ARTICLE
Improving patient
experience and outcomes
following serious injury
Angela Beaton, Katrina O’Leary, Julie Thorburn, Alaina Campbell,
Grant Christey
ABSTRACT
AIM: To explore injured patients’ experiences of care to identify areas for improvement in routine service
delivery from surgical teams in the transition from inpatient to community-based care.
METHODS: Qualitative study drawing on 17 in-depth, semi-structured interviews, conducted from 1 October
2017 to 31 November 2017, with trauma patients (and patient-nominated key support people and health or
social care professionals) registered by the Midland Trauma System Registry (New Zealand).
RESULTS: All patient respondents had been under the primary care of surgical sub-specialty teams at
Waikato Hospital rather than the specialised trauma service that primarily cares for patients with major
multi-system trauma. Patients perceived their pre-hospital and emergency care as high quality and highly
valued the compassion of staff during their inpatient phase of care. Exceptions were the perception of
communication gaps across the spectrum of care from admission to discharge and beyond, limited access
to psychosocial services to manage ongoing psychological trauma and a lack of preparedness for discharge.
Following discharge, respondents reported the high level of reliance on key support people, inadequate
information provision about what to expect in relation to the journey through the health system after
discharge, and a lack of coordination of post-discharge care.
CONCLUSION: This study highlights perceived issues in the patient care pathway in the transition from
inpatient to community-based care, especially communication and discharge information provided by
surgical clinical teams and Accident Compensation Corporation (ACC). Comprehensive inpatient care and
clinical handover to primary care (rather than discharge planning processes) by dedicated clinical trauma
services may provide more holistic models for surgical services to improve their influence on the transition
of trauma patients into the community, assisted by organisation changes and support to enable effective
service delivery. Specifically, trauma patients and their carers perceived the need for better screening and
treatment for psychological trauma in the inpatient and outpatient setting; better information exchange
prior to the transition from inpatient to primary care; more convenient and accessible follow-up services
including a single point of contact for coordination of post-discharge care; and acknowledgement and
practical support to relieve the significant and pervasive carer burden identified in this study. These
findings provide the opportunity to implement focused system changes to provide more equitable and
effective support in the transition to community care and beyond. The end result will be better experiences
for patients and whānau, and improved health and vocational outcomes following serious injury.
A
trauma system is an organised, coordinated effort in a defined geographic
area, which delivers the full range of
care to all injured patients, and is integrated
with the local public health system with a
focus on prevention.1 Injured patients have
the best chance of making a good recovery
if the trauma system performs well and is
effectively integrated into wider health and
social care systems, leading to lower mortality rates, reduced lifelong disability and
improved quality of life, with demonstrated
cost savings to the health system.
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Serious injury means that the patient met
the eligibility criteria for the study and was
admitted to Waikato Hospital with the possibility of long-term functional deficit. Eligible
patients had complex injuries; that is, they
experienced injuries to two or more body
regions or one significant injury to one body
region with the possibility of long-term
deficit. Qualitative studies of patient and
whānau experience following serious injury
are few, with most focusing on traumatic
brain and spinal cord injuries.2–7 This is
the first qualitative study to investigate the
experience of Waikato Hospital trauma
patients and their whānau as they transition from inpatient surgical services to
community-based care. The findings will
inform system changes to support improved
health, vocational and social outcomes for
injured patients.
