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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 Nurses' work in relation to patient health outcomes: an observational study comparing models of primary care.(BioMed Central Ltd, 2024-10-04) Sheridan N; Hoare K; Carryer J; Mills J; Hewitt S; Love T; Kenealy T; Primary Care Models Study GroupBACKGROUND: Māori are over-represented in Aotearoa New Zealand morbidity and mortality statistics. Other populations with high health needs include Pacific peoples and those living with material deprivation. General practice has evolved into seven models of primary care: Traditional, Corporate, Health Care Home, Māori, Pacific, Trusts / Non-governmental organisations (Trust/NGOs) and District Health Board / Primary Care Organisations (DHB/PHO). We describe nurse work in relation to these models of care, populations with high health need and patient health outcomes. METHODS: We conducted a cross-sectional study (at 30 September 2018) of data from national datasets and practices at patient level. Six primary outcome measures were selected because they could be improved by primary care: polypharmacy (≥ 65 years), glucose control testing in adults with diabetes, immunisations (at 6 months), ambulatory sensitive hospitalisations (0-14, 45-64 years) and emergency department attendances. Analysis adjusted for patient and practice characteristics. RESULTS: Nurse clinical time, and combined nurse, nurse practitioner and general practitioner clinical time, were substantially higher in Trust/NGO, Māori, and Pacific practices than in other models. Increased patient clinical complexity was associated with more clinical input and higher scores on all outcome measures. The highest rates of preventative care by nurses (cervical screening, cardiovascular risk assessment, depression screening, glucose control testing) were in Māori, Trust/NGO and Pacific practices. There was an eightfold difference, across models of care, in percentage of depression screening undertaken by nurses and a fivefold difference in cervical screening and glucose control testing. The highest rates of nurse consultations afterhours and with unenrolled patients, improving access, were in PHO/DHB, Pacific, Trust/NGO and Māori practices. Work not attributed to nurses in the practice records meant nurse work was underestimated to an unknown degree. CONCLUSIONS: Transferring work to nurses in Traditional, Health Care Home, and Corporate practices, would release general practitioner clinical time for other work. Worse patient health outcomes were associated with higher patient need and higher clinical input. It is plausible that there is insufficient clinical input to meet the degree of patient need. More practitioner clinical time is required, especially in practices with high volumes of complex patients.Item Hauora Māori - Māori health: a right to equal outcomes in primary care.(BioMed Central Ltd, 2024-02-27) Sheridan N; Jansen RM; Harwood M; Love T; Kenealy T; Primary Care Models Study GroupBackground For more than a century, Māori have experienced poorer health than non-Māori. In 2019 an independent Tribunal found the Government had breached Te Tiriti o Waitangi by “failing to design and administer the current primary health care system to actively address persistent Māori health inequities”. Many Māori (44%) have unmet needs for primary care. Seven models of primary care were identified by the funders and the research team, including Māori-owned practices. We hypothesised patient health outcomes for Māori would differ between models of care. Methods Cross-sectional primary care data were analysed at 30 September 2018. National datasets were linked to general practices at patient level, to measure associations between practice characteristics and patient health outcomes. Primary outcomes: polypharmacy (≥ 55 years), HbA1c testing, child immunisations, ambulatory sensitive hospitalisations (0–14, 45–64 years) and emergency department attendances. Regressions include only Māori patients, across all models of care. Results A total of 660,752 Māori patients were enrolled in 924 practices with 124,854 in 65 Māori-owned practices. Māori practices had: no significant association with HbA1c testing, ambulatory sensitive hospitalisations or ED attendances, and a significant association with lower polypharmacy (3.7% points) and lower childhood immunisations (13.4% points). Māori practices had higher rates of cervical smear and cardiovascular risk assessment, lower rates of HbA1c tests, and more nurse (46%) and doctor (8%) time (FTE) with patients. The average Māori practice had 52% Māori patients compared to 12% across all practices. Māori practices enrolled a higher percentage of children and young people, five times more patients in high deprivation areas, and patients with more multimorbidity. More Māori patients lived rurally (21.5% vs 15%), with a greater distance to the nearest ED. Māori patients were more likely to be dispensed antibiotics or tramadol. Conclusions Māori practices are an expression of autonomy in the face of enduring health system failure. Apart from lower immunisation rates, health outcomes were not different from other models of care, despite patients having higher health risk profiles. Across all models, primary care need was unmet for many Māori, despite increased clinical input. Funding must support under-resourced Māori practices and ensure accountability for the health outcomes of Māori patients in all models of general practice.Item From incomer to insider: The development of the TRANSPEC model - A systematic review of the factors influencing the effective rapid and early career TRANsition to a nursing SPECiality in differing contexts of practice(Public Library of Science, 2019) Hegney D; Chamberlain D; Harvey C; Sobolewska A; Knight B; Garrahy AObjective Shortages in the speciality nursing workforce, both nationally and internationally are driving the