Dissertations / Theses on the topic 'Queensland hospitals'

Within Australia and in Europe. there is evidence of growth in the incidence of non¬standard forms of employment such as part-time and casual work. Part of this growth can be attributed to changes in the structure of the economy and the increasing importance of service industries where non-standard forms of employment proliferate. There is also evidence, however, that employers at the firm level are progressively expanding their use of non-standard employment and reducing their reliance on full-time labour. One explanation for this organisational-level phenomena has been suggested by Atkinson (1987) in his account of the ‘flexible firm’. Atkinson claims that employers are increasingly attempting to divide the workforce into two major segments: a skilled, full-time core labour force and an unskilled, non-standard segment. This thesis examines Atkinson’s ‘flexible firm’ model through a study of labour-use practices of three acute hospitals in Queensland. A main finding of this thesis is the generalised and substantial growth of non-standard employment in all types of Queensland hospitals. The growth of non-standard hospital labour is not as, Atkinson would suggest, largely the result of demand-side strategies of employers but is also conditioned by supply-side factors. Gender, rather than skill, is found to be an important determinant of the proliferation of non-standard employment. Non-standard employment is not the major labour adjustment mechanism in all sectors of the hospital industry. Labour intensification is a critical and overlooked form of labour adjustment in the public sector. Overall, this thesis concludes that employers’ labour-use practices need to be conceptualised within the context of the opportunities and constraints imposed by the interaction of demand and supply-side factors.

Within Australia and in Europe. there is evidence of growth in the incidence of non¬standard forms of employment such as part-time and casual work. Part of this growth can be attributed to changes in the structure of the economy and the increasing importance of service industries where non-standard forms of employment proliferate. There is also evidence, however, that employers at the firm level are progressively expanding their use of non-standard employment and reducing their reliance on full-time labour. One explanation for this organisational-level phenomena has been suggested by Atkinson (1987) in his account of the ‘flexible firm’. Atkinson claims that employers are increasingly attempting to divide the workforce into two major segments: a skilled, full-time core labour force and an unskilled, non-standard segment. This thesis examines Atkinson’s ‘flexible firm’ model through a study of labour-use practices of three acute hospitals in Queensland. A main finding of this thesis is the generalised and substantial growth of non-standard employment in all types of Queensland hospitals. The growth of non-standard hospital labour is not as, Atkinson would suggest, largely the result of demand-side strategies of employers but is also conditioned by supply-side factors. Gender, rather than skill, is found to be an important determinant of the proliferation of non-standard employment. Non-standard employment is not the major labour adjustment mechanism in all sectors of the hospital industry. Labour intensification is a critical and overlooked form of labour adjustment in the public sector. Overall, this thesis concludes that employers’ labour-use practices need to be conceptualised within the context of the opportunities and constraints imposed by the interaction of demand and supply-side factors.
Thesis (PhD Doctorate)
Doctor of Philosophy (PhD)
Griffith Business School
Griffith Business School
Full Text

New health technologies are undoubtedly one of the most significant contributors in improving health and quality of life. Nonetheless, they also create challenges in ensuring they provide value for money and that they are safe and effective. In order to address these issues, health technology assessment (HTA) processes have been developed. Today, HTA has become an essential tool for making decisions about choosing and introducing new health technologies. However, concern has been expressed about HTA dissemination and use by decision makers especially at the institutional level. There is little published research to date from the HTA users’ point of view in this area of concern. Thus, this study aims to investigate the effectiveness of the dissemination of HTA products at the institutional level using the diffusion of innovation theory supplemented by the promoting action on research implementation in health services (PARIHS) framework as the research conceptual framework in order to determine the major determinants. These determinants include the decision making processes for introducing new health technologies, and the organisational and individual factors that contribute to the adoption processes in hospitals.
Thesis (PhD Doctorate)
Doctor of Philosophy (PhD)
School of Public Health
Griffith Health
Full Text

The demand for health care in Australia has been influenced by the numerous changes in financing arrangements at Federal Government, State Government and institutional levels during the last two decades. The task of performing empirical studies of health care demand has been made difficult by the frequent changes that have occurred with health insurance arrangements in particular. This research project commences at a macro level and traces the development of health insurance in Australia with particular emphasis on the issues that have influenced demand for primary health care. The debate on the appropriateness of voluntary and compulsory health insurance systems is discussed in the context of the theoretical issues that influence health care demand. An historical overview of the development of the Queensland's health care system is presented with the emphasis being on the provision of primary health care. Aspects of the provision of primary medical care through hospital outpatient services and community health centres are compared and contrasted. The paucity of information on outpatient activity is discussed and suggestions provided from the literature are offered to overcome this problem. The need for more adequate measures of activity is discussed in terms of this being a prerequisite for effective planning, evaluation and policy development. The theoretical aspects of utilisation are discussed with reference to empirical studies of demand and utilisation of primary health care services. As well, the influence of health insurance and provider behaviour on demand for health care are discussed. This leads into the development of the hypothesis to be tested, that outpatient utilisation of Queensland public hospitals has decreased since the introduction of Medicare in 1984. Statewide aggregate data of hospital outpatient activity were analysed concurrently with data obtained from surveys of patients attending outpatient clinics at two nearby Brisbane hospitals. The data from theses sources support the hypothesis proposed. The analysis of the data provides sufficient evidence on the attributes of the patients attending outpatient services to question the appropriateness of continuing to provide outpatient services as effective alternative forms of care.

