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Quality end-of-life care in the adult critical care remains a high priority for numerous professional agencies and organizations due to advanced technologies that sustain or extent life, regardless of life quality. The purpose of this study was to describe how family members of patients in adult critical care attain awareness that their loved one is dying or near death in the adult critical care setting. Two research questions were addressed: 1) What is the human-environment health process of knowing that end-of-life is imminent by family members of patients in the adult critical care area?, and 2) What factors influence the human-environment health process of knowing that end-of-life is imminent by family members in the adult critical care area? A Glaserian grounded theory design was utilized to conduct this retrospective study. Both primary (interviews) and secondary (poem, nursing art, song, media and film) data sources supported the emerging theory. The Process of Death Imminence Awareness by Family Members of Patients in Adult Critical Care contained six phases: Patient's Near Death Awareness, Dying Right in Front of Me, Turning Points in the Patient's Condition, No Longer the Person I Once Knew, Doing Right by Them, and Time to Let Go. Influencing factors associated with this process were discussed as process facilitators and hindrances. Supportive nursing behaviors and actions as well as family member's emotional, behavioral, and physical reactions to having a critically ill family member were also discussed. This substantive theory will guide nursing education, practice, and research in the creation of nursing interventions, instrumentation, protocols, and policies and procedures aimed at providing cost effective quality end-of-life care in this specialized area of care.

This thesis presents a framework for the deployment of algorithms that support the correlation and real-time classification of physiological data streams through the development of clinically meaningful alerts using a blend of expert knowledge in the domain and pattern recognition programming based on clinical rules. Its relevance is demonstrated via a real world case study within the context of neonatal intensive care to provide real-time classification of neonatal spells. Events are first detected in individual streams independently; then synced together based on timestamps; and finally assessed to determine the start and end of a multi-signal episode. The episode is then processed through a classifier based on clinical rules to determine a classification. The output of the algorithms has been shown, in a single use case study with 24 hours of patient data, to detect clinically significant relative changes in heart rate, blood oxygen saturation levels and pauses in breathing in the respiratory impedance signal. The accuracy of the algorithm for detecting these is 97.8%, 98.3% and 98.9% respectively. The accuracy for correlating the streams and determining spells classifications is 98.9%. Future research will focus on the clinical validation of these algorithms and the application of the framework for the detection and classification of signals in other clinical contexts.

Objective: To explore the decision making approaches used by nurses who chose to work in critical care and factors influencing the process of decision making. Design and methods Qualitative descriptive methods using semi-structured interviews with nurses who had chosen to work in critical care within the past year. Results Ten nurses weighed staying in their current positions with moving to critical care. Two nurses considered two or more specialty units. The nurses used rational-intuitive and satisficing decision making approaches in making their employment decision. Limited knowledge and unrealistic expectations of work life in critical care, pressure from others, and inadequate professional support made nurses’ employment decisions more difficult. Social support, personal values for growth and learning, and paid educational incentives within employment offers facilitated their employment decisions. Conclusions Several factors negatively influenced nurses’ decision making approaches to making an employment decision. Findings revealed the need for decision support interventions focused on making employment choices for nurses.

Thesis (MNursing (Advanced Practice))--University of South Australia, 1995

Problem investigated: The activation and implementation of the Medical Emergency Team (MET) system. Procedures followed: The ability of the objective activation criteria to accurately identify patients at risk of three serious adverse events (cardiac arrest, unexpected death and unplanned intensive care admission) was assessed using a nested, matched case-control study. Sensitivity, specificity and Receiver Operating Characteristic curve (ROC) analyses were performed. The MET implementation process was studied using two convenience sample surveys of the nursing staff from the general wards of twelve intervention hospitals. These surveys measured the awareness and understanding of the MET system, level of attendance at MET education sessions, knowledge of the activation criteria, level of intention to call the MET and overall attitude to the MET system, and the hospital level of support for change, hospital capability and hospital culture. The association of these measures with the intention to call the MET and the level of MET utilisation was assessed using nonparametric correlation. Results obtained: The respiratory rate was missing in 20% of subjects. Using listwise deletion, the set of objective activation criteria investigated predicted an adverse event within 24 hours with a sensitivity of 55.4% (50.6-60.0%) and specificity of 93.7% (91.2-95.6%). An analysis approach that assumed the missing values would not have resulted in MET activation provided a sensitivity of 50.4% (45.7- 55.2%) and specificity of 93.3% (90.8-95.3%). Alternative models with modified cut-off values provided different results. The MET system was implemented with variable success during the MERIT study. Knowledge and understanding of the system, hospital readiness, and a positive attitude were all significantly positively associated with MET system utilisation, while defensive hospital cultures were negatively associated with the level of MET system utilisation. Major conclusions: The objective activation criteria studied have acceptable accuracy, but modification of the criteria may be considered. A satisfactory trade-off between the identification of patients at risk and workload requirements may be difficult to achieve. Measures of effectiveness of the implementation process may be associated with the level of MET system utilisation. Trials of the MET system should ensure good knowledge and understanding of the system, particularly amongst nursing staff.