Methods
Setting
Patients were identified through the
Midland Trauma System’s population-based
trauma registry, which captures data on
major and non-major trauma patients
admitted to six hospitals within the Midland
region of New Zealand. The MTS registry has
the following eligibility criteria (Midland
Trauma System, n.d.) and can register
over 200 data points related to each major
trauma event:
MTS registry inclusion
•
•
Admission to a Midland hospital as
a result of and within seven days of
injury
Death in hospital as a result of injury
MTS registry exclusion
•
Trauma patients discharged from the
emergency department
•
Injuries from documented pathological processes
•
Isolated peri-prosthetic fractures
•
Exertional injuries
•
Hanging/drowning/foreign bodies
without anatomical injury
•
Poisoning
•
Patients admitted primarily for
pre-existing medical conditions not
directly as a result of injury
Sampling strategy
The following patients were eligible to
participate:
•
16 years of age or above
•
Injury Severity Score (ISS)8 equal to or
above 8
•
Blunt trauma mechanism
•
Waikato Hospital as the definitive
acute care provider
•
Waikato district domicile patient
Exclusion of injury within the Abbreviated
Injury Scale (AIS) body region 1 (head/
neck). The AIS is an anatomical scoring
system that grades injuries on a scale of 1
to 6 to assess the potential for risk to life; an
AIS score of 1 is minor and 6 is reflective of a
non-survivable injury.8
A heterogeneous purposive sample of all
eligible patients was used to target sample
diversity across gender, age and ethnicity.9–11
A total of 17 participants were recruited
to the study, including eight patient participants (up to 12- months post-discharge),
eight patient-nominated key support people,
and one patient-nominated health professional (an occupational therapist). Only one
patient participant felt able to nominate a
health or social care professional involved
in their care. Participants provided consent
prior to interviews and were informed that
the interview questions may raise issues
that could cause distress. If this occurred,
the distressed patient protocol was applied,
and participants were provided options for
follow up.
Ethics approval was gained from the
Health and Disability Ethics Committee NZ
(HDEC), and project approval provided by Te
Puna Oranga Maori Consultation Research
Review Committee, Waikato District Health
Board.
Data collection
A total of 17 participants participated in
semi-structured, in-depth interviews rather
than focus group, to enable participants to
speak freely about their experiences and
perceptions.12 Kanohi ki te kanohi (face to
face) interviews were offered to encourage
trust, which is critical to engagement and
relationship development with Māori.13 The
interviewer was not known to the participants. The purposive sampling was done
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by an MTS hub data analyst and details of
potential patients were kept confidential
from the researchers and interviewer.
Participants were recruited to the study
and interviewed until saturation occurred
(which was earlier than anticipated). Saturation occurred when the same themes were
recurring, and no new insights into these
themes were given by additional sources of
data. Patients were invited to participate in
one interview (by telephone or kanohi ki te
kanohi) up to 12 months post-discharge.12
All interviews were conducted between
1 October 2017 and 30 November 2017.
Interviews were recorded with participant
consent using a digital voice recorder. A
topic guide (Appendix) was used to provide
interviewer prompts of key issues for exploration, including the injury; treatment of
the injury; experience with compensation
agencies; impact on work life, home life,
transport and health; communication and
cultural needs; and perception of recovery.
Data analysis
Each interview was transcribed from
the audio recording for analysis using the
NVIVO Version 8.0. Braun and Clarke’s14
six-phase process of thematic analysis
was used to identify important thematic
groupings and the relationships between
them. Transcripts were read a number of
times to ensure consistency of meaning of
individual responses, initial codes were
given within each interview, then compared
and integrated across the entirety of the
transcripts enabling theme development
(AB and KO). Two researchers coded the
data and confirmed the themes to ensure
the thematic analysis was authentic and of
good quality. AB is an experienced health
services researcher (PhD) with extensive
health services research experience in areas
other than trauma and critical care; KO
is an emerging researcher and registered
nurse (RN, MN, Crit Care) with 30 years’
experience working intensive care, emergency department and remote area nurse in
Australia and New Zealand. Larger, broader
themes developed and were able to be
described and labelled. Participant quotes
were included to illustrate patient experience themes post serious injury.
Results
Participant profiles
The ages of patient participants ranged
from 16 to 79 years (Table 1). All patient
participants nominated a key support
person; however, of the eight patients interviewed up to 12 months post-discharge, all
but one could not identify who was responsible for their care coordination following
discharge and were therefore not able to
nominate a health or social care professional to participate in an interview. The one
patient-nominated health professional was
an occupational therapist.
Patients perceived their pre-hospital
and emergency care as high quality and
highly valued the compassion of staff,
although expressed concerns regarding
access to psychosocial services, reliance on
key support people, poor communication
and information provision and a lack of
preparedness for discharge, and coordination of post-discharge care.
The need for routine screening and
access to psychosocial services
All patients perceived ongoing physical
and emotional stressors associated with
the initial traumatic impact, regardless of
the time since discharge. Several patients
reported hiding their physical and emotional
concerns from their key support person
to avoid upsetting them, which added to
the sense of isolation they were already
feeling. Ongoing effects such as pain, fatigue,
reduced memory, emotional instability,
physical decline and financial pressure
caused concern for the future and the
unknown likelihood of returning to pre-accident health. Some patients returned to
work earlier than they should have, misrepresenting their recovery to their doctors in
order to get clearance for work.
