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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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    Nurse practitioners in rural primary health care in New Zealand : an institutional ethnography : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing, Massey University, Albany, New Zealand
    (Massey University, 2017) Adams, Sue
    Nurse practitioners are an effective and appropriate health workforce for delivering health services to underserved and rural populations. Since 2001, New Zealand has been registering nurse practitioners through a robust educational, regulatory, and legislative framework, and from 2014, all nurse practitioners are authorised prescribers. However, the numbers of nurse practitioners working in rural primary health care have been slow to materialise. Despite an ageing demographic, the increasing prevalence of long term conditions, ongoing health inequalities, and a declining rural medical workforce, there remains a persistence to pursue the general practitioner-led model of care. The purpose of this study was to critically examine the work required to establish nurse practitioner services in rural primary health care in New Zealand. Institutional ethnography, developed by Dorothy Smith, provided the overall approach to the inquiry. The activities and experiences of people in local settings are textually organised by the institutional ruling relations. This inquiry explored the work and experiences that nurses undertook on their journey to become nurse practitioners and deliver services in rural primary health care, and how these were institutionally shaped and coordinated. Interviews were initially conducted with nurse practitioners and nurse practitioner candidates as the primary informants. The interviews were analysed using a mapping technique to identify text-based work processes and show connections, tensions, and contradictions with authoritative or ruling texts. Further data was collected through secondary informant interviews and the tracing and identification of texts. The findings revealed that there were multiple texts and discourses being enacted locally, which facilitated or hampered their work to become nurse practitioners. The ongoing institutional domination of medicine retained general practitioner-led primary care, despite policy and nursing professional texts that promoted social justice. Service fragmentation and frequent changes in policy, structure, and management of organisations at local and national level, resulted in further challenges and work processes by the nurse practitioners to maintain and implement services. Together with the lack of a cohesive national policy and implementation framework for nurse practitioners, the opportunity for nurse practitioners to meet the health needs of the rural population of New Zealand continues to be discounted.
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    The effect of pre-information on clinical inference and nursing actions : a thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Psychology at Massey University
    (Massey University, 1979) McIntosh, Muriel Joan
    A study to examine the effects of pre-information (what a nurse learns about a patient before they meet) on clinical inference and nursing actions, in a simulated nurse-patient situation. It was hypothesised that the nature of the pre-information will influence the way the patient is perceived, and the resulting nursing actions. The research was conducted in an obstetrical setting. There were 55 subjects within three groups. Two groups comprised student midwives, and the third group was of second year comprehensive nursing students near the completion of clinical experience in maternal and child health nursing. A five minute videotape sequence of a role-played post-natal patient was made for use in the research. All subjects were given the same initial pre-information, viewed the videotape and gave written descriptions of what they saw on the videotape and their response (as the nurse in the situation). This data provided a base-line for each subject. Subjects were then given additional pre-information concerning the patient's physical condition, her baby's condition, or formed part of the control group (receiving no additional pre-information). The procedure was repeated. These responses were then compared with the base-line for each subject. Responses were coded by means of content analysis. Group data was analysed using a multivariate one way analysis of variance graphical display. The results indicated support of the hypothesis that the nature of the pre-information does influence the way in which a nurse perceives a patient, and resulting nursing actions. Implications of these findings for nursing are discussed.
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    Lived experiences of nurses as they engage in practice at an advanced level within emergency departments in New Zealand : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Human Social Science (Nursing) at Massey University
    (Massey University, 2005) Davies, Mark
    At this present time New Zealand has seventeen Nurse Practitioners™ none of whom work in the emergency setting; nonetheless emergency nurses throughout New Zealand are practising at an advanced level in departments nationwide. The aim of this research project was to examine the lived experiences of five nurses as they prepare for, and engage in practice at an advanced level within emergency departments in New Zealand. The theoretical framework for this project was one of phenomenological enquiry based on a synthesis of Husserlian and Heideggerian philosophy. Following a form of purposive sampling to select participants, unstructured in-depth interviews were used as the method of choice for data collection. The concept of data horizontalisation integrated within Colaizzi's (1979) procedural steps for data examination guided the analysis and findings of this work. Descriptions of the participants lived experiences, underpinned by Husserlian principals, identified eight subjects that were explored in-depth from their perspective. This was followed by further analysis, interpretation and discussion of the phenomenon under review from the researcher's perspective; guided by the fundamental elements of the Heideggerian approach to enquiry. The results show that there are numerous similarities to be had in common with our colleagues overseas in relation to the many issues that impact on nurses working in or toward advanced practice within emergency departments here in New Zealand. However there also exist issues that are unique to the New Zealand context and as such have the potential to impact either positively of negatively on the development of the advanced nursing role in this country, such as the Health Practitioners Competency Assurance (HPCA) Act 2003 and other legislation that relate either directly or indirectly to the scope of practice for advanced practitioners, whatever their area of expertise. The research process identified several concepts that require further debate and discussion; from which knowledge can be gained that will either add to or augment the body of knowledge that is required for the advancement of nursing practice within emergency departments here in New Zealand.