Malnutrition is reported to be common in hospitals (10-60%), residential aged care facilities (up to 50% or more) and in free living individuals with severe or multiple disease (>10%) (Stratton et al., 2003). Published Australian studies indicate similar results (Beck et al., 2001, Ferguson et al., 1997, Lazarus and Hamlyn, 2005, Middleton et al., 2001, Visvanathan et al., 2003), but are generally limited in number, with none conducted across multiple centres or in residential aged care facilities. In Australia, there is a general lack of awareness and recognition of the problem of malnutrition, with currently no policy, standards or guidelines related to the identification, prevention and treatment of malnutrition. Malnutrition has been found to be associated with the development of pressure ulcers, but studies are limited. The consequences of the development of pressure ulcers include pain and discomfort for the patient, and considerable costs associated with treatment and increased length of stay. Pressure ulcers are considered largely preventable, and the demand for the establishment of appropriate policy, standards and guidelines regarding pressure ulcers has recently become important because the incidence and prevalence of pressure ulcers is increasingly being considered a parameter of quality of care. The aims of this study program were to firstly determine the prevalence of malnutrition and its association with pressure ulcers in Queensland Health hospitals and residential aged care facilities; and secondly to estimate the potential economic consequences of malnutrition by determining the costs arising from pressure ulcer attributable to malnutrition; and the economic outcomes of an intervention to address malnutrition in the prevention of pressure ulcers. The study program was conducted in two phases: an epidemiological study phase and an economic modelling study phase. In phase one, a multi centre, cross sectional audit of a convenience sample of subjects was carried out as part of a larger audit of pressure ulcers in Queensland public acute and residential aged care facilities in 2002 and again in 2003. Dietitians in 20 hospitals and six aged care facilities conducted single day nutritional status audits of 2208 acute and 839 aged care subjects using the Subjective Global Assessment, in either or both audits. Subjects excluded were obstetric, same day, paediatric and mental health patients. Weighted average proportions of nutritional status categories for acute and residential aged care facilities across the two audits were determined and compared. The effects of gender, age, facility location and medical specialty on malnutrition were determined via logistic regression. The effect of nutritional status on the presence of pressure ulcer was also determined via logistic regression. Logistic regression analyses were carried out using an analysis of correlated data approach with SUDAAN statistical package (Research Triangle Institute, USA) to account for the potential clustering effect of different facilities in the model. In phase two, an exploratory economic modelling framework was used to estimate the number of cases of pressure ulcer, total bed days lost to pressure ulcer and the economic cost of these lost bed days which could be attributed to malnutrition in Queensland public hospitals in 2002/2003. Data was obtained on the number of relevant separations, the incidence rate of pressure ulcer, the independent effect of pressure ulcers on length of stay, the cost of a bed day, and the attributable fraction of malnutrition in the development of pressure ulcers determined using the prevalence of malnutrition, the incidence rate of developing a pressure ulcer and the odds risk of developing a pressure ulcer when malnourished (as determined previously). A probabilistic sensitivity analysis approach was undertaken whereby probability distributions to the specified ranges for the key input parameters were assigned and 1000 Monte Carlo samples made from the input parameters. In an extension of the above model, an economic modelling framework was also used to predict the number of cases of pressure ulcer avoided, number of bed days not lost to pressure ulcer and economic costs if an intensive nutrition support intervention was provided to all nutritionally at risk patients in Queensland public hospitals in 2002/2003 compared to standard care. In addition to the above input parameters, data was obtained on the change in risk in developing a pressure ulcer associated with an intensive nutrition support intervention compared to standard care. The annual monetary cost of the provision of an intensive nutrition support intervention to at risk patients was modelled at a cost of AU$ 3.8-$5.4 million for additional food and nutritional supplements and staffing resources to assist patients with nutritional intake. A probabilistic sensitivity analysis approach was again taken. A mean of 34.7 + 4.0% and 31.4 + 9.5% of acute subjects and a median of 50.0% and 49.2% of residents of aged care facilities were found to be malnourished in Audits 1 and 2, respectively. Variables found to be significantly associated with an increased odds risk of malnutrition included: older age groups, metropolitan location of facility and medical specialty, in particular oncology and critical care. Malnutrition was found to be significantly associated with an increased odds risk of having a pressure ulcer, with the odds risk increasing with severity of malnutrition. In acute facilities moderate malnutrition had an odds risk of 2.2 (95% CI 1.6-3.0, p<0.001) and severe malnutrition had an odds risk of 4.8 (95% CI 3.2-7.2, p<0.001) of having a pressure ulcer. The overall adjusted odds risk of having a pressure ulcer when malnourished (total malnutrition) in an acute facility was 2.6 (95% CI 1.8-3.5, p<0.001). In residential facilities, where the audit results were presented separately, the same pattern applied with moderate malnutrition having an odds risk of 1.7 (95% CI 1.2-2.2, p<0.001) and 2.0 (95% CI 1.5-2.8, p<0.001); and severe malnutrition having an odds risk of 2.8 (95% CI1.2-6.6, p=0.02) and 2.2 (95% CI 1.5-3.1, p<0.001), for Audits 1 and 2 respectively. There was no statistical difference between these odds risk ratios between the audits. The overall adjusted odds risk of having a pressure ulcer when malnourished (total malnutrition) in a residential aged care facility was 1.9 (95% CI 1.3-2.7, p<0.001) and 2.0 (95% CI 1.5-2.7, p<0.001) for Audits 1 and 2 respectively. Being malnourished was also found to be significantly associated with an increased odds risk of having a higher stage and higher number of pressure ulcers, with the odds risk increasing with severity of malnutrition. The economic model predicted a mean of 3666 (Standard deviation 555) cases of pressure ulcer attributable to malnutrition out of a total mean of 11162 (Standard deviation 1210), or approximately 33%, in Queensland public acute hospitals in 2002/2003. The mean number of bed days lost to pressure ulcer that were attributable to malnutrition was predicted to be 16050, which represents approximately 0.67% of total patient bed days in Queensland public hospitals in 2002/2003. The corresponding mean economic costs of pressure ulcer attributable to malnutrition in Queensland public acute hospitals in 2002/2003 were estimated to be almost AU$13 million, out of a total mean estimated cost of pressure ulcer of AU$ 38 526 601. In the extension of the economic model, the mean economic cost of the implementation of an intensive nutrition support intervention was predicted to be a negative value ( -AU$ 5.4 million) with a standard deviation of $AU3.9 million, and interquartile range of –AU$ 7.7 million to –AU$ 2.5 million. Overall there were 951 of the 1000 re-samples where the economic cost is a negative value. This means there was a 95% chance that implementing an intensive nutrition support intervention was overall cost saving, due to reducing the cases of pressure ulcer and hospital bed days lost to pressure ulcer. This research program has demonstrated an independent association between malnutrition and pressure ulcers, on a background of a high prevalence of malnutrition, providing evidence to justify the elevation of malnutrition to a safety and quality issue for Australian healthcare organisations, similarly to pressure ulcers. In addition this research provides preliminary economic evidence to justify the requirement for consideration of healthcare policy, standards and guidelines regarding systems to identify, prevent and treat malnutrition, at least in the case of pressure ulcers in Australia.