“As soon as I got the clearance I just
went back, even though… I still can’t close
my fingers properly. I’m forcing myself to
squeeze it and just do my jobs. I needed that
money because I had bills to be paid… I just
felt hopeless. Because I couldn’t support my
family or do anything for them.”
– Steven
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Table 1: Patient participant demographics.
Patient
participant
pseudonym
Gender
Ethnicity
Age
range
Timeframe
since
discharge
from
hospital
Mechanism
of injury
Patient reported
injuries
Key support
person
relationship
to
participant
Hailey
Female
NZ European
46–60
6 weeks
Fall
Liver laceration,
fractured ribs,
punctured lung
Friend
Tina
Female
NZ European
31–45
6 months
Workplace
incident
Fractured ribs,
punctured lung
Sister
Elizabeth
Female
NZ European
16–30
6 months
Road traffic
crash
Multiple
fractures (arms,
legs, pelvis),
kidney injury,
concussion
Partner
Mike
Male
NZ European
46–60
6 months
Fall
Fractured ribs,
punctured lung
Wife
Steven
Male
Māori
46–60
12 months
Road traffic
crash
Multiple
fractures (ribs,
pelvis, fingers),
concussion
Wife
Belinda
Female
NZ European
46–60
6 weeks
Workplace
incident
Limb amputation
Husband
Karen
Female
NZ European
>61
6 weeks
Fall
Multiple fractures
(nose, compound
fracture of leg
and wrist)
Friend
Joe
Male
NZ European
>61
12 months
Fall
Fractured ribs
Wife
Patients, their key support people, and
the nominated service provider all stated
that earlier access to psychological care or
counselling could have avoided escalating
issues and concerns regarding restoration of
function.
initiated in hospital, was one of the practical
recommendations suggested by patients and
key support people to improve the patient
experience following serious injury.
“… I would have much preferred earlier
access to counselling. It still would have
been difficult after hospital, but it probably
would have shortened the amount of time
[for recovery]. I wouldn’t have lost a lot of my
life… lost a lot of dignity, all that sort of stuff.
…I was in a really, really dark place and I was
quite suicidal for a long time.”
All patients were highly appreciative
of the support provided by key support
people and the crucial role they played in
recovery, stating their key support person
was the primary factor that facilitated
recovery. Recognition was afforded to the
key support person for preserving order
during a perceived tumultuous time and
maintaining communication with everyone;
family, friends, (in some cases) the media
and service providers.
– Elizabeth
Improved access to counselling services
following routine psychological screening
Pivotal role of the key support
person
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“I just felt hopeless. Because I couldn’t
support my family or do anything for
them. Everything (was left) up to our eldest
daughter. She did a wonderful job. Without
her and my sister-in-law… they’ve done
wonders. Kept the family all intact, let
them know what’s happening. It was quite
amazing.”
– Steven
All patients were concerned with the
concept of carer burden, as often the key
support person would have to assume the
extra financial obligations, home responsibilities, carer duties, become the patient’s
champion when dealing with service
providers, and preserve the memory of
events patients were often unable to recall
due to analgesia and/or turmoil during the
acute hospital phase.
Inadequate communication and
information provision
The quality of patient care is improved
when members of the healthcare team
work in collaboration to share their patient
care perspectives, yet many barriers exist
that can obstruct a team-based system.15,16
While all participants were satisfied with
the overall care they received during their
admission and were highly appreciative of
the pre-hospital and emergency care they
received, all participants shared concern
regarding communication during rehabilitation (in-hospital and at follow up clinics).
“The biggest problem was communication
from day one. The ambulance were brilliant,
the trauma team [emergency department
staff] were brilliant and then it turned to
custard, to put it politely. There just hasn’t
been any follow up...”
– Karen
A lack of staff continuity also contributed
to feelings of insecurity from being lost
in the system, and unfamiliarity with
staff contributed towards a perception of
confusion as to who was caring for them
and in what capacity.
“In the hustle and bustle of the weeks at
hospital things got overlooked… you’d go
through three or four shifts of nurses and
think have any of them reminded (her) to do
that.”
