Abstract: This article explores the role of the registered nurse (RN) in the critical care environment. It presents the Intensive Care Unit (ICU) as a unique environment, with a specific relationship to technology, and a history that mirrors scientific development. It explores the tensions for a caring profession with a distinct culture practising in a highly medicalised, acute environment, and affirms the value of quality human care.

Abstract: Grounded theory methodology has guided the grounded theory methods used to explore the acute care paediatric nurses' perspective of what they do when a child has had a severe accident. The research was initiated from the experience of nursing children in the context of a rehabilitation centre and wondering how acute care nurses promoted a child's recovery after a severe unintentional injury. Many avenues were used to search international and New Zealand literature but the scarcity of literature related to what acute care paediatric nurses do was evident. Nursing children in the acute care ward after a severe accident is complex. It encompasses nursing the family when they are experiencing a crisis. It is critical that the acute care nurse monitors and ensures the child's physiological needs are met, and the nurse “works with” the child to maintain and advance medical stability. Nursing interactions are an important part of “working with”, communication is the essence of nursing. This research has focussed on the nurses' social processes whilst caring for the physical needs of the child and interacting with the family and multidisciplinary team when appropriate. An effective working-relationship with a nurse and family is founded on trust. Grounded theory methods supported the process of exploring the social processes of “building trust” whilst “working with” families in a vulnerable position. Nurses rely on rapport to be invited into a family's space to “work with” and support the re-establishment of the parenting role. The “stepping in and out” of an effective working-relationship with a family is reliant on trust. Nurses build trust by spending time to “be with”, using chat to get to know each other, involving and supporting the family to parent a “different” child and reassuring and giving realistic hope to help the child and parents cope with their changed future. A substantive theory of the concept of “building trust to work with” has been developed using grounded theory methods. The theory has been conceptualised using the perspective of seven registered nurses working in paediatric acute care wards that admit children who have had a severe traumatic accident.

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 draws on her experience as the 'Paediatric Link Nurse' in an Intensive Care Unit (ICU) within a metropolitan area in New Zealand to examine the proposed changes to ventilation practice. Currently, due to ventilator availability and medical and nursing practice, the usual mode of mechanical ventilation is volume-limited with pressure breath triggering. The author suggests this mode can compromise effective ventilation of paediatric patients, due to air leaks around the uncuffed endotracheal tubes of infants and small children. This air leak makes a guaranteed tidal volume almost impossible and can cause ventilator breath stacking and volutrauma. This can impact on the patient's comfort, sedation requirements and airway security, and affects how these patients are nursed. Thus the ventilation of these paediatric patients by the current volume-limiting mode may be not always be optimal for the infant/child. A new ventilator will be available to the unit, with a pressure-controlled, flow breath-triggering mode available. The author critiques the possibility of using this mode of ventilation, suggesting how this will impact on nursing practice in ICU, and of the education and knowledge that will be required. She suggests this change to ventilation practice may improve comfort and safety for the intubated child/infant, through the delivery of an optimal mode of ventilation.

Abstract: Making the transition to an area of specialist nursing practice is challenging for both the learner and staff who are responsible for education and skill development. This study uses grounded theory methodology to explore the question: “How do nurses learn critical care nursing?” The eight registered nurses who participated in this study were recruited from a range of intensive care settings. The criteria for inclusion in the study included the participant having attained competency within the critical care setting. Data was collected from individual interviews. This study found that nurses focus on two main areas during their orientation and induction into critical care nursing practice. These are learning to do (skill acquisition) and learning to be (professional socialisation). The process of transition involves two stages: that of learning to do the tasks related to critical care nursing practice, and the ongoing development of competence and confidence in practice ability. The relationship of the learner with the critical care team is a vital part of the transition to competency within the specialist area. This study identifies factors that influence the learner during transition and also provides an understanding of the strategies used by the learners to attain competency. These findings are applicable to educators and leaders responsible for the education and ongoing learning of nurses within critical care practice. The use of strategies such as simulated learning and repetition are significant in skill acquisition. However attention must also be paid to issues that influence the professional socialisation process, such as the quality of preceptor input during orientation and the use of ongoing mentoring of the learner.