Malnutrition is reported to be common in hospitals (10-60%), residential aged care facilities (up to 50% or more) and in free living individuals with severe or multiple disease (>10%) (Stratton et al., 2003). Published Australian studies indicate similar results (Beck et al., 2001, Ferguson et al., 1997, Lazarus and Hamlyn, 2005, Middleton et al., 2001, Visvanathan et al., 2003), but are generally limited in number, with none conducted across multiple centres or in residential aged care facilities. In Australia, there is a general lack of awareness and recognition of the problem of malnutrition, with currently no policy, standards or guidelines related to the identification, prevention and treatment of malnutrition. Malnutrition has been found to be associated with the development of pressure ulcers, but studies are limited. The consequences of the development of pressure ulcers include pain and discomfort for the patient, and considerable costs associated with treatment and increased length of stay. Pressure ulcers are considered largely preventable, and the demand for the establishment of appropriate policy, standards and guidelines regarding pressure ulcers has recently become important because the incidence and prevalence of pressure ulcers is increasingly being considered a parameter of quality of care. The aims of this study program were to firstly determine the prevalence of malnutrition and its association with pressure ulcers in Queensland Health hospitals and residential aged care facilities; and secondly to estimate the potential economic consequences of malnutrition by determining the costs arising from pressure ulcer attributable to malnutrition; and the economic outcomes of an intervention to address malnutrition in the prevention of pressure ulcers. The study program was conducted in two phases: an epidemiological study phase and an economic modelling study phase. In phase one, a multi centre, cross sectional audit of a convenience sample of subjects was carried out as part of a larger audit of pressure ulcers in Queensland public acute and residential aged care facilities in 2002 and again in 2003. Dietitians in 20 hospitals and six aged care facilities conducted single day nutritional status audits of 2208 acute and 839 aged care subjects using the Subjective Global Assessment, in either or both audits. Subjects excluded were obstetric, same day, paediatric and mental health patients. Weighted average proportions of nutritional status categories for acute and residential aged care facilities across the two audits were determined and compared. The effects of gender, age, facility location and medical specialty on malnutrition were determined via logistic regression. The effect of nutritional status on the presence of pressure ulcer was also determined via logistic regression. Logistic regression analyses were carried out using an analysis of correlated data approach with SUDAAN statistical package (Research Triangle Institute, USA) to account for the potential clustering effect of different facilities in the model. In phase two, an exploratory economic modelling framework was used to estimate the number of cases of pressure ulcer, total bed days lost to pressure ulcer and the economic cost of these lost bed days which could be attributed to malnutrition in Queensland public hospitals in 2002/2003. Data was obtained on the number of relevant separations, the incidence rate of pressure ulcer, the independent effect of pressure ulcers on length of stay, the cost of a bed day, and the attributable fraction of malnutrition in the development of pressure ulcers determined using the prevalence of malnutrition, the incidence rate of developing a pressure ulcer and the odds risk of developing a pressure ulcer when malnourished (as determined previously). A probabilistic sensitivity analysis approach was undertaken whereby probability distributions to the specified ranges for the key input parameters were assigned and 1000 Monte Carlo samples made from the input parameters. In an extension of the above model, an economic modelling framework was also used to predict the number of cases of pressure ulcer avoided, number of bed days not lost to pressure ulcer and economic costs if an intensive nutrition support intervention was provided to all nutritionally at risk patients in Queensland public hospitals in 2002/2003 compared to standard care. In addition to the above input parameters, data was obtained on the change in risk in developing a pressure ulcer associated with an intensive nutrition support intervention compared to standard care. The annual monetary cost of the provision of an intensive nutrition support intervention to at risk patients was modelled at a cost of AU$ 3.8-$5.4 million for additional food and nutritional supplements and staffing resources to assist patients with nutritional intake. A probabilistic sensitivity analysis approach was again taken. A mean of 34.7 + 4.0% and 31.4 + 9.5% of acute subjects and a median of 50.0% and 49.2% of residents of aged care facilities were found to be malnourished in Audits 1 and 2, respectively. Variables found to be significantly associated with an increased odds risk of malnutrition included: older age groups, metropolitan location of facility and medical specialty, in particular oncology and critical care. Malnutrition was found to be significantly associated with an increased odds risk of having a pressure ulcer, with the odds risk increasing with severity of malnutrition. In acute facilities moderate malnutrition had an odds risk of 2.2 (95% CI 1.6-3.0, p<0.001) and severe malnutrition had an odds risk of 4.8 (95% CI 3.2-7.2, p<0.001) of having a pressure ulcer. The overall adjusted odds risk of having a pressure ulcer when malnourished (total malnutrition) in an acute facility was 2.6 (95% CI 1.8-3.5, p<0.001). In residential facilities, where the audit results were presented separately, the same pattern applied with moderate malnutrition having an odds risk of 1.7 (95% CI 1.2-2.2, p<0.001) and 2.0 (95% CI 1.5-2.8, p<0.001); and severe malnutrition having an odds risk of 2.8 (95% CI1.2-6.6, p=0.02) and 2.2 (95% CI 1.5-3.1, p<0.001), for Audits 1 and 2 respectively. There was no statistical difference between these odds risk ratios between the audits. The overall adjusted odds risk of having a pressure ulcer when malnourished (total malnutrition) in a residential aged care facility was 1.9 (95% CI 1.3-2.7, p<0.001) and 2.0 (95% CI 1.5-2.7, p<0.001) for Audits 1 and 2 respectively. Being malnourished was also found to be significantly associated with an increased odds risk of having a higher stage and higher number of pressure ulcers, with the odds risk increasing with severity of malnutrition. The economic model predicted a mean of 3666 (Standard deviation 555) cases of pressure ulcer attributable to malnutrition out of a total mean of 11162 (Standard deviation 1210), or approximately 33%, in Queensland public acute hospitals in 2002/2003. The mean number of bed days lost to pressure ulcer that were attributable to malnutrition was predicted to be 16050, which represents approximately 0.67% of total patient bed days in Queensland public hospitals in 2002/2003. The corresponding mean economic costs of pressure ulcer attributable to malnutrition in Queensland public acute hospitals in 2002/2003 were estimated to be almost AU$13 million, out of a total mean estimated cost of pressure ulcer of AU$ 38 526 601. In the extension of the economic model, the mean economic cost of the implementation of an intensive nutrition support intervention was predicted to be a negative value ( -AU$ 5.4 million) with a standard deviation of $AU3.9 million, and interquartile range of –AU$ 7.7 million to –AU$ 2.5 million. Overall there were 951 of the 1000 re-samples where the economic cost is a negative value. This means there was a 95% chance that implementing an intensive nutrition support intervention was overall cost saving, due to reducing the cases of pressure ulcer and hospital bed days lost to pressure ulcer. This research program has demonstrated an independent association between malnutrition and pressure ulcers, on a background of a high prevalence of malnutrition, providing evidence to justify the elevation of malnutrition to a safety and quality issue for Australian healthcare organisations, similarly to pressure ulcers. In addition this research provides preliminary economic evidence to justify the requirement for consideration of healthcare policy, standards and guidelines regarding systems to identify, prevent and treat malnutrition, at least in the case of pressure ulcers in Australia.