– Sibling, key support person
Reported lack of communication both in
hospital and at follow up clinics, resulted in
missed (minor) injuries, and some delays in
treatment, which patients and key support
people felt affected their confidence in the
care received and recovery time.
Lack of preparedness for discharge
Communication surrounding discharge
processes was described as a significant
concern and the discharge process itself
was felt to be ad hoc rather than meeting
patients’ expectations of a meticulously
considered practice. Almost all patients
reported distress when medical staff
sought discharge as they reported no prior
discussions with them about going home.
Discharge was generally required on the
day and did not always acknowledge and
address home conditions and the provision
of discharge supports. Patients and key
support people reported that discharge
from hospital was perceived as stressful,
and many felt ill prepared for discharge.
All reported apprehension at the perceived
lack of discharge planning. Key support
people were alarmed at the thought of the
responsibility of caring for their family
member without adequate resources as they
had expectations of being supplied with
equipment, which may have been eased
through referral to allied health to assist
with discharge planning.
“There was a bit of… we’ll just push you
out the door and you can go home …because
(my husband) wouldn’t have been able to look
after me and there was the conversation of is
there anyone at home that can look after you
and I was like well not really …if I’m in trouble
he’s not really going to be there to help me
out. I explained to them my house… is… old…
and I’ve got pets, toilet outside, awkward little
steps and stuff, and at that stage I was still
sleeping sitting up in the hospital bed because
I couldn’t lie flat, but they wouldn’t listen and
discharged me anyway.”
– Tina
A further practical recommendation
suggested by patients and their key
support people was to ensure more specific
discharge information and preparation
is provided for patients and key support
people during the hospital stay and before
patient discharge from hospital.
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Lack of coordination of postdischarge care
A consistent emerging theme was the sense
of a lack of coordination of post-discharge
care, and the absence of a consistent point of
contact for ongoing management. Frustration
at the lack of communication surrounding
follow-up appointments was frequently
expressed. Participants reported multiple
appointments on multiple days of the week
with physical, social and financial consequences. Patients commonly reported staff in
outpatient clinics requesting regular follow
up for them, but not receiving appointment
invitations. This produced a lack of confidence in the current booking system.
“I think it was two appointments one day
and the third appointment was about three
days later. Because they were all in Hamilton,
I did try and get them all on one day and it
just wouldn’t work. It’s… extra travel and
time. …everything is based in Hamilton and
that’s an hour’s drive, and yes ACC do pay for
that but when you go an hour there, an hour
back plus the appointment it’s actually a big
chunk out of the day.”
– Belinda
A further practical recommendation
suggested by patients and their key
support people was that travel to follow up
appointments could be avoided through
the use of a virtual trauma clinic, where
possible. Patients and key support people
believed this would reduce much of the
disruption and the tangible and intangible
costs associated with attending clinics.
Discussion
This study is the first to provide a detailed
description of patient experiences following
serious injury and admission to Waikato
Hospital. It highlights perceived issues and
limitations in the patient care pathway
following serious injury, especially relating
to access to psychosocial services, the high
level of reliance on key support people,
inadequate communication and information
provision and a lack of preparedness for
discharge and coordination of post-discharge care. Despite significant issues with
parts of the transition process, most patients
emphasised the high quality of care and
empathy provided by in-hospital services
during their admission phase of care.
Several limitations of the study are noted.
