Abstract: As carers of patients who are clinical research participants, nurses' contribution to the success of clinical trials is acknowledged in the literature. Ethical dilemmas and challenges that clinical trials may present for nurses are also recognised. Although there is some discussion regarding these issues, few studies explore and identify the perceptions of intensive care nurses regarding clinical trials and how they may impact on nursing practice. This thesis explores and describes the viewpoints and experiences of sixty intensive care nurses from a tertiary level referral centre in New Zealand engaged in clinical research activities. The descriptive study utilised a self-administered questionnaire to gather information regarding nurses' roles in clinical trials, associated issues encountered and contributory factors, and the impact of issues on nursing practice, stress and satisfaction levels. Suggestions for potential strategies to minimise the impact of issues on nurses' practice were also sought. Descriptive statistical and content data analyses identified three key areas in which nurses' encounter issues associated with clinical trials and their practice: nurses' workload; ethical concerns; educational preparation and support. The findings indicate that, when issues exist in these areas, routine patient care can be delayed, the enactment of nurses' patient advocacy role can be affected, and nurses' stress and satisfaction levels can be negatively impacted upon. The perceptions of a group of intensive care nurses who are enveloped in the daily balance of patient care, the need for clinical research, and their professional obligations are discussed in this thesis. While the study's findings are reflective of one group of nurses in a distinct practice setting, their experiences can prompt other nurses, research teams and clinical leaders to reflect upon their own clinical research environment.

Abstract: Good nutrition is essential following acute spinal cord injury. Poor nutrition can lead to the deleterious effects of protein-calorie induced hypermetabolism and poor functional and rehabilitation outcomes. Nutritional management for patients with acute cervical or high thoracic spinal cord injury admitted to the Canterbury District Health Board's Burwood Spinal Unit and Christchurch Hospital's Department of Intensive Care Medicine (CHDICM) differ. The Burwood Spinal Unit has a delayed approach to nutritional management in contrast to the implementation of early enteral feeding by CHDICM. This prompted a literature review to critically consider the evidence underpinning clinical practice in this field. Literature revealed that nutritional management in the first 72 hours after spinal cord injury is a complex process. The complexities of when to commence, the method of delivering, and the target dose of enteral nutrition in the first 72 hours after spinal cord injury are due to the perceived risk of a spinal ileus and the ensuing, such as adverse effects on abdominal and respiratory function, resulting from enteral feeding intolerance. Literature revealed that delayed nutrition is largely based on expert opinion, while early enteral feeding has limited but stronger scientific research evidence. Nevertheless, it is desirable to use the best evidence currently available to develop, implement and evaluate an evidence-based, protocol driven, clinical pathway for nutritional management of patients within 72 hours of an acute cervical or high thoracic SCI. The author concludes that to ensure an acute spinal cord injury clinical pathway is based on scientific evidence, prospective, multi-centre, randomised controlled trials are needed to substantiate early enteral feeding and identification of the degree of and risk of complications from spinal ileus after acute cervical or high thoracic spinal cord injury.

Abstract: The author's art project “Posthuman Pathology” is a postmodern examination of the resolutely modernist culture of critical care medicine. She uses conceptual art practices in conjunction with the techniques of anti-aesthetics in order to dismantle, open out and critique ideas which are foundational to the culture of critical care.

Abstract: The author presents research on nursing strategies that reduce the psychological effects of critical illness and prevent the intensive care unit (ICU) atmosphere from adversely affecting the nurse-patient relationship. Post-traumatic stress disorder and other phobic anxiety syndromes are noted as a risk among former ICU patients. Four interventions to put in place for discharge are presented: patient-centred nursing, communication, multidisciplinary care, and patient/family education.

Abstract: The aim of this research is to provide an analysis of the scope of nursing practice and inter-professional role responsibility for ventilatory decision-making in Australian and New Zealand intensive care units (ICU). Self-administered questionnaires were sent to nurse managers of eligible ICUs within Australia and New Zealand. Survey responses were available from 54/180 ICUs. The majority (71%) were located within metropolitan areas and categorised as a tertiary level ICU (50%). The mean number of nurses employed per ICU bed was 4.7 in Australia and 4.2 in New Zealand, with 69% (IQR: 47-80%) of nurses holding a postgraduate specialty qualification. All units reported a 1:1 nurse-to-patient ratio for ventilated patients with 71% reporting a 1:2 nurse-to-patient ratio for non- ventilated patients. Key ventilator decisions, including assessment of weaning and extubation readiness, were reported as predominantly made by nurses and doctors in collaboration. Overall, nurses described high levels of autonomy and influence in ventilator decision-making. Decisions to change ventilator settings, including FiO(2) (91%, 95% CI: 80-97), ventilator rate (65%, 95% CI: 51-77) and pressure support adjustment (57%, 95% CI: 43-71), were made independently by nurses. The authors conclude that the results of the survey suggest that, within the Australian and New Zealand context, nurses participate actively in ventilation and weaning decisions. In addition, they suggest, the results support an association between the education profile and skill-mix of nurses and the level of collaborative practice in ICU.

Abstract: This study is an extension of a previous study by Riker, Picard and Fraser (1999) to determine whether doctors and nurses rate patients similarly using the Sedation-Agitation Scale (SAS) in a natural Intensive Care Units (ICU) setting. The author notes that it is essential to establish whether these different professionals provide consistent scores and have a mutual understanding of the SAS and its constituent levels. This will help ensure that clinical decisions relating to sedation-needs can be made appropriately and consistently. This quasi-experimental reliability study was set in a 12-bed tertiary general ICU in New Zealand. The SAS had recently been introduced into this unit and a convenience sample of 42 nursing and medical staff performed paired ratings on 69 randomly selected adult ICU patients over an eight week time frame. The mean patient age was 58 years, and 79% of patients were on continuous infusions of Propofol. Intubated patients made up 91% of the sample. 74% of patients were given the same SAS score by the doctor-nurse pair. The weighted kappa score for inter-rater agreement was 0.82 indicating very good agreement. Of the 26% of scores where there was a difference, the two readings were only one score apart. Most of the difference occurred around SAS scores of 1-2 and 3-4. Further analysis found no staff or patient variables to be statistically significant in impacting on the ratings. The SAS was found to be a reliable sedation-scoring tool in a general ICU when used by nurses and doctors of varying experience.