Abstract: This study investigates the way that medical, nursing and institutional discourses construct knowledge in the specific context of Not-for-resuscitation (NFR)in a New Zealand general hospital where NFR guidelines are available in the wards and from the regional ethics committee. The thesis argues that there are ranges of techniques that staff use to construct NFR knowledge, enacted through various forms of speech and silence, which result in orderly and disorderly experiences for patients nearing death. The study was conducted through a critical analysis of the talk of health professionals and the Chairperson of the Regional Ethics Committee.

Abstract: This dissertation reports on a scholarly journey to better understand the processes of clinical decision-making by nurses. It begins by identifying the various terms used to describe a clinical decision, its components and the contexts within which clinical decisions are made. Two philosophies of decision-making are summarised. Some insight into the history of the phenomenological and the rationalist theories of decision-making is offered. The author notes that it became evident that both of these theories are applicable to all nurses and their clinical decision making competencies. Four studies that were undertaken to analyse the decision-making methods of nurse practitioners are critiqued. Of the studies two are British, one is American and one is Australian. The author has summarised the combined findings that identified that the nurses were using a blend of decision-making processes that involved rational decision making as well as the use of intuition. The studies identified that sound clinical decision-making is determined by appropriate educational and clinical preparation and supported by a formal mentoring process and the use of critical reflective practice. In conclusion, the author reflects on her knowledge of decision making prior to embarking on the dissertation and states her intent to facilitate and support advanced decision-making by her colleagues. She goes on to say that uppermost is the need for an institutional and managerial environment that encourages advanced and independent decision-making by nurses.

Abstract: The transition of patients from intensive care to the ward environment is a regular occurrence in intensive care. Today patients are often transferred earlier and sicker due to the demands for intensive care beds. This results in patients with higher acuity being cared for in the wards. Here ward nurses have to meet the ongoing complex demands of caring for higher acuity patients, alongside managing high patient-to-nurse ratios, staffing concerns, and varying levels of experienced nurses. This research explored the experiences of ward nurses receiving patients transferred from intensive care. The aims were to identify any areas of concern, highlight specific problems that occur on transition and to address what information is pertinent to ward nurses when receiving patients from intensive care. A qualitative descriptive methodology using focus groups was utilised to gather information about these experiences. Three focus groups were held with ward nurses from various wards within the study setting hospital. All participants had considerable contact with intensive care and were familiar with the processes of transferring patients. Five themes emerged from the focus groups – Patients as intensive care staff say they are; Time to prepare the biggest thing; Documentation as a continuation of patient care; They forget what its like; and Families, a need to know about them. The theme Patients as intensive care staff say they are relates to reliable information sharing focused on the patient, their needs and condition. Participants expressed their concern that patients were not always in the condition that the intensive care staff stated they were on the referral. Having adequate time to prepare was considered important for the majority of ward nurses receiving patients from intensive care. Documentation was highlighted in the theme Documentation as a continuation of patient care particularly in relation to fluid balances and vital sign history. The theme They forget what its like suggests there is a perception that intensive care nurses have a lack of understanding of what the ward staff can actually manage. Decreased staffing levels during certain shift patterns and a lack of appropriately experienced staff on the wards is a common concern for ward nurses. Ward nurses also recognised that caring for families was part of their role. Patients and families may respond differently to the transfer process and their inclusion in transfer planning was seen as essential. Communication was a reoccurring element throughout all themes.The author concludes that communication is the paramount factor that impacts on a 'smooth transition' for ward nurses. A 'smooth transition' refers to the transfer of patients from intensive care to the next level of care. Subsequently, nurses' perceptions need to change, whereby transfer planning from ICU should be the focus rather than discharge planning. Transfer planning and education for all nursing staff is vital if the transfer process is to be improved. Consequently, transitional care within the context of ICU aims to ensure minimal disruption and optimal continuity of care for the patient. The knowledge gained from this research may provide better understanding of the multifaceted issues linked with transitional care that may be adapted for a wider range of patients in various clinical environments.

Abstract: The aim of this research paper is to explore the processes of clinical decision-making in relation to emergency nurses and to examine the educational requirements for the development of clinical decision-making skills. Clinical decision-making is foundational to professional nursing practice. It is the expectation of the profession and the organisations in which nurses work that appropriate clinical decision-making will occur. Patients also rightly expect, when being cared for by nurses, that the clinical decisions pertaining to their care will be optimal.

Abstract: The aim of this study was to test the hypothesis that triaging certain emergency department patients through a rapid assessment clinic (RAC) improves the waiting times, and times in the department, for all patients presenting to the emergency department. For ten weeks an additional nurse and doctor were rostered. On the odd weeks, these two staff ran a RAC and on even weeks, they did not, but simply joined the other medical and nursing staff, managing patients in the traditional way. During the five weeks of the RAC clinic a total of 2263 patients attended the emergency department, and 361 of these were referred to the RAC clinic. During the five control weeks a total of 2204 patients attended the emergency department. There was no significant difference in the distribution across triage categories between the RAC and non-RAC periods. The researchers found that the rapid management of patients with problems which do not require prolonged assessment or decision making, is beneficial not only to those patients, but also to other patients sharing the same, limited resources.

Abstract: The objective of this paper is to outline a study firstly, assessing ICU nurses' ability in articulating respiratory physiology to provide rationale for their clinical decision-making and secondly, the barriers that limit the articulation of this knowledge. Using an evaluation methodology, multiple methods were employed to collect data from 27 ICU nurses who had completed an ICU education programme and were working in one of two tertiary ICUs in New Zealand. Quantitative analysis showed that nurses articulated a low to medium level of knowledge of respiratory physiology. Thematic analysis identified the barriers limiting this use of respiratory physiology as being inadequate coverage of concepts in some ICU programmes; limited discussion of concepts in clinical practice; lack of clinical support; lack of individual professional responsibility; nurses' high reliance on intuitive knowledge; lack of collaborative practice; availability of medical expertise; and the limitations of clinical guidelines and protocols. These issues need to be addressed if nurses' articulation of respiratory physiology to provide rationale for their clinical decision-making is to be improved.