This thesis describes the process of service provision and evaluates the non-invasive cardiac diagnostics of exercise stress testing and Holter monitoring between two Queensland rural and remote health facilities. A multi-site retrospective chart review was conducted to document testing process and quantitatively evaluate the impact of facility location on key test parameters including time frames, proportions, and the travel implications related to distance and cost to patients living in non-metropolitan areas. Findings demonstrate that patients requiring these investigations travel significantly longer distances, with a high proportion exceeding recommended process and outcome time frames compared to documented standards.

Pastoral care in our day has its origins in the Christian church and the religious (Soul) care of members. Pastoral care in the hospital has been, and continues to be articulated in the traditional terminology of religious care. This thesis argues that in our multicultural and multifaith society re-articulation of pastoral care is now required; taking account of the nature of belief, genuine valuing of story, and focused presence. Such benchmarks create authentic engagement through which pastoral care becomes capable of crossing religious boundaries to foster spiritual comfort. This thesis maps these factors – belief, story and presence - within the literature review, drawing on the experience of many researchers in pastoral care, and of those who in various ways have engaged with others in sharing their own lives, experiences and reflections. The review sources engage with pluralism, the differences between spiritual and religious care, the importance of authenticity and the way this might be discerned through a brief study of belief, story, and presence.
Thesis (PhD Doctorate)
Doctor of Philosophy (PhD)
School of Humanities
Arts, Education and Law
Full Text

The aim of this thesis has been to map the ethical journey of experienced nurses now practising in rural and remote hospitals in central and south-west Queensland and in domiciliary services in Brisbane. One group of the experienced nurses in the study were Directors of Nursing in rural and remote hospitals. These nurses were “hands on”, “multi-skilled “ nurses who also had the task of managing the hospital. Also there were two Directors of Nursing from domiciliary services in Brisbane. A grounded theory method was used. The nurses were interviewed and the data retrieved from the interviews was coded, categorised and from these categories a conceptual framework was generated. The literature which dealt with the subject of ethical decision making and nurses also became part of the data. The study revealed that all these nurses experienced moral distress as they made ethical decisions. The decision making categories revealed in the data were: the area of financial management; issues as end of life approaches; allowing to die with dignity; emergency decisions; experience of unexpected death; the dilemma of providing care in very difficult circumstances. These categories were divided into two chapters: the category related to administrative and financial constraints and categories dealing with ethical issues in clinical settings. A further chapter discussed the overarching category of coping with moral distress. These experienced nurses suffered moral distress as they made ethical decisions, confirming many instances of moral distress in ethical decision making documented in the literature to date. Significantly, the nurses in their interviews never mentioned the ethical principles used in bioethics as an influence in their decision making. Only one referred to lectures on ethics as being an influence in her thinking. As they described their ethical problems and how they worked through them, they drew on their own previous experience rather than any knowledge of ethics gained from nursing education. They were concerned for their patients, they spoke from a caring responsibility towards their patients, but they were also concerned for justice for their patients. This study demonstrates that these nurses operated from the ethic of care, tempered with the ethic of responsibility as well as a concern for justice for their patients. Reflection on professional experience, rather than formal ethics education and training, was the primary influence on their ethical decision making.

