3. Electronic Theses and Dissertations (ETDs) - All submissions
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Item Translating research evidence into clinical practice in relation to the implementation of early mobility programmes in South Africa and Zimbabwean government hospitals' intensive care unitst(2019) Tadyanemhandu, CathrineBackground: The early mobilisation of patients in the intensive care unit (ICU) is advocated as an intervention that may attenuate the consequences of critical illness. Recent evidence shows that the early mobilisation of patients in ICU is feasible, safe and is associated with improvement in the patients’ clinical outcomes. However, not all units have adopted an early mobilisation programme as the standard practice of care for every ICU patient. There remains a paucity of evidence to explain why studies supporting the early mobilisation of patients in ICU are not being translated into practice as only a small percentage of patients are being mobilised out-of-bed, and this has resulted in an evidence-practice gap. Purpose: The overall purpose of this study was to determine whether research evidence related to early mobilisation is being implemented in clinical physiotherapy practice in the ICUs of government hospitals in Zimbabwe and South Africa (SA); to identify the factors (barriers and facilitators) related to the implementation of such interventions; and the design strategies that may address the identified gaps at either the provider, patient or healthcare system level. Methods: A mixed methods approach was used to address the aims of the study. An explanatory sequential study design in which a cross-sectional survey of 18 hospitals (n=5 in Zimbabwe; n=13 in SA) was done; this was followed by in-depth interviews with 22 physiotherapists (n=4 from Zimbabwe; n=18 from SA) working in ICUs to determine the prevalence of early mobilisation practice in the units, the ICU organisational structures and the barriers and facilitators that influence the early mobilisation of patients in SA and Zimbabwean government hospital ICUs. Lastly, a Delphi study with a panel of 23 experts from SA and Zimbabwe was done to explore expert opinions and consensus on the strategies to be implemented in SA and Zimbabwean government hospital ICUs to overcome the identified barriers to early mobilisation practice. Results: The findings of the study suggest that there are very low rates of out-of-bed mobility activities performed in the ICUs in SA and Zimbabwean hospitals (19.5% and 25% respectively). Reasons why patients were not mobilised out-of-bed differed between the two countries with the majority of the patients from Zimbabwe not being mobilised on account of sedation and unresponsiveness (n=13; 32.5%), whilst the patients from SA were not mobilised as they were unresponsive (n=50; 24.4%, p<0.05). There was a significant difference in the indications for ICU admission between the two countries, with the majority of the patients from Zimbabwe being in the unit on account of acute respiratory failure (n=13; 30%) and for postoperative care (n=10; 25%), whilst traumatic injury (n=86; 41.9%) and postoperative care (n=54; 26.3%) were the main indications for ICU admission in the SA cohort (p=0.001). Predictors of out-of-bed activities were the type of ICU, the method of ventilation, and the number of days in ICU (p<0.05). Facilitators to early mobilisation identified by the physiotherapy clinicians included awareness campaigns of the benefits of early mobilisation in staff training and practice; the acceptance of the intervention as the standard of care; the availability of protocols on sedation, delirium assessment and early mobilisation in the unit; multidisciplinary team engagement; adequate staff numbers (especially physiotherapists); and, adequate mobilisation equipment (e.g. portable ventilators, walking frames and bedside chairs). Barriers to early mobilisation identified included variability in the manner of defining early mobilisation and the activities that constitute it; undefined roles within the multidisciplinary team responsible for the implementation of early mobilisation; negative perspectives of the clinicians about the intervention; the poor clinical reasoning skills of the clinicians; delayed consultations by specialists in the general ICUs; the high turnover rate of the ICU staff; the lack of protocols in the unit; patients in an unstable condition; inadequate staff numbers; and a lack of mobility equipment. The expert panel agreed that there is a need to standardise the practice of early mobilisation in units in SA and Zimbabwe by defining the specific activities considered as early mobilisation; through the development of detailed protocols and guidelines to assist with early mobilisation; by enlisting champion leaders in ICU who advocate for the early mobilisation of patients; by ensuring the timely management of orthopaedic fractures; by promoting the admission of patients into specialised units; by making