receiving RS, the minority (n = 12, 15.7%) received NHF; however, all these required subsequent hospitalisation. The absolute prevalence of the requirement for escalation of RS was n = 22 (28.9%). The hospitalisation rate was 22% higher, and the hospital length of stay was 42% longer for those requiring RS escalation in the ED. Māori demonstrated a 5.8% higher risk of requiring escalation of care on an absolute scale (n = 6, 33.3%) vs (n = 16, 27.5%), and a 22% increased risk on a relative scale (RR 1.22; 95% CI 0.56 to 2.67; p = 0.60) than non-Māori. Conclusions: When the results from the two methods were integrated, the main finding was that nearly a third of those receiving RS required escalation of their RS, with those receiving NHF requiring less escalation than those receiving all other forms of RS combined. These findings align with the meta-analysis of studies for the comparison of NHF compared to COT but not the comparison of NHF compared to NIV.
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    A randomised control trial of a Quick response team for older people : a thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Nursing at Massey University
    (Massey University, 2000) Bapty, Linda Marianne
    A Randomised Controlled Trial of a Quick Response Team for Older People Who Have Experienced a Health Crisis This research investigated the impact of Quick Response Team (QRT) care on levels of independence in older people at three months, as measured by changes in living accommodation and home support packages. It was part of a large collaborative project, a randomised clinical controlled trial that tested efficacy, safety, and cost sayings of a crisis intervention programme for older people in Central Auckland. The QRT, an intensive short-term multidisciplinary scheme developed in Canada, was evaluated as being very effective in preventing hospital admissions and enabling early discharges. This study explored the effectiveness of QRT care within the context of health care in New Zealand. The study population included people over 55 years of age who lived at home and, mainly due to increased social needs, would normally be cared for in hospital. QRT nurses and geriatricians at Auckland Hospital identified and screened patients, in the Emergency Department for the Admission Prevention arm of the study, and on in-patient wards for the Early Discharge arm of the study. Data on age, gender, demographics, problems, and reasons for seeking hospital care were obtained from patient records and through personal and telephone interviews with patients, family, hospital staff, GPs, and community health providers. QRT nurses completed comprehensive assessments at study entry including details about: living accommodation and the use of formal supports, such as District Nursing, rehabilitation therapy, meal services, home help, day programmes, and respite care. Consenting patients (Ṉ = 285) were randomly assigned either to control groups receiving the usual in-patient hospital care or to experimental groups receiving QRT care. Visiting nurses, rehabilitation therapists, and social workers provided care and coordinated home supports for the QRT intervention groups, which included live-in home help if required. Medical supervision was provided by hospital geriatricians in a shared role with GPs. Interviews were completed again three months after study entry. Subjects in all groups after three months showed an increase in dependency as evidenced by changes in living accommodation and care support packages, however there were no significant differences in the changes between the experimental and control groups (p < 0.05). Therefore, regarding levels of independence, care at home by the QRT was judged to be as effective as hospital care for older people experiencing a health crisis. The results obtained in this study need to be considered along with the results of the larger tial.
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    A thematic analysis of factors influencing decisions to use physical restraint in acute mental health settings : a thesis submitted in partial fulfilment of the requirements for the degree of Master of Philosophy in Nursing, Massey University
    (Massey University, 2007) Edgar, Murray James
    This study investigates the factors that influence nurses' decisions to use physical restraint or to attempt alternative interventions within acute mental health inpatient settings. The objective was to better understand the background to these decisions in the hope that this will lead to the development of more consistent and justifiable approaches to challenging behaviour displayed by some mental health patients. Eight nurses working or recently working in acute mental health services in two different District Health Boards were interviewed using a semi-structured interview technique. The sample was purposive, with participants being asked about their experiences with physical restraint, using specific events from their clinical practice. These interviews were then reviewed by the researcher and note taken of areas for further exploration or clarification. A second interview focussed on the areas identified as of particular interest to this research. 32 events of restraint use or near-use were related to the researcher, giving a significant amount of data for analysis. A thematic analysis approach was used to identify and examine themes within the data. The central thesis emerging from the data and its analysis is that much of what influences nurses' decisions relates to intrinsic factors such as their attitudes towards the patients in their care, whether the patients are appropriately domiciled in mental health services, and assessments of the causes of the challenging behaviour. The importance of working as a team and trusting colleagues emerged as a strong yet previously under-researched theme. Implications for nursing practice are discussed. Particular emphasis is placed on the further development of Calming and Restraint programmes for nurses working in acute mental health settings. The need to address the background attitudinal factors from both a training and service delivery perspective is strongly evident.