need for the development of an evidence-based model to inform recruitment and retention into speciality nursing practice. This study aimed to identify the factors influencing rapid and early career transition into speciality nursing practice. Methods A comprehensive systematic review of the literature was undertaken using a convergent qualitative synthesis design where results from qualitative, quantitative and mixed methods studies were transformed into qualitative findings. Databases included CINAHL, Medline, Scopus and PsycINFO. Search terms were: nurse, early career, rapid career, transition, specialty, and Medical Subject Heading terms included: professional development and educational, nursing, and continuing. Using validated tools, papers were independently assessed by a minimum of two reviewers. Results Twenty-three research articles were included. There were no randomized control trials. Through thematic analysis and matrix mapping of the results, the TRANSPEC model was developed. The model outlines three phases of transition: pre-entry, incomer and insider. There has been little focus on pre-entry with programs being designed at the incomer and insider phases. Impacting on these phases are three concepts: the self (professional and personal), the transition processes (informal and formal) and a sense of belonging. The overarching theme influencing the phases and concepts is the context of practice. Enablers and inhibitors influence successful transition and therefore impact on recruitment and retention. Each nurse’s transition is influenced by time. Conclusions For successful transition, the enablers and inhibitors impacting on the three concepts, phases and the context of practice need to be considered when developing any program. It is apparent that while previous studies have focused on the transition processes, such as curricula, the development of the self and a sense of belonging are also essential to successful transition. Further studies should include the pre-entry phase.Item An investigation into the preparedness for and experiences in working with Māori nursing students among New Zealand tertiary institutes, schools and nurse educators : a thesis presented in partial fulfilment for the requirements for the degree of Doctor of Education, Massey University, Manawatū, Aotearoa New Zealand(Massey University, 2020) Roberts, JenniferNursing education in Aotearoa New Zealand is situated in a unique bicultural context. Māori, the Indigenous people of Aotearoa New Zealand have overall, poorer outcomes in health and education compared to non-Māori, which relate to the colonial legacy of the nation. One strategy to address Māori health outcomes is to increase the Māori nursing workforce. Despite a range of strategies in tertiary education and in nursing, the number of Māori nurses remains relatively static, and overall Māori nursing students do not have equity of educational outcomes in nursing. With a critical lens informed by Freire’s Pedagogy of the Oppressed, this explanatory sequential mixed method study uses a questionnaire followed by interviews to understand the experiences and preparedness of nurse educators in working with Māori nursing students. The findings of the questionnaire demonstrate that throughout New Zealand, nursing schools and the educational institutes in which they are situated are informed by a range of strategies aimed at supporting Māori learners. Overall, nurse educators felt prepared to work with Māori, but the questionnaire also revealed resistance to Māori as priority learners. This finding was followed up in the interviews. Interview findings demonstrated that environments encompassing te ao Māori (the Māori world) and staff practises that aligned with this were enabling for Māori nursing students. Despite this, a counter-narrative described many barriers to this becoming fully realised in nursing education practice. Ongoing colonising practices in education, racism, varied understandings and practices of Cultural Safety and dissatisfaction with current Cultural Safety regulatory guidelines were found to be hindering a nursing culture that is responsive to Māori. The research posits that the nursing profession needs to develop a shared critical consciousness and refocus efforts to position Cultural Safety as a critical concept in nursing education and practice. One method proposed to achieve this is in returning to the original intent of Kawa Whakaruruhau/ Cultural Safety and begin to apply it as a decolonising model for nursing education and practice.Item Insight into adult epilepsy care in New Zealand : an exploration of the nurses' role and care they provide for adults with epilepsy : a thesis presented in partial fulfilment of the requirements for the degree of Masters of Philosophy in Nursing at Massey University, Wellington, New Zealand(Massey University, 2018) McCarthy, KinukoEpilepsy is one of the most common neurological disorders that has an on-going tendency for reoccurring seizures. It is estimated to affect between 20,000 and 28,000 people in New Zealand (Bergin, Sadleir, & Walker, 2008). Epilepsy care includes not only giving treatment but also providing continuous support to people with epilepsy (PWE). Nurses have the potential to play a significant role in epilepsy care by providing education and support to PWE and their families. Through my working experience as an Epilepsy Speciality Clinical Nurse, I recognised issues in epilepsy care and I found out that there have been no studies in New Zealand relating to a nurse’s role and care of PWE. This is why I decided to undertake study of and exploration of the nurses’ role and care they provide for PWE. Grounded theory methodology was adopted to explore adult epilepsy care by interviewing nurses who provide care to PWE. Data was collected using semi-structured interviews by telephone, Skype, or face-to-face from the nurses. The data was analysed by open coding, development