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Item 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, AmberBackground: 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.Item 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 FrancesIntroduction: 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.Item Slow and steady-small, but insufficient, changes in food and drink availability after four years of implementing a healthy food policy in New Zealand hospitals(BioMed Central Ltd, 2024-12) Mackay S; Rosin M; Kidd B; Gerritsen S; Shen S; Jiang Y; Te Morenga L; Ni Mhurchu CBACKGROUND: A voluntary National Healthy Food and Drink Policy (the Policy) was introduced in public hospitals in New Zealand in 2016. This study assessed the changes in implementation of the Policy and its impact on providing healthier food and drinks for staff and visitors in four district health boards between 1 and 5 years after the initial Policy introduction. METHODS: Repeat, cross-sectional audits were undertaken at the same eight sites in four district health boards between April and August 2017 and again between January and September 2021. In 2017, there were 74 retail settings audited (and 99 in 2021), comprising 27 (34 in 2021) serviced food outlets and 47 (65 in 2021) vending machines. The Policy's traffic light criteria were used to classify 2652 items in 2017 and 3928 items in 2021. The primary outcome was alignment with the Policy guidance on the proportions of red, amber and green foods and drinks (≥ 55% green 'healthy' items and 0% red 'unhealthy' items). RESULTS: The distribution of the classification of items as red, amber and green changed from 2017 to 2021 (p < 0.001) overall and in serviced food outlets (p < 0.001) and vending machines (p < 0.001). In 2021, green items were a higher proportion of available items (20.7%, n = 815) compared to 2017 (14.0%, n = 371), as were amber items (49.8%, n = 1957) compared to 2017 (29.2%, n = 775). Fewer items were classified as red in 2021 (29.4%, n = 1156) than in 2017 (56.8%, n = 1506). Mixed dishes were the most prevalent green items in both years, representing 11.4% (n = 446) of all items in 2021 and 5.5% (n = 145) in 2017. Fewer red packaged snacks (11.6%, n = 457 vs 22.5%, n = 598) and red cold drinks (5.2%, n = 205 vs 12.5%, n = 331) were available in 2021 compared to 2017. However, at either time, no organisation or setting met the criteria for alignment with the Policy (≥ 55% green items, 0% red items). CONCLUSIONS: Introduction of the Policy improved the relative healthiness of food and drinks available, but the proportion of red items remained high. More dedicated support is required to fully implement the Policy.Item Lowering hospital walls to achieve health equity(BMJ Publishing Group Ltd, 2018-09-20) Matheson A; Bourke C; Verhoeven A; Khan MI; Nkunda D; Dahar Z; Ellison-Loschmann LHospitals have evolved to become integral and dominant components of health systems, although their functions, organisation, size, degree of centralisation, and resourcing varies across countries. Despite this diversity, hospitals are generally focused on providing services for sick people rather than prevention. Although many have shown the capacity to quickly adopt new technologies, especially for diagnosing and managing illness, achieving institutional change to tackle the systemic causes of health inequities has proved much more difficult. We argue that the actions of hospitals contribute to health inequities. This is important given that hospitals hold an inordinate share of power, resources, and influence within health and community systems—while primary care and prevention are consistently undervalued and underfunded. We draw on four opportunistically selected country case examples to show the role that hospitals can play in overcoming systemic barriers to health equity. Each example highlights health sector actions taken for particular population groups: women and children in Pakistan and Rwanda and the indigenous peoples of Australia and New Zealand.Item Effectiveness of hospital transfer payments under a prospective payment system: An analysis of a policy change in New Zealand(John Wiley and Sons Ltd, 2022-07) Schumacher CProspective payment systems reimburse hospitals based on diagnosis-specific flat fees, which are generally based on average costs. While this encourages cost-consciousness on the part of hospitals, it introduces undesirable incentives for patient transfers. Hospitals might feel encouraged to transfer patients if the expected treatment costs exceed the diagnosis-related flat fee. A transfer fee would discourage such behavior and, therefore, could be welfare enhancing. In 2003, New Zealand introduced a fee to cover situations of patient transfers between hospitals. We investigate the effects of this fee by analyzing 4,020,796 healthcare events from 2000 to 2007 and find a significant reduction in overall transfers after the policy change. Looking at transfer types, we observe a relative reduction in transfers to non-specialist hospitals but a relative increase in transfers to specialist