Abstract: Explains the need for nurse-led Patient-at-Risk-Teams(PART) to prevent unnecessary ICU admissions. Investigates which nurse allocation policy between PART and ICU would result in the best outcomes for patients and hospitals. Provides econometric models to estimate the impact of critical care nurses on hospital length of stay. Proposes queueing and simulation models to obtain the optimal nurse allocation policy for minimising the ICU mortality rate. Validates proposed models at Middlemore Hospital from 2015 to 2016. Estimates the financial and mortality impact of allocating another nurse to PART per shift.

Abstract: The aim of this study was to assess intensive care nurses' knowledge of pressure ulcers and the impact of an educational programme on knowledge levels. A knowledge assessment test was developed. A cohort of registered nurses in a tertiary referral hospital in New Zealand had knowledge assessed three times: before an educational programme, within two weeks after the programme, and 20 weeks later. Completion of the educational programme resulted in improved levels of knowledge. Mean scores on the assessment test were 84% at baseline and 89% following the educational programme. The mean baseline score did not differ significantly from the mean 20-week follow-up score of 85%. No association was detected between demographic data and test scores. Content validity and standard setting were verified by using a variety of methods. Levels of knowledge to prevent and manage pressure ulcers were good initially and improved with an educational programme, but soon returned to baseline.

Abstract: This dissertation considers the implications of the relationship between nurses and the patient's family, when family members visit intensive care units (ICUs) following the acute admission of a relative there. In particular it explores the issues of power and control, nurses might have in this setting, the culture that supports that, and the implications this has for practice in the New Zealand context. A comprehensive literature review on the perspective of nurses in relation to relatives visiting adult intensive care units was conducted. The author concludes that nurses modify policies related to visiting access for family members to suit themselves, and the needs of their patient. Nurses use a variety of tactics to maintain a position of power and control by looking out for themselves first, their patient second, and relatives third. The need of the patient and their families is not well understood by nurses, and nurses feel they have inadequate skills to cope with the needs and stresses of visiting relatives. The author suggests that for nurses to provide family focused care in ICU they must develop a therapeutic relationship with all concerned. ICU nursing culture affects nurses ability to focus on caring for their patients and their families. Nurses in ICU appear to need to maintain power and control over their environment but further research is needed to identify the current situation in New Zealand ICUs.

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: This study provides insight into the experience of being an ICU nurse and relative of a critically ill patient. Analysis of data from interviews of four ICU nurses who had experienced having a family member admitted to ICU brought up several themes. These included: a nurses' nightmare, knowing and not knowing, feeling torn, and gaining deeper insight and new meaning. Recommendations for organisational support for ICU nurse/relatives, and education for staff are made, based on the findings.

Abstract: As the healthcare system moves toward a consumer-driven paradigm, visiting hours for family and significant others of the intensive care unit patient have become a topic of interest and discussion. Research since the 1970s has generated controversy and speculation over the ideal visiting practices in the adult intensive care unit. The aim of this dissertation was to examine the benefits for the patient, family members and nurses of appropriate visiting practices within intensive care areas in order to establish if open visiting is the best regime for patients in the adult intensive care unit (ICU). This dissertation explores visiting practices in adult critical care unit settings. Specifically, the benefits of visiting for patients, and the factors that may impede or facilitate visiting practices within the ICU were critically discussed. These factors included the benefits and disadvantages of open visiting, and the nurse as an influential factor in visiting. These areas linked together to form the basis for consideration of visiting in the ICU. Review of existing literature pertaining to visiting in the ICU indicated that patients wanted open visiting hours yet also indicated that they would like some visiting restrictions. Nurses appeared to value family input into care and were aware of patient and family needs, even though they may restrict visiting to suit their own work practices. Family members can provide the patient with psychological support, provide important historical data, assist the nurse with selected aspects of physical care, and actively encourage the patient's efforts to recover. The outcome of this exploration is the recommendation of an open visiting policy tailored to individual patients, as, the author suggests, this would foster nursing practice and ultimately benefit patients and their families.

Abstract: This dissertation explores the assessment of nurses' clinical competence in the adult ICU setting. Specifically, methods for the assessment of competence are critiqued for their practical application to the novice nurse with less than six months experience in ICU. The assessment methods considered are continuous clinical assessment, self-assessment, peer review, objective structured clinical examination (OSCE), portfolio and computer assisted assessment. Several criteria are applied to the methods including the ability of each method to assess skills, knowledge and attitudes or values. Each method is critiqued for its implications in terms of cost and staffing resource, benefits and barriers to implementation. In addition, reliability and validity issues are considered for each method. The outcome of this exploration is the recommendation of a combination of methods; namely, portfolio and OSCE, for the assessment of competence in the ICU novice. The author concludes that this finding enhances current understanding within the ICU specialty of the multidimensional nature of competence assessment.