mobility equipment available; through the creation of physiotherapy posts; and through skills training for all staff responsible for implementing early mobilisation activities for patients in ICUs. Conclusion: The rate of out-of-bed mobilisation activities in SA and Zimbabwean government hospital ICUs was found to be low and to be influenced by patient unresponsiveness, sedation and haemodynamic instability. The predictors of out-of-bed mobilisation activity included the type of ICU, the method of ventilation and the number of days in ICU. Overcoming the highlighted barriers will require a cultural change with regard to ICUs that prioritises the following: the early mobilisation of patients; developing standard operating procedures (clinical practice guidelines and protocols); multidisciplinary team engagement; coordinating the execution of early patient mobilisation; and effective communication among team members. These expert consensus strategies serve as the first step in guiding the development campaign to a focused approach and to use research evidence to promote better quality patient care in daily clinical practice in an ICU setting.Item The development of a standardised adaption program for enrolled nurses in critical care units of a private healthcare group in South Africa(2018) Dunsdon, JeananneCritical care units are highly technological environments and the nursing staff who work in the units are highly trained and competent to work within this environment. They are passionate care givers and deliver safe quality patient care. Due to the everincreasing shortage of professional nurses working within the critical care units, it has become necessary to introduce enrolled nurses into these specialised areas. This has resulted in an increasing sub-standard nursing care as well as increased complaints from patients and doctors. Enrolled nurses are not trained to work in these high-tech environments and therefore do not have the same level of competence as professional nurses. Adaptation programs (otherwise known as orientation programs) are in place, but the content of these programs and the evaluation of competency was questionable. The purpose of this phased study was to develop an adaptation program for enrolled nurses practicing in the critical care units, to facilitate competent care of patients within the critical care units by enrolled nurses. Phase 1 explored and described the content and functionality of the existing adaptation programs in the critical care units. In phase 2 a standardised adaptation program for enrolled nurses practicing in the critical care units was developed to equip them with the knowledge and competence to care for patients in the critical care units within their scope of practice. In phase 3, the adaptation program as piloted. This study used an intervention research design and employed mainly qualitative methods. The population of this study was the enrolled nurses, and professional nurses working in the selected critical care units of this private healthcare group in Gauteng, South Africa. The first phase of the study showed that the current adaptation programs were inadequate and consisted mainly of tick lists with no efforts to measure competency. Nominal groups of both enrolled nurses and professional nurses indicated a need for a standardized program which emphasized documentation, soft skills and certain competencies. Pre-testing indicated a knowledge deficit in several areas on the part of the enrolled nurses. Once the new program was designed based on the data collected, v it was piloted on nine enrolled nurses. Indicators related to patient satisfaction, affective and psychomotor competency of the enrolled nurses and satisfaction of their supervisors improved. There was little evidence, however, that knowledge levels improved. The researcher concluded the study by making recommendations for Nursing practice, education and research.Item The knowledge, attitudes and perceptions of organ procurement and donation among medical doctors in critical care settings in academic hospitals in Johannesburg, South Africa(2017) Solomon, CleoBackground: Statistics for the Johannesburg region demonstrate a low level of cadaveric organ donation within the public health care sector. The reasons for this are not clear. Information gathered in a previous study suggest that urban dwelling South Africans have a good attitude towards donation. It was hypothesized that knowledge, attitudes and perceptions of organ donation within the medical community may be contributing to this, and thus may be identified as a potential target for future intervention in order to effect an increase in donation rates. Methods: A self-administered questionnaire was completed by 105 of a total population of 190 doctors working in critical care, trauma, and accident and emergency departments in three academic hospitals in Johannesburg, South Africa. This cross sectional descriptive survey aimed to determine attitudes, knowledge and perceptions of