Complete exclusion of AIS body region one
(head/neck) limited the number of eligible
participants. Service provider perspectives
were not fully explored as only a single
participant from this group was nominated, which reinforced patient perceptions
regarding lack of coordination of post-discharge care. The sample size limited the
ability to explore emerging concepts seen
in smaller patient subgroups, including
perceptions regarding cultural responsiveness. A larger study would provide the
opportunity to explore additional emerging
themes more thoroughly. The study was
limited by sample size through its focus
on adult patients managed at Waikato
Hospital (where most major trauma patients
are managed), which may not reflect the
wider, less severely injured patients in the
MTS population. Nevertheless, saturation
occurred for the key themes described in
this study, and patients felt very strongly
that these should be disseminated widely
with a view to promoting system improvements. Due to the inclusion criteria, the
difference in experience between patients
managed by anatomically-oriented surgical
services in comparison with the dedicated
Trauma Service at Waikato Hospital was
not assessed. Along with improvement
of specific services such as psychological
counselling, it is likely that more widespread adoption of the continuation of
care model used by the Waikato Trauma
Service could improve consistency across
all discharging services in the delivery
of information and clinical care in the
transition to the community. The continuation of care model has been reported to
improve patient outcomes by coordinating
timely access to appropriate care through
improved coordination and communication
between multidisciplinary staff which can
be overseen by trauma coordinators. Length
of hospital stay may also be reduced through
timely discharge and communication with
onward support services. Furthermore,
length of time spent in more costly higher
dependency settings may be reduced
through timely transfer of care.17
Most patients expected a single point for
communication and advocacy; a person
or a service who would take responsibility
for meeting needs, although there were
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mixed reports as to which service provider
should hold responsibility of this. General
practitioners were generally not thought
of as first points of contact and while some
patients stated the cost of GP consultations
was more than they could afford, most
patients expected ongoing assessment by
treating staff from the hospital. Patients
often reported ongoing health concerns but
had no knowledge of who to report it to and
whether they should; they expressed apprehension when needing to report symptoms
previously raised with medical staff, leaving
patients with perceived uncertain medical
diagnoses. While not uncommon,18 the
impact of suboptimal handovers at hospital
discharge on the patient experience and
potentially avoidable hospital readmissions19
warrants further investigation to ensure
system level improvement occurs such as
the use of ISBAR—introduction, situation,
background, assessment, recommendation—
to guide a clinical handover to primary care
rather than the provision of a discharge
summary, which may be perceived as an
administrative process only.
Confidence was lost with outpatient
clinics as patients were promised regular
engagement and, in some cases, failed to
receive appointment bookings. The lack
of staff continuity in follow-up clinics also
contributed to this, as patients wanted
review by staff familiar with their injuries.
Bookings were felt to be made irrespective
of the inconvenience this may cause with
multiple appointments on multiple days;
satellite clinics or virtual clinics appear not
to be offered or explored but were suggested
by patients to support follow-up care. Most
patients perceived a sense of isolation and
lack of psychosocial support, turning to
their key support person for assistance. This
caused anxiety for all patients, who felt that
ongoing physical and emotional assessments
should be an essential part of treatment
for a patient with serious injury, including
engagement with psychological or counselling services from the earliest reasonable
point following admission. These issues
were exacerbated when patients themselves
were key support person for other more
seriously injured family members.
The key support person was crucial to
the patient and their recovery, which is
a common finding.20 With deficiencies
perceived in counselling assistance from
in-hospital and post-discharge service
providers, the key support person would
often be the only avenue for patients to
receive emotional care. Additionally, the
key support person became the only link
to a social network system, travel means
and financial support. Most patients were
concerned about the burden transferred to
their key support person and chose to be
interviewed with their key support person
in attendance; it became evident that the
patients relied upon the key support person
for recall of events. Without recording
events, recollection of much of the recovery
was vague for some patients due to an
intensive care stay, analgesia, and the turmoil
surrounding an admission with an acute
injury. Immense gratitude was expressed
regarding support from key support people
during the hospital stay and post discharge
care. The altruism of all participants was
evident through the concern expressed
for other patients who may not have the
care of a key support person, with patients
describing the central role of the key support
person in orchestrating discharge supports
and coordinating appointments.
Surviving a traumatic event resulting
in serious injury is a time of chaos and
confusion for patients and their key support
people. Inadequate communication from
staff during the in-hospital phase about
what to expect following discharge, especially links to community health and social
services, adds to this predicament significantly. Once patients and their key support
people adjust to the initial impact of the
traumatic event, further adjustments are
required to manage the ongoing effects of
the event such as the physical and emotional
concerns and financial pressures. Key
support people are the single largest factor
in facilitating patients’ recovery from serious
injury yet are left significantly unsupported.
