Abstract: This study was undertaken in a combined medical/surgical unit in an acute general hospital in New Zealand using the grounded theory research methodology. It aimed at identifying the types of information nurses pass on verbally regarding their patients, but which they do not document in the legal nursing record.

Abstract: The author investigates the premises that form the basis of nursing practice in acute care. Assumptions about patients and caregiving are often at odds with each other. The origins of these tenets are mapped from Florence Nightingale through to present nursing theorists. Overlapping areas of nursing and medical care in the acute care setting are examined, and the conflict that can arise between traditional nursing care and the expected medical nursing role is examined. He argues that the challenge for acute care nurses is to find a balance between normative nursing and the medical model.

Abstract: This thesis looks at the prospect of developing and implementing case management as a model of care for complex patients in an acute medical setting. An extensive literature review was conducted to explore the concept of case management and to identify the role of the case manager, including the qualities and qualifications required for the position. Clinical pathways are a tool used in case management so these are also included in the literature review. As the author had been involved in the development of the first clinical pathway for Hutt Valley Health, this is used as an example to clarify how case management and clinical pathways can be used in conjunction. A discussion chapter examines the advantages and disadvantages of case management which shows that it can be an effective and efficient model of care through the development of clinical pathways. The ethical implications of case management are also considered. The thesis concludes with recommendations for the continued development of case management as a model of care to improve the quality of care for both patients and the organisation. During the course of the thesis, other areas that are worth further investigation have also been identified, such as the relevance of case management to different cultures. The thesis suggests that a proposal for case management for complex patients in the acute care setting is developed along with a job description for the role of the case manager.

Abstract: Alleviating patient suffering, providing comfort and pain relief are all central to the philosophical caring position nurses have always espoused. Despite this, patients continue to suffer pain although we have the means to provide pain relief. The author notes that research has identified that nurses have a knowledge deficit regarding pain and its management, as well an erroneous attitudes, which combined are blamed for an inability to make significant progress in this area. This study was undertaken to uncover the contextual aspects of working within a New Zealand health care institution that affect nurses' ability to manage their patient' pain effectively. It highlights the difficulties and the complicated nature of working within an institution in the 1990's health care environment, where accountability for pain is absent and where pain is often under-assessed and under-treated. By using focus group of nurses, the author notes she was able to uncover constructions on nursing practice, which, she suggests, have been missing from the literature, but prevent nurses from implementing their knowledge. Using a constructivist research, she used nurse's stories and current literature to argue one way forward in, what she terms, the pain management debacle. This study revealed a diverse range of contextual factors that prevent nurses from using their knowledge. Many of the constraints on nursing practice are the results of complex organisational structures within health reform, which have significantly affected the nurse's ability to provide quality-nursing care. One of the most important factors limiting the management of the patient' pain is the inability of the nurse to autonomously initiate analgesia. While nurses are largely responsible for the assessment of pain, they are usually powerless to access necessary analgesia, without a medical prescription. The author argues that once an initial medical diagnosis has been made, nurses are usually left responsible for patient comfort and the management of pain. To do so effectively, nurses need to able to prescribe both pharmacological and non-pharmacological measures for the patient. Presently nurses are prescribing using a variety of illegitimate mechanisms, needing the endorsement of a doctor. To fulfil this role, nurses must be adequately prepared educationally and given the authority to either prescribe autonomously, of provided with extensive “standing orders”. While legislative changes in New Zealand in 1999 extended prescribing right to a few nurses within certain areas of care, the ward nurse is unlikely to gain prescribing rights in the near future. The author concludes that a way forward may be to encourage and further develop the use of protocols for managing pain via standing orders. Standing orders are common place within nursing practice today, have the support of the Nursing Council of New Zealand and are currently under-going legislative review. An institutional commitment to developing pain protocols for nurses would recognise the nurses active role and expertise in the management of pain and facilitate expedient relief for the patient.

Abstract: The author suggests that a nursing service would benefit by using the concept of budgets and budgeting control, in terms of management accounting and its applicability to a hospital based nursing service. The main objective of this study was to suggest a possible line of approach towards the construction of an information system designed to yield reliable and useful data, without which there can be little hope of any truly effective guide to the development of nursing services.