of categories, and theoretical coding. During this process, the epilepsy care pathway and the negative cycle of epilepsy diagrams were developed. At the end of the analysis two theories ‘Epilepsy care in New Zealand is far from ideal due to the lack of guidelines for nursing practice’ and ‘If the profile of epilepsy nursing is raised in New Zealand, delivery of the epilepsy care would improve’ were developed. The findings are discussed in relation to these two theories and consequently four recommendations: creating guidelines, building epilepsy nurses’ network, promoting more research on epilepsy nurses’ role and their value in epilepsy care, and increase utilisation of digital technologies, were made to improve the delivery of epilepsy care in New Zealand.Item Nursing practice in a hospital context : the subjective experiences of four female nurses : a thesis presented in partial fulfilment of the requirements for the degree Master of Arts in nursing at Massey University(Massey University, 1989) Goffe, RobynThis thesis focuses on the practice of four female registered nurses in a hospital context. It examines the degree of control these nurses feel they have over what they do and how they practice. The influence of other members of the health team on that practice is explored. Socialist feminist theory has provided the framework and feminist research the methodology for the investigation of female nurses' perceptions of their work and the forces that shape and control the practise of nursing at present. That the structure within which nurses work constrains their practice is demonstrated in this study. It is however the structure of the nursing profession and the relations between nurses which is seen to have the most impact on nursing practice.Item Theory and practice in the induction of five graduate nurses : a reflexive critique : a thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Education at Massey University(Massey University, 1985) Perry, JudithThis thesis investigates the induction of comprehensive nurses into a professional culture during their polytechnic nursing education and first year of hospital practice. It combines a critical theory approach with case study method. The ways in which social forces constrain individual and professional action are demonstrated through a critical reflexive analysis of the perceptions of five recently graduated comprehensive nurses. Each graduate was interviewed at regular intervals over a three month period. It is argued that previous studies of professional socialisation of nurses conducted within both empirico-analytic and interpretive epistemologies, have tended to objectify the day-to-day actions that students and new graduates take. While providing descriptions of the socialisation process, previous studies have not explored the reflexivity of understanding and action as well as the structural constraints of nursing education and practice. In this thesis critical social theory provides a framework in which to reveal, through empirical research, the constraining conditions of actions, and, through interpretive forms of enquiry, human perception and understanding. The reflections of the five participants in this study reveal that there are similar structural constraints in education as in hospital based nursing practice. There is, in effect, a continuity of structural constraints and this is contrasted with a disjunction between knowledge and beliefs gained through education and those apparently required in nursing practice. The graduates' perceptions are discussed and interpreted in terms of both the intended and the unintended learning states engendered by their actual experiences in the polytechnic and hospital settings. It is suggested that, at present, nursing education and practice are shaped by forms of technical control which arise from the dominant ideologies already embedded in the education and health care structures. In particular, nursing curricula are dominated by the technical linear paradigm of curriculum design which contributes to a distorted separation of theory and practice and which obscures the process of reproduction of professional culture. It is argued that a more socially critical approach to the design of nursing curricula might begin to transform some of the structures which presently inhibit and constrain the professional choices and actions of student and graduate nurses.Item Time perspectives in nursing practice : a thesis ... for the degree of Master of Arts in Nursing Studies at Massey University(Massey University, 1982) Hamilton, CharmaineThis study examines the relationship between the concepts of time and nursing practice. This study was designed to: - ascertain which of the two time perspectives best represented the view of time held by a selected group of nurses - generate data which would give an indication of the way in which these nurses view time in its totality - examine the relationship between cyclic and linear time and six selected job components common to all nursing practice Data was obtained from 346 nurses employed in two hospitals and a maternity annex using a self report questionnaire. The items in the questionnaire were developed to examine nurses' perception of time in a free choice situation, their perception of cyclic and linear time in a forced choice situation and their perception of time as it related to six components of their work. The results indicate that: nurses in this study did not view the concepts of cyclic and linear time as mutually exclusive entities. At the time of this study approximately two thirds of subjects viewed time as predominantly linear and the remaining third viewed time as predominantly cyclic. Nurses in the more senior employment categories are more likely to have a linear view of time than those in the more junior employment categories. This is supported by the result indicating that a greater percentage of nurses within senior employment categories selected the diagram representing the concept of linear time, than those in the more junior categories. It is also supported by results indicating that while nurses in all employment categories perceived their work as involving some routine duties and that established procedures exist as a basis for practice, nurses in the more senior employment categories perceived their work as involving a greater degree of forward planning and decision making than those in the more junior employment categories. 