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selling and social services that extend
from hospital to community-based
services to improve outcomes for
patients and whānau;24
In summary, this study identified
several possible areas for improvement to
service delivery following serious injury,
specifically:
1.
the review of service provider
communication and service delivery
processes and practices in co-design
with former patients and key support
people, particularly in relation to
information sharing and discharge
planning;
4.
review of post-discharge assessment
and follow-up services, including the
use of virtual multi-disciplinary clinics
linked to expert helpline services to
assist with capacity for ad hoc support
from an informed, single-point-ofcontact, post-discharge service;25
2.
the establishment of trauma navigators (specific trauma discharge
planners), for patients not admitted
under a trauma service, to assist with
the provision of more holistic, integrated care;21–23 and the use of ISBAR
(introduction, situation, background,
assessment, recommendation) to
guide a clinical handover to primary
care rather than the provision of
a discharge summary, which may
be perceived as an administrative
process only;
5.
engagement of ACC and GPs in
redesign of the information exchange
and follow-up processes;
6.
increasing the visibility of carer
burden to community service
providers to aid the development of
effective carer-support services; and
7.
the application of comprehensive
trauma care and discharge planning
methods currently employed by
specialised trauma services to surgical
service discharges of all trauma
patients.
3.
focused service improvements to
support early screening for psychological trauma and facilitation of early
engagement with psychological, coun-
Although undertaken in the Waikato
region of New Zealand, opportunities for
improvement may apply to other healthcare
contexts.
Appendix
Interviewer prompts used in semi-structured interviews with patients
treated at Waikato Hospital following serious injury
About the injury
•
Briefly describe the event and the resulting injuries.
Treatment of injury
•
Was St John/Helicopter service involved at the scene?
•
How do you feel about the care you received?
•
How could the treatment you received be improved?
•
How do you feel about the care you received in hospital?
•
How could the treatment you received be improved?
Hospital-based care
•
How do you feel about the communication you received?
•
Describe the discharge planning/process?
•
What follow up clinic appointments were arranged for you?
•
Have these changed over time?
•
Are the services and treatments meeting your needs?
•
How do you feel your cultural needs have been met following your injury?
•
How could this have been improved?
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Post discharge care
ACC participants
•
How do you feel about the care you’ve received from ACC?
•
Is there anything you feel could have been done differently by ACC regarding your
recovery?
•
Can you tell me about any rehabilitation assistance?
•
Did these services meet your needs?
•
Are there any improvements that could be made?
Private health insured participants/another insurer
•
Did you make a claim with your private health insurer for your injury?
•
Can you tell me about your experiences with your health insurer since your injury?
•
Is there anything you feel could have been done differently by your health insurer to
help your recovery?
Work life/finances
•
What impact did the accident have on work life?
•
If you have returned to work, did you need clearance from a health professional?
•
Were you ready to return to work?
•
Did this involve a return to work program?
•
Can you tell me what impact the accident had on you financially?
•
If you weren’t provided with financial compensation from ACC, did you seek assistance from other means? Eg, family, bank, Work and Income NZ
•
What financial costs have you had as a result of the injury?
•
What costs weren’t covered by ACC?
Home life and relationships
•
What impact has the injury had on your home life?
•
Can you describe any disruptions that occurred?
•
Has the injury affected your relationships with friends or relatives in any way?
Transport
•
Have you had any transport issues since the accident?
Health
•
What impact has the injury had on your general health?
•
Probe: Memory, fatigue, decreased mobility.
•
Are these ongoing since the accident?
•
What has helped you recover the most?
•
What has made it harder to recover?
•
How do you think you’re coping emotionally?
•
Probe: Have they sought counselling/psychological assistance?
Perception of recovery
•
How well/quickly do you feel that you have recovered?
•
How do you think the injury will impact on your future?
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Competing interests:
Nil.
Acknowledgements:
The authors would like to thank Waikato Institute of Technology for funding aspects of
this project.
Author information:
Angela Beaton, Centre for Health and Social Practice, Waikato Institute of Technology,
Hamilton; Katrina O’Leary, Midland Trauma System, Waikato Hospital, Hamilton;
Julie Thorburn, Centre for Health and Social Practice, Waikato Institute of Technology,
Hamilton; Alaina Campbell, Midland Trauma System, Waikato Hospital, Hamilton;
Grant Christey, Midland Trauma System, Waikato Hospital, Hamilton; Waikato Clinical
School, University of Auckland, Auckland.
Corresponding author:
Dr Angela Beaton, Director, Centre for Health and Social Practice, Waikato Institute of
Technology, Private Bag 3036, Waikato Mail Centre, Hamilton 3240.
angela.beaton@wintec.ac.nz
URL:
http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2019/vol-132-no1494-3-may-2019/7866
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