facilities. It suggests that the policy change created a focusing effect that encourages public health care providers to transfer patients only when necessary to specialized providers and retain those patients they can treat. We also find no evidence that the transfer fee harmed the quality of care, measured by mortality, readmission and length of stay. The broader policy recommendation of this research is the introduction or reassessment of transfer payments to improve funding efficiency.Item The use of telephone communication between nurse navigators and their patients(Public Library of Science (PLoS), 2020) Heritage B; Harvey C; Brown J; Hegney D; Willis E; Baldwin A; Heard D; Mclellan S; Clayton V; Claes J; Lang M; Curnow VBackground Hospitals and other health care providers frequently experience difficulties contacting patients and their carers who live remotely from the town where the health service is located. In 2016 Nurse Navigator positions were introduced into the health services by Queensland Health, to support and navigate the care of people with chronic and complex conditions. One hospital in Far North Queensland initiated an additional free telephone service to provide another means of communication for patients and carers with the NNs and for off-campus health professionals to obtain details about a patient utilising the service. Calls made between 7am and 10pm, seven days per week are answered by a nurse navigator. Aim To report utilisation of the service by navigated clients and remotely located clinicians compared to use of navigators’ individual work numbers and direct health service numbers. We report the reason for calls to the free number and examine features of these calls. Methods Statistical analysis examined the call reason, duration of calls, setting from where calls originated and stream of calls. Interactions between the reasons for calls and the features of calls, such as contact method, were examined. Results The major reason for calls was clinical issues and the source of calls was primarily patients and carers. Clinical calls were longer in duration. Shorter calls were mainly non-clinical, made by a health professional. Setting for calls was not related to the reason. The most frequent number used was the individual mobile number of the NN, followed by the hospital landline. Although the free number was utilised by patients and carers, it was not the preferred option. Conclusion As patients and carers preferred to access their NN directly than via the 1800 number, further research should explore options best suited to this group of patients outside normal business hours.Item Where we are and how we got here : an institutional ethnography of the Nurse Safe Staffing Project in New Zealand : a thesis in fulfilment of the requirements for Doctor of Philosophy, Massey University, School of Nursing, College of Health, Manawatu, New Zealand(Massey University, 2019) McKelvie, RhondaFrontline nurses in New Zealand hospitals still work on short-staffed shifts 18 years after they began to express concerns about unsafe staffing and threats to patient safety. The Nurse Safe Staffing Project and its strategies (Escalation planning and the Care Capacity Demand Management Programme) were designed to address the incidence and risks of short-staffing. After a decade, these strategies are yet to yield tangible improvements to frontline nursing numbers. Using institutional ethnography, I have charted a detailed description and analysis of how aspects of the strategies of the Nurse Safe Staffing Project actually work in everyday hospital settings. Competing institutional knowledge and priorities organise what is happening on short-staffed shifts, and nurses are caught in the crossfire. The central argument throughout this thesis is that nurses’ vital situated knowledge and work are being organised by and overridden in this competitive institutional milieu. I show how what actually happens is consequential for nurses, patient care, and staffing strategies. This analytical exploration contributes knowledge about nurses’ situated and intelligent compensatory work on short-staffed shifts, how this knowledge is displaced by abstracted institutional knowledge, and the competing social relations present in environments where nurse-staffing strategies are negotiated.Item Patients who present to the Emergency department but do not wait : an exploratory study : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Nursing at Massey University(Massey University, 2004) Baur, PeterPeople who do not require urgent treatment often visit Emergency Departments. Furthermore, a small - yet significant - group leave the Emergency Department (ED) before even being seen by a doctor. Previous studies suggest that most people who do not wait (DNW) having presented to the ED and then leave without being seen by a doctor may have non-urgent conditions. However, other studies contradict this. This is an exploratory study into this subject. Its main aims are to: □ correctly define this DNW group who present to EDs; □ identify the size of a DNW population in a New Zealand setting; □ establish common factors that influence people's decision to present then leave and; □ ascertain whether nursing practice may impact on this population of emergency presentations. Data collection took place, over a period of 4 months, in a Level 5 District Health Board Emergency Department in New Zealand. The study uses a retrospective cross-sectional postal survey design to secure data on people's experiences of the ED, asking them, amongst other things, why they did not wait. The study sample consisted of 642 people. 