The nutrient intakes of 35 pregnant teenagers (mean age 17 years) and 25 pregnant adults (mean age 26 years) attending the Mater Mothers Misericordiae Hospital in Brisbane were studied and compared. The nutrient intakes of the pregnant teenagers were also compared with those of a group of non-pregnant teenagers (mean age 16.9 years) of a similar socio-economic status. The 24 hour recall and food frequency questionnaire were used to determine nutrient intake. The 24 hour recall and food frequency questionnaire were used to determine nutrient intakes. Life size photographs were used to determine portion sizes. Between one and three recalls were done for each subject on different days of the week. Correlations between intakes determined by the two methods were generally good and mean intakes determined by the two methods were not significantly different in most cases. The food photographs improved the accuracy of these methods. No significant difference in the intake of energy, protein, iron, zinc, vitamin A and vitamin C of the pregnant teenagers and pregnant adults and the pregnant teenagers and non-pregnant teenagers were found. The pregnant adults had a greater intake of calcium than the pregnant teenagers. The intakes of energy was less than estimated requirements for Australian women and zinc and iron intakes were less than the Australian RDis for pregnant women. The intake of protein, Vitamin A, Vitamin C and calcium were adequate compared to the Australian RDI's. No significant difference was found between the weight gain of the pregnant teenagers and pregnant adults. Both groups had weight gains greater than recommended for Australian women. The birthweights of the infants and length of gestations of the pregnant teenagers and pregnant adults were not significantly different. Despite the intake of energy, iron and zinc being less than recommended for both groups birthweight and length of gestation were similar to the Australian average. This suggests that the RDis for these nutrients are excessive. Haemoglobin and serum ferritin levels of the pregnant women were studied. There was no significant difference between the levels of haemoglobin and serum ferritin of the two groups. Despite a number of pregnant women having haemoglobin and serum ferritin levels indicative of anaemia and storage depletion, no significant association was found between iron status and birthweight or length of gestation. It was concluded that the older pregnant teenagers attending the Mater Mothers Hospital are at no greater nutritional risk than the pregnant adults at the same hospital.

This thesis is the study of airborne grass pollens effect on asthma emergency department (ED) presentations in Queensland (QLD). Time series and spatiotemporal analysis investigated burden, seasonality and trends for ED presentation and risk for hospital admission. Burden was largely driven by female children and lightning showed an independent effect on asthma ED presentations during the study period. The burden of allergic respiratory disease in subtropical regions is significant and with increasing pollen exposure and a growing population, risk of thunderstorm asthma in QLD cannot be disregarded.

This study aimed to examine the use of hospital emergency departments and to investigate the level of satisfaction with the emergency department service among patients from a non-English-speaking background compared to those of patients from an English-speaking background in Queensland. The findings of this study might inform health professionals and policy planners to develop educational interventions and policies to ensure equitable use of emergency services among the populations.

This thesis evaluated the effectiveness and cost-saving potential of a health service delivery model in Queensland Australia, the Hospital in the Nursing Home program. The research adopted a before-after controlled study design, comparing the outcomes between an intervention hospital and a control hospital during the pre- and post-intervention periods. Findings from the research supported that the intervention was preferred over the current practice, which reduced the attendances to emergency departments (EDs) and inpatient hospitals from patients in residential aged care facilities, shortened their length of ED stay, and saved the overall costs.

This study is the first to employ an epidemiological framework to evaluate the ‘fit-for-purpose’ of ICD-10-AM external cause of injury codes, ambulance and hospital clinical documentation for injury surveillance. Importantly, this thesis develops an evidence-based platform to guide future improvements in routine data collections used to inform the design of effective injury prevention strategies. Quantification of the impact of ambulance clinical records on the overall information quality of Queensland hospital morbidity data collections for injury causal information is a unique and notable contribution of this study.

This thesis applied a grounded theory methodology to generate a theoretical understanding of the challenging and ambiguous dimensions of the contemporary role of the public-sector nurse educator within Australia. New knowledge provides a useful structure to examine nurse educator support and mechanisms to foster constructive workplace learning, collaborative relationships and effective contributions to better health care.

This project aimed to determine if the attendance of Critical Care Paramedics at out-of-hospital cardiac arrests in Queensland was still associated with a survival benefit despite the diminishing gap in the skill set between Critical Care and Advanced Care Paramedics. The study found that amongst patients with the greatest chance of survival, those patients who were attended by Critical Care Paramedics were more than twice as likely to survive to hospital discharge.