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    Practice nurses' perceptions of their contribution to the care of individuals with chronic health conditions : an exploratory descriptive study : a thesis submitted in partial fulfilment of the requirements for the degree of Master of Philosophy in Nursing at Massey University
    (Massey University, 2006) Davies, Deborah C
    The release of the New Zealand Primary Health Care (PHC) Strategy (King, 2001), placed an increased emphasis on the provision of healthcare in the community or primary health care setting, and in particular on the role of PHC nursing. Alongside this, new roles are being created which practice nurses are expected to fulfil such as 'Care Plus', which is an initiative of the PHC strategy providing funding for increased care of people with high needs due to chronic conditions or terminal illness. Practice nurses are health care providers in general practice settings, and it is assumed that they make a significant contribution to the health of individuals with chronic conditions. In this study an exploratory descriptive approach was used to explore practice nurses' perceptions of their contribution to the care of individuals with chronic conditions. The total number of participants was eleven. Thematic content analysis was used to develop themes from the data. Overall practice nurses described three key areas of contribution: The preparation of the individual for an appointment at the general practice, care provided by the practice nurse at the general practice, and the giving of information. Each theme consisted of a considerable level of complex processes employed by the practice nurses, with all being inextricably interwoven within the care. A number of dualities were apparent that impact on the contribution practice nurses perceive they make to individuals with chronic conditions, within the reality of their practice contexts. The systems within which the practice nurse participants described working posed certain challenges to the fulfilment of the role of registered nurse. Recommendations include the significance of the development and maintenance of nurse-client relationships, achieving a balance between the organisation provided by computerised systems and client centred care, and the concept of adequate time for interactions with individuals. Recommendations regarding nursing's role in acknowledgment of the individual as an active participant in care, the recognition of an individual's right of choice regarding ongoing contact with the general practice, and a need to recognise a focus of care as support of client self-management also arise from this study.
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    Saving lives and changing dirty nappies : illuminating nursing in the neonatal nurse practitioner role : the New Zealand experience : a thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Nursing at Massey University
    (Massey University, 2000) Jones, Bronwyn
    In New Zealand Neonatal Nurse Practitioners (NNPs) have been practicing in an advanced nursing role since 1994. The nature of expert nursing makes it difficult for NNPs to articulate the nursing component of the NNP role. It is essential that the expert nursing component of the NNP role be documented to maintain the role within the culture of nursing. Aim: The aim of this thesis was to explore and describe how expert nursing is incorporated in the NNP role, in the New Zealand context. Method: An explorative design, using multiple data collection methods, was used. These methods included questionnaires, interviews, journal-keeping (journalling), and analysis of written data. All NNPs in current practice were sent questionnaires (n=18) and a purposive sample of 5 NNPs agreed to be interviewed and keep journals. Standing orders, job descriptions and other written data from each of the three neonatal services that employ NNPs was compared and analysed. Results: Fifteen NNPs (83.3%) responded to the questionnaires. Results showed that NNPs tend toward a nursing identity, but see themselves as sitting between nursing and medicine. Professional issues were important to the NNPs. There was some ambivalence toward the NNPs leadership role in the questionnaire results, but interview and journal data showed the NNPs performing a multifaceted leadership role. Neonatal Nurse Practitioners are committed to post-graduate education, with a tendency toward preferring that to be in a nursing school with access to medical resources. The qualitative data revealed six themes derived from practice. They were 'a consciousness of baby', 'orientation to family', 'uniqueness of NNP care', 'leadership', 'culture of nursing' and 'NNP experience of advanced practice'. Expert nursing was embedded in the clinical themes and implicated in the professional themes of NNP practice. Conclusions: Expert nursing is inherent in the practice of the NNP role in New Zealand. Neonatal Nurse Practitioners practice in a unique role in the care of sick babies, incorporating medical skills with nursing philosophy and expertise. Education needs to address some of the issues of nursing in this advanced practice role. There is a need for institutional support for the NNP role. The NNP group needs to develop as a support and educational network.