Problem investigated: The activation and implementation of the Medical Emergency Team (MET) system. Procedures followed: The ability of the objective activation criteria to accurately identify patients at risk of three serious adverse events (cardiac arrest, unexpected death and unplanned intensive care admission) was assessed using a nested, matched case-control study. Sensitivity, specificity and Receiver Operating Characteristic curve (ROC) analyses were performed. The MET implementation process was studied using two convenience sample surveys of the nursing staff from the general wards of twelve intervention hospitals. These surveys measured the awareness and understanding of the MET system, level of attendance at MET education sessions, knowledge of the activation criteria, level of intention to call the MET and overall attitude to the MET system, and the hospital level of support for change, hospital capability and hospital culture. The association of these measures with the intention to call the MET and the level of MET utilisation was assessed using nonparametric correlation. Results obtained: The respiratory rate was missing in 20% of subjects. Using listwise deletion, the set of objective activation criteria investigated predicted an adverse event within 24 hours with a sensitivity of 55.4% (50.6-60.0%) and specificity of 93.7% (91.2-95.6%). An analysis approach that assumed the missing values would not have resulted in MET activation provided a sensitivity of 50.4% (45.7- 55.2%) and specificity of 93.3% (90.8-95.3%). Alternative models with modified cut-off values provided different results. The MET system was implemented with variable success during the MERIT study. Knowledge and understanding of the system, hospital readiness, and a positive attitude were all significantly positively associated with MET system utilisation, while defensive hospital cultures were negatively associated with the level of MET system utilisation. Major conclusions: The objective activation criteria studied have acceptable accuracy, but modification of the criteria may be considered. A satisfactory trade-off between the identification of patients at risk and workload requirements may be difficult to achieve. Measures of effectiveness of the implementation process may be associated with the level of MET system utilisation. Trials of the MET system should ensure good knowledge and understanding of the system, particularly amongst nursing staff.

This thesis explores triage code as a predictor of direct nursing care time, thus its potential usefulness in a model for calculating and allocating nurse requirements in emergency departments. A framework for nursing work is proposed. This framework is based on the works of O'Brien-Pallas, Irvine, Peereboom, and Murray (1997) and Houser (2003). It suggests that the structures of environmental complexity, nursing characteristics, patient nursing complexity, and patient medical condition and severity, impact on the processes of direct and indirect nursing care to affect patient outcomes. A prospective, non-experimental study was undertaken to examine the relationship between direct nursing care time and triage code. Six potential confounding variables were selected for this study: length of stay, age, ethnicity, sex, complaint type, and discharge category. Data were collected for 261 visits over a three day period in one New Zealand emergency department. Patient visits averaged 200 minutes. The mean direct nursing care time per visit was 49 minutes. On average, patients with more urgent triage codes, longer length of stay, or who were not discharged, received more direct nursing care. The model developed predicted 49% of variation in direct nursing care time (p < .05) related to triage code (16%), length of stay (31%) and disposition category (2%).Further exploration of the proposed framework has potential to develop a model allowing managers to identify nurse staffing required for optimal nursing care in emergency departments.

Thesis (Ph. D.)--University of New South Wales, 1999. / Also available online.

Thesis (Ph. D.)--Carleton University, 2004. / Includes bibliographical references (p. 196-215). Also available in electronic format on the Internet.