The introduction of legislation governing the management of mental illness in Queensland led to complaints from paramedics and their industrial association to the Commissioner of the Queensland Ambulance Service regarding the inadequacy of education and training to fulfil their new practice obligations. The industrial association asserted that their members were ill-prepared, insufficiently skilled, and unsupported professionally to make clinical judgements and decisions about mental illness in the pre-hospital emergency care setting. Furthermore, they raised concerns that their members were at significant risk of harm from patients with mental illness, and that they were vulnerable to litigation for actions of negligence and breaches of duty of care that were a direct result of the inadequacy of their education and training. These concerns, coupled with a lack of published literature that might address them, highlighted the need for a deeper understanding of how paramedics accomplish clinical judgement and decision-making of mental illness in the field, and the factors that influence this aspect of their work. Integral to the concerns were questions about the relationship between the formal expectations of paramedic practice—in the form of legislation and clinical policy—and their actual judgement practice in the field. At issue in this study was the preparedness of paramedics to recognise, assess, and manage mental illness in everyday practice and the sufficiency of education and training programs, clinical standards, policy, and legislation for ensuring quality practice and accountability in the field. To understand how paramedics accomplish clinical judgement and decision-making of mental illness in the Queensland pre-hospital emergency care setting and the factors that influence this aspect of their work, this thesis adopted a descriptive theoretical framework of judgement and decision-making (Bell, Raiffa, & Tversky, 1988a) and undertook an interpretive, naturalistic case study according to Stake (1995). In this study, the cases were paramedics, the context was the Queensland pre-hospital emergency care setting, and the issue was how they accomplished clinical judgement and decision-making of mental illness. The study of paramedic clinical judgement and decision-making of mental illness was conducted in two iterative and recursive phases.
Thesis (PhD Doctorate)
Doctor of Philosophy (PhD)
School of Education and Professional Studies
Arts, Education and Law
Full Text

There is a scarcity of research that informs Interface Health Service (IHS) development. This research applied a mixed methods approach to profile older emergency department patients and patterns of health service use and to explore their ED experiences in public hospital EDs in South-East Queensland. IHS was under-utilised by older people with complex co-morbidities. Lack of communication and need identification were factors that undermined the effectiveness of IHS in reaching this cohort which highlighted a need for change.

In 2001, there were an estimated 2.4 million Australians aged 65 and over, or 12.5% of the total population of 19.4 million. Over the next 50 years is it expected that one quarter of the total population will be aged 65 or over (Australian Institute of Health and Welfare [AIHW], 2002). In recent years, the priority attached to ageing issues has increased substantially in Australia and in most first world countries at both a national and international level. Concerns over the implications of population ageing have prompted responses to ensure the sustainability of economic, health and social support systems that are directly influenced by the changing age structure of the population. Older Australians are the largest consumers of health care. As a result of the general ageing process, older adults are at risk of developing iatrogenic complications associated with hospital admission. Services that have been implemented overseas and in Australia that aim to provide care for patients in their own environment include hospital in the home (HIH) and, more recently hospital in the nursing home (HINH). The ability to be able to deliver acute care within the Aged Care Facility (ACF) has not previously been evaluated extensively within Australia. Further, it is not known whether the HINH model utilised in a Queensland demonstration contained sufficient components to benefit patient care. Therefore, an evaluation of the structure, processes and outcomes of this model was conducted in order to inform all stakeholders involved and allow for further refinement. Thus, the aims of this research study were to: 1. Determine which factors predict poor outcomes for all older people who present to the ED and are admitted to hospital; 2. Determine whether HINH enrolment was a predictor for better outcomes for ACF residents; 3. Evaluate the structures involved in the HINH program; and 4. Evaluate the processes involved in the HINH program. In addressing these aims three phases of research were undertaken. The first was a precursor to the evaluation. It involved conducting a cohort study that described the clinical characteristics and outcomes of all acutely unwell older adults who presented to an Emergency Department (ED) in south-east Queensland. The second and third phases evaluated the HINH program that was implemented in order to improve the care pathway for ACF residents who presented to hospital. A structure, process and outcomes approach was used to do this. The second phase focussed on evaluating outcomes. A case control study was used to compare outcomes of ACF residents enrolled into the HINH program (cases) with ACF residents who were not enrolled into the program (controls). The third phase of this research evaluated the structures and processes of the HINH program using semi-structured interviews with doctors, nurses and HINH patients. This research has provided the first comprehensive evaluation of a HINH program within Australia utilising a structure, process and outcomes approach. Results from Phase 1 highlighted that negative outcomes occurred for ACF residents as well as the health care organisation when ACF residents presented to the ED and were admitted to hospital. Results from Phase 2 identified that enrolment into the HINH program had a significant positive impact on patient and health care organisation outcomes. Furthermore, by providing hospital care in the ACF, the HINH program, was a cheaper alternative to the standard in-hospital treatment, allowed for more in-hospital bed days to be available and reduced the risk of hospital related complications such as death for patients. Findings from Phase 3 showed that for this HINH program to operate, effective referral and communication strategies were integral. Given the current political climate that is concerned over the implications of population ageing, this evaluation is timely. The HINH program is one innovative model of health care delivery that benefits the economic, health and social support systems for ACF residents and the health care organisation.
Thesis (PhD Doctorate)
Doctor of Philosophy (PhD)
School of Nursing and Midwifery
Faculty of Health
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Background: Domestic violence is a form of violence that has become an internationally recognised problem with high prevalence rates globally (WHO, 2013). It is a form of gendered violence in that it disproportionately affects the lives of women, causing serious adverse outcomes for their health and wellbeing. Frontline healthcare professionals such as medical professionals, nurses, and social workers within Emergency Departments are often the first point of contact with healthcare services for women experiencing domestic violence. It is essential that these healthcare staff and services prioritise and meet the needs of these victims and survivors of domestic violence. Study Objective: The purpose of this study was to explore emergency healthcare professionals’ responses to patients experiencing domestic violence in regional hospitals in Queensland, Australia. Research Design: This qualitative study employed semi-structured interviews within a Straussian grounded theory methodology. Participant Population: The target participant population for this study was male and female emergency medical professionals, nurses and social workers who were employed in the Emergency Departments of two regional Queensland hospitals within Australia. Participant Screening: Participants within this study were screened using a developed self-assessment screening protocol. Participants were screened for two main reasons. Firstly, there remains a high prevalence of domestic violence experienced by healthcare professionals. Secondly, domestic violence may cause both physical and psychological harm. The use of this screening protocol ensured that no participant would be unduly distressed by their participation in this study. Data Collection: The study collected data in two forms. Firstly, demographic data was collected through anonymous paper-based surveys. Secondly, data on the care provided to patients experiencing domestic violence was collected through audio-recorded semi-structured interviews. Data Analysis: The demographic data collected from the anonymous paper-based surveys was analysed employing descriptive statistics. The audio-recorded semi-structured interviews were transcribed, then analysed utilising Straussian grounded theory; a form of constant comparative analysis. Results: This study found several areas of concern around the care provided to domestic violence victims in regional Emergency Departments. It found there was a lack of clinical guidance for healthcare professionals surrounding the identification, management and referral of patients. Referral options and pathways were not clearly established or utilised, and a lack of service availability hindered ongoing patient healthcare. A lack of education and training further contributed to the provision of suboptimal care. The physical design of the Emergency Department, models of care that prioritise physical trauma, and the demand for bed space resulted in decreased identification, and therefore inadequate health management. Finally, ill-informed and entrenched attitudes about why women do not leave abusive relationships reflected a lack of knowledge and negatively affected care. Conclusions: There are considerable and significant gaps in the care provided in regional Emergency Departments to victims of domestic violence. These gaps in care compromise the safety of the patient and result in inadequate healthcare being provided. These gaps in care may lead to further deterioration of the patient’s health and wellbeing and an increased risk of morbidity and mortality. Therefore it is imperative that further research is undertaken, and this knowledge translated into processes and initiatives which may improve health outcomes for patients. Specifically, a much stronger focus on DV is required for all healthcare professionals in the Emergency Department environment. There needs to be a health workforce comprehensively educated in DV and violence against women. Emergency healthcare professionals need to demonstrate a significant depth of knowledge surrounding the signs, symptoms and identification of domestic violence in order to initiate appropriate healthcare and promote the safety and wellbeing of women and their children. In order to facilitate this healthcare, there needs to be well-developed clinical practice guidelines, protocols, policies and procedures to support Emergency Department healthcare professionals to recognise, respond and refer patients who present with injuries consistent with domestic violence, particularly those with non-lethal strangulation which has long-term adverse health outcomes for victims.