489 people were sent postal surveys which resulted in a response rate of 18% (n = 92). Data was analysed and compared using a combination of quantitative and qualitative techniques, using SPSS© and MS Excel© statistics software, elements of operations research (field observation) and content analysis. Subjective data was illuminated and extended by qualitative methods, namely interpretative and descriptive content analysis and an abstract conceptualisation of the themes generated is offered. Regional Ethics Committee approval was sought and granted prior to this investigation commencing. The results indicate that the majority of DNWs occur during daylight hours. The mean age of those who DNW was 27 years. They tended to be male. The greatest proportion of the DNW population analysed lived locally and waited a mean time of 112 minutes before choosing to leave. All Australasian Triage Scale categories (except ATS 1) demonstrated examples of those who took a DNW discharge. The most common complaints people presented with were ones they had endured for more than 12 hours and were sometimes days old. A high proportion of people reported that they received definitive treatment within 12 -24 hours following their departure from the ED. Common themes identified as reasons people chose to leave the ED related to their perception of action, perception of their illness and environment. Additional themes extracted from the data that influenced people's decisions to leave concerned their perceptions of staff communication/behaviour; systems processes; feelings of abandonment; other commitments and waiting time.Item 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 MarianneA 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.Item Hospital information systems : a nursing viewpoint : a thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Nursing Studies at Massey University(Massey University, 1983) Wenn, JaniceThis thesis is concerned with hospital information systems. The literature relating to management information systems is examined in conjunction with the literature which specifically focuses upon hospital and nursing information systems. A field study, using a case study approach, is designed and implemented, its purpose being to analyse five sub-systems of a current hospital information system in use in one Hospital Board. This field study utilises a basic systems analysis methodology focusing upon the problem identification and performance identifications of the analysis cycle. In the problem identification phase forty-two subjects are interviewed, (83.3% of the sample being nurses in management positions). Check lists designed to test the sub-systems abilities to generate, store, retrieve and utilise data, and test the subjects knowledge of the sub-systems are devised and applied. The data obtained from the application of check lists is analysed and data flow charts and in-depth interview schedules developed for use in phase two or the performance identification phase of the field study. In phase two (performance identification) eleven subjects in administrative positions within the Hospital Board are interviewed using the data flow charts and the in-depth interview schedules as tools for eliciting data. Contrary to the author's expectations the field study results reveal a considerable diversity. In phase one the respondents possessed a sound knowledge of the admission/discharge, patient care and nursing management sub-systems. 85,7% of the nurse respondents have knowledge of the patient care sub-system and a further 79.2% have some knowledge of its ability to generate, store, retrieve and utilise information. In common with the administrators the high level of knowledge of retrieval and utlisation (89.2%) would indicate frequent use of the system. By contrast only 5.4% of the respondents in phase one had knowledge of retrieval and utilisation of the staffing information sub-system as compared with 100% in the administrators group. This same pattern emerges for the financial sub-system with 13.5% of the respondents having knowledge of retrieval and 18.9% of utilisation of the sub-system compared with 81.8% of administrators. These results indicate to the author that information systems development tends to be associated with each health discipline rather than with the macro development of a relevant, comprehensive hospital information system. To this end a series of questions are raised and possible answers provided. Finally a model which could become a prescription for future development is presented.