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    The nurse practitioner-led primary health care clinic : a community needs analysis : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Nursing at Massey University
    (Massey University, 1999) Clendon, Jill
    Aim. To determine the feasibility of establishing a nurse practitioner-led, family focused, primary health care clinic within a primary school environment as an alternate or complementary way of addressing the health needs of 'at risk' children and families to the services already provided by public health nurses. Method. Utilising needs analysis method, data was collected from three sources - known demographic data, 17 key informant interviews and two focus group interviews. Questions were asked regarding the health needs of the community, the perceptions of participants regarding the role of the public health nurse in order to determine if a public health nurse would be the most appropriate person to lead a primary health care clinic, and the practicalities of establishing a clinic including the services participants would expect a clinic to provide. Analysis was descriptive and exploratory. Results. A wide range of health needs were identified from both the demographic data and from participant interviews. Findings also showed that participants' understanding of the role of the public health nurse was not great and that community expectations were such that for a public health nurse to lead a primary health care clinic further skills would be required. Outcomes from investigating the practicalities of establishing a nurse practitioner-led clinic resulted in the preparation of a community-developed model that would serve to address the health needs of children and families in the area the study was undertaken. Conclusion. Overall findings indicated that the establishment of a nurse practitionerled, family focused, primary health care clinic in a primary school environment is feasible. While a public health nurse may fulfil the role of the nurse practitioner, it was established that preparation to an advanced level of practice would be required. It is likely that a similar model would also be successful in other communities in New Zealand, however the health needs identified in this study are specific to the community studied. Further community needs assessments would need to be completed to ensure health services target health needs specific to the communities involved.
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    Nurse practitioner diagnostic reasoning : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University, New Zealand
    (Massey University, 2013) Pirret, Alison Margaret
    Introduction: Nurse practitioners were introduced to increase patients’ access to healthcare, improve patient outcomes, and provide a sustainable solution to ongoing workforce shortages. They provide a diagnostic role previously delivered by doctors, however, their ability to perform this role has been challenged. Methodology: The study used a post-positivist mixed methods convergent parallel design to explore nurse practitioner diagnostic reasoning and compare it to that of registrars. Methods included a complex case scenario using think aloud protocol to determine diagnostic abilities, including identifying correct diagnoses, problems and actions; a previously validated intuitive/analytic reasoning instrument to identify diagnostic reasoning style; a maxims questionnaire to identify maxims used to guide diagnostic reasoning; and a demographic data sheet to identify variables influencing the results of the former. The study included 30 nurse practitioners and 16 registrars. An expert panel determined the correct diagnoses/problems and actions for the case scenario using a Delphi technique. Registrar data provided normative data and norm-referenced testing compared the nurse practitioner data to the normative data. Results: Nurse practitioners identified a mean of 10.30 (range=4-17, Mdn=10, mode=9, SD=3.09) correct diagnoses, problem and action items as identified by the expert panel whereas registrars identified a mean of 10.88 (range=6-21, Mdn=10, SD=3.88); there was no statistically significant difference between the two groups (U=238.5, z=-.04, p=.97). Nurse practitioners’ diagnostic reasoning reflected an analytic-intuitive style whereas registrars reflected an analytic style, however, this difference was not statistically significant, t(44)=1.91, p=.06. Diagnostic reasoning style was not related to diagnostic reasoning abilities in either the nurse practitioner (rs=-.14, n=30, p=.46) or registrar (rs=.03, n=16, p=.90) groups. There was no difference in how nurse practitioners and registrars employ maxims to guide their diagnostic reasoning, t(44)=-.89, p=.38. Maxims used to guide diagnostic reasoning were not related to diagnostic reasoning abilities in either the nurse practitioner (r=-.17, n=30, p=.37) or registrar (rs=-.08, n=16, p=.77) groups. Conclusion: Nurse practitioners’ diagnostic reasoning, although incorporating more System I processes than registrars, does not differ from that of registrars. This supports the nurse practitioner role as a sustainable solution firstly, to effectively meet the health needs of the New Zealand population and secondly, to address workforce shortages.