Katherine Pemberton studied adults who suffered out-of-hospital cardiac arrest over a 13-year period in Queensland and investigated survival. She identified some important population subsets at risk of reduced survival and identified factors to predict increased survival. Her work will be used by Ambulance Services to inform ways to improve resuscitation practices and policy.

This study was born out of anecdotal evidence from midwives and nurses involved with the care of pregnant women, who claimed that the management of pregnant women in a Queensland Emergency Department (ED) could be significantly improved. Anecdotal examples were provided which demonstrated that care was often inconsistent and not woman-centred when a pregnant woman attended the ED. The ED is a demanding and sometimes chaotic place, with staff having to triage and manage the most life threatening and urgent cases on a priority basis. As evidenced by the literature and study results, the main reason for pregnant women attending an ED is threatened miscarriage; this can be a devastating event in the life of a woman and her family. Nevertheless, it is generally triaged as semi-urgent, since the woman's physical condition is stable. This particular scenario has led to many emotive media reports, uncorroborated by clinicians, such as, 'birth in toilet in hospital without care', as well as governments and hospital administrators advocating changes to practice, with little or no consultation or planning. Anecdotal evidence by both the ED staff and the maternity staff at the research hospital confirmed that such impulsive changes in this particular health district were considered inappropriate and unsustainable and would do little to address the problem and improve the care of pregnant women in the ED. This study therefore endeavoured to employ a participatory strategy to improve the triage and management of pregnant women when they attended the ED. To achieve this the following research questions were formulated, with a view to conducting a participatory action research study: what is/are the current problem/s with the triage and management of pregnant women in the ED?; why does this problem exist?; how can the situation be improved?; and, how effective is the plan that has been developed and implemented in improving the situation for pregnant women who attend the ED?. Action Research methodology underpins this study. Action research is a form of collective self-reflective enquiry undertaken by a group of people to understand and improve practices to real life problems (Kemmis & McTaggart, 1988). A key purpose of action research is to produce strategies and practical knowledge which are useful to people in everyday life (Reason & Bradbury, 2006). A multi-disciplinary Participatory Action Research Group (PARG) made it possible to explore and assess the triage and management of pregnant women in the ED from the perspectives of nurses, doctors and midwives. Throughout each stage of the research process a critical theory standpoint informed the analysis, with particular reference to Habermas' theories of knowledge-constitutive interests and communicative action. The study's design promoted a collaborative working relationship with expert clinicians that created opportunities whereby the participants involved in the research were empowered to bring about positive change for pregnant women and themselves. The PARG reached consensus on identifying three main themes in the data. These themes concerned communication, knowledge and care. The first theme, communication, was highlighted as an important area that staff could improve upon in order to provide more humanistic care to women, especially with the concept of language use. It was also identified that interdisciplinary communication was problematic as the different clinical areas had limited understanding of the everyday difficulties that each experienced, which caused tension and ineffective interactions. The second theme, knowledge, was also very important in understanding the reasons for inconsistency in the triage and management of pregnant women in the ED. Once the PARG identified the main areas of knowledge concern for both staff and women, they were able to formulate and implement strategies to help improve the situation. The final theme, care, represented the paucity of psychological care compared to physiological care in the ED and a deeper appreciation among the ED staff of the impact a miscarriage can have on a woman and her family. In addition, the PARG recognised situations where woman-centred care was in the background and health-professional centred-care was in the foreground, and the possible reasons for this occurring. This research resulted in the implementation and the evaluation of a number of strategies that directly improved the triage and management of pregnant women in the ED. Strategies included, but are not limited to: new triage flow chart for bleeding in early pregnancy; advice sheet for women with bleeding in early pregnancy; revised policies; development of two pamphlets to distribute to women concerning miscarriage and available support options; education sessions for the ED staff on common pregnancy related conditions; new furniture and renovations to the gynaecology room in the ED; and a resource book for the ED staff containing information from the Stillbirth and Neonatal Death Society (SANDS). Further significant outcomes of the research included an increased awareness and understanding by staff in both the ED and the maternity areas of the problems, and the improved networking and collaborative relationships that were established as a result of the PARG. This alone had significant impact on how women were triaged and managed in the ED. However, the most significant outcome is that even though the research is completed, the collaborative relationships that were established by undertaking this research continue to develop, grow and create a positive influence on the care that pregnant women receive when they attend this ED.