13.68% of the total population of two hospitals could not define clearly their personal definition of the word 'time'. 23.44% of respondents viewed time as a unit of measure, while 12.06% saw it in terms of its availability and a further 12.06% related it to the concepts of life and existence.Item The social context and the relevancy of nursing curricula : a thesis ... for the degree of M.A. (Soc. Sc.) in Nursing at Massey University(Massey University, 1981) Idour, Margaret GladysA study based on a perception of nursing as a socially prescribed service, initiated and developed to assist a society to care for members with some inability to maintain self-care. It is argued that, to fulfil its purpose, nursing has an ongoing need to identify and adapt to the changing social realities of a society. 'Social realities' have been defined as the actual conditions, pressures, disabilities and abilities, limitations and resources that exist in the lifespace of people and form the environment within which nursing practises. A system approach was adopted since it provides for the identification as well as the solution of problems. As a first step a theoretical framework, the 'triadic nursing model' was developed to delineate the key issues nursing has to contend with in contemporary societies. Next, from the operative component of the triadic nursing model an educational tool, with a system approach, named the 'curriculum relevancy process' (CRT) was developed. CRP, defined as an information-seeking, problem solving, and evaluative process, has three phases. Only the first or information-seeking phase of CRP has been activated, and, moreover, further elaborated to form an information system or process. Two main activities were undertaken to gain information about contemporary social realities and resultant disorders. To define the social context in which nursing practises an examination was made of: - dominant trends and problems; - the effects of contemporary social realities on social institutions, particularly the family; - changing patterns of ill-health; - the management of technology; and the clarification of values in an age of degenerative and man-made disease. From this review it was noted that major issues of today included the problems of rapid and persistent change, and its effects on social institutions and individuals. As well, diseases associated with increasing urbanisation, industrial and technological developments, mobile populations, and the hazards of pollution were found to be prominent. The rapidly escalating costs of health care was also emphasised, and the need to clarify values in order to make optimal choices in the use of available resources. The need for individuals, groups, and societies to have their self-care abilities promoted was also stressed. The second, and more specific activity, was the use of the information system to focus on the social context in which nursing functions in NZ. For this purpose, information was sought from both voluntary and official sources. The need for broader information about a society's socio-health and nursing needs and problems has been stressed as a basic requirement for maximizing curricular choices. Particular emphasis has been given to the collection of information from the 'mass media' since it provides perceptions of socio-health needs closer to the grass-roots of society. Characteristics of data collected from the mass media showed that 33% of items were related to specific health problems. Problems of most concern were alcoholism, mental ill-health, inadequate health care knowledge, chronic disorders associated with genetic, pathological, and traumatic incidents, drug addiction, and increasing sexually transmitted disease. Twenty-six percent of items related to family issues including delinquency in children and adolescents, stress due to psychosocio-economic issues, children-at-risk through abuse, accidents, and marital issues, assaults in the family, and stress due to weakened kinship ties and communication problems. Twenty-eight and one half % of items affected the community in general. Over 52% of this class related to some concern about inadequate and/or inappropriate health services. Alienation, reduced social exchange, particularly for the elderly, and suicide incidents were also of considerable concern. Twelve and one half % of items dealt with environmental problems such as exploitation of natural resources, industrial/technological hazards, traffic congestion and accidents. Based on the priority of socio-health needs shown above relevant curricula for NZ nurses would be concerned with: - the degenerative disorders of an ageing population in an increasingly industrial society; - behavioural disorders such as alcoholism, drug dependency, smoking, wrong dietary habits, and trauma associated with behavioural and other 'life-style disease; - the problems of the basic social unit, the family; - the care of the frail elderly; the physically/mentally disabled (genetic and pathological). - and the changing social patterns of relationships. For the consumers of nursing curricula - clients, students, and society-one implication drawn is that there is urgent need to increase the level of responsibility for health care. And amongst the recommendations it is stressed that, as the use of the 'self' in relating to and caring for others is so vital, the development of good interpersonal skills is essential.