Research Doctorate - Doctor of Philosophy (PhD)
Introduction: Investment in new hospital infrastructure is one of the most costly investments that governments make in Australia, yet construction responses often fail to take into account the need for close collaboration with key stakeholders to achieve the intended outcomes. Given the projected demands on Emergency Departments (EDs) and health care into the future, it is important that the efficiency and effectiveness of these investments are maximised. Research is required to provide evidence-based recommendations for future policy and practice. Aim: To identify whether upgrades/expansions of Emergency Department facilities through capital expenditure result in increases in throughput and/or efficiency in Emergency Departments. Method: This study critically examines the construction of new Emergency Department facilities in New South Wales (NSW) and Queensland (QLD). Quantitative analysis is used to test the effects of various strategies to address improved performance against Key Performance Indicators (KPIs), with a particular focus on construction as a high-cost strategy with long-term implications and resource impacts.

The core principles of the Queensland Ambulance Service (QAS) that are founded on improving the health and well-being of all persons have remained relatively stable since 1892. This is despite changes in organisational structure, policies, protocols and procedures employed by operational paramedics. The primary scope of QAS operations is focused on the pre-hospital aspects of the health care continuum and has seen changes over time, with particularly rapid changes in the last two years to the content and nature of paramedic clinical practice. Timely and appropriate pain management in the pre-hospital environment is paramount to effective patient care. It is readily identified as a priority within the paramedic profession. Numerous studies have identified many factors that hinder the delivery of adequate pain management to patients with pain. A comprehensive review of the literature related to prehospital pain management, education and barriers to pain management has been conducted. This thesis has attempted to identify if educational programs improved knowledge and changed clinical behaviour, specifically patient care interventions and patient health outcomes. This information is valuable to those who develop clinical standards and education for ambulance services. As a result, this information could be used to help design programs that better meet the educational needs of paramedics and ultimately the needs of their patients and the community. The literature did not sufficiently identify the influences on clinical behaviour other than knowledge, so from this outcome it was identified that future studies must examine a theoretical model that can be used to assess paramedics’ intention to administer morphine to patients experiencing pain. The Theory of Planned Behaviour (TPB) was identified as an effective model for analyzing paramedic behavioural intention; it was recognised that this theory might help to identify and better understand the constructs of attitudes, social norms and behavioural control beliefs that influence paramedics’ intention to administer opioids to patients with pain. The purpose of this study was to analyse the ability of the direct measures of the Theory of Planned Behaviour (TPB) Model to mediate factors influencing ambulance paramedics’ intention to administer Morphine to patients with pain. Participants of this study were Advanced Care and Intensive Care Paramedics who were deemed competent in Morphine administration through the education division of the Queensland Ambulance Service. Data were collected by means of a questionnaire that used the constructs of the TPB, including subjective norm, perceived behavioural control and attitude. While participants reported strong intentions to administer Morphine they also reported negative attitudes towards the behaviour (morphine administration). The constructs of the TPB explained 26 per cent of the variance in intention to administer Morphine with subjective norm being the strongest significant predictor. The findings related to specific attitudes and normative pressures provide an understanding into paramedic’s pain management behaviour. This research may be the first step to identify if concepts taught in the classroom are being transferred to the clinical setting. Potential findings that may be identified in this study could be used to improve organisational awareness of factors that contribute to the future education and professional development of QAS Paramedics.

"The time from onset of a cardiac arrest to defibrillation is crucial hence access to and use of a defibrillator by all nurses essential. The purpose of this study was to use an established theoretical framework to examine and describe the defibrillation practices and beliefs of rural registered nurses in the Australian state of Queensland. The Theory of Reasoned Action (TRA) and Theory of Planned Behaviour (TPB) guided the research processes for this two phase study. In the first phase, focus group (n = 13) discussions identified the salient beliefs of the population. By eliciting nurses' beliefs, the subsequent quantitative study (n = 434) was conducted to determine the influences of these beliefs on nurses' use or non-use of defibrillators. The results showed that: (1) less than half of the cohort of participants were permitted to defibrillate; (2) the defibrillation beliefs of those nurses permitted to defibrillate were significantly more positive than those not permitted to do so; (3) the direct measures of TPB and selected variables external to the model predicted a significant portion of the variance in the measure of nurse-initiated defibrillation intention; and, (4) subjective norm emerged as the strongest predictor of intention. In conclusion, Queensland rural hospital nurses and employers still have some distance to travel down the path of nurse-initiated defibrillation. The TPB is a viable framework on which to base interventions designed to promote defibrillation by rural nurses. Understanding the role of social norms is of central importance to ensure all nurses can initiate the chain of survival expeditiously whenever the need arises."