doctors working in these settings towards organ donation and donor recruitment. Results: 65/105 (61.9%) of respondents had a positive attitude towards donation. This was reflected in their own willingness to donate organs after brain death (95% CI: 51.9-71.2%). The majority (65.7%) were unaware of the presence of protocols for organ donor identification and referrall. Only 46.7% of the respondents knew who to contact from an organ procurement organisation, once a donor is identified. Of the total respondents, 39% had ever managed a donor or contacted the transplant co-ordination team, and 39% knew the criteria for brain death.There was a significant association between a positive answer in the questions relating to experience questions and actual knowledge of the criteria for brain death. 90/105 (85.7%) agreed that organ donation could assist the family of the donor with the grieving process. The presence of an organ procurement team was felt to be the best option for improving organ donation rates. Conclusion: Doctors in critical care settings demonstrate similar levels of positive attitude towards donation as urban dwelling laypersons. Potential areas of intervention to improve donation rates include clearly defined protocols for donor identification and management, education regarding brain death criteria, and external support for family counselling.Item The scope of practice of physiotherapists who work in intensive care in South Africa: a questionnaire-based survey(2015-09-17) Lottering, Michele AndersonPatients admitted to the intensive care unit (ICU) require continuous monitoring and care from all staff working in ICU; this includes doctors, nursing staff, physiotherapists, dieticians and various other medical staff. Conventionally ICU was predominantly staffed by physicians and nursing personnel, with other members of health care having a minor part to play in the patient’s care whilst in ICU. Depending on the country, type of unit, amount of staff and level of training, the physiotherapist may screen the patients to assess if they require physiotherapy and if so, what intervention will be required; on the other hand, in some units the physiotherapist may rely on referral from the doctors and administer the treatment requested by the doctor for the particular patient. In 2000, Norrenberg and Vincent conducted a study to establish the profile of physiotherapists working in ICU in Europe. Van Aswegen and Potterton (2005) adjusted the questionnaire compiled by Norrenberg and Vincent (2000) to be more suitable for the South African setting. A pilot study using this questionnaire was done to determine the scope of practice of physiotherapists in ICU in South Africa. The content of the modified questionnaire used by Van Aswegen and Potterton (2005) was not validated prior to its implementation and a sample of convenience was used. Results reported from that survey were therefore only preliminary and no additional surveys had been performed to date. Objectives: The aim of this study was to establish the current scope of practice of physiotherapists in ICU in South Africa. To determine if physiotherapists’ scope of practice in ICU in South Africa has changed since the report published by Van Aswegen and Potterton (2005). To compare South African physiotherapists’ scope of practice in ICU with that reported on an international level. Methodology: A pre-existing questionnaire used by Van Aswegen and Potterton (2005) was content validated for this study. After consensus was reached on the final version of this questionnaire, it was uploaded onto SurveyMonkey. Physiotherapists that worked in ICU in the government sector, hospitals belonging to the Life, MediClinic and NetCare groups or that were members of the Cardiopulmonary Physiotherapy Rehabilitation Group of the South African Society of Physiotherapy were invited to participate in this study. Results: A total of 319 questionnaires were sent out and 108 responses were received. The combined response rate for this survey was 33.9%. An assessment technique that was performed ‘very often’ by respondents was an ICU chart assessment (n=90, 83.3%), auscultation (n=94, 81, 8%) and strength of cough effort (n=81, 75%). Assessment techniques that were ‘almost never’ or ‘never’ used included assessment of lung compliance (n=75; 69.4%), calculation for the presence of hypoxemia (n=74; 68.5%) and patient readiness for weaning (n=63; 58.3%). Treatment techniques performed by respondents ‘very often’ included manual chest clearance techniques (n=101, 93.5%), mobilising a patient in bed (n=91, 84.3%), positioning a patient in bed (n=91, 84.3%), airway suctioning (n=89, 82.4%), mobilising a patient out of bed (n=84, 77.8%), deep breathing exercises (n=83, 76.9%) and peripheral muscle strengthening exercises (n=79, 73.1%). Treatment techniques that were ‘never’ or ‘almost never’ used included the flutter device (n=77, 71.3%), implementation and supervision of non-invasive ventilatory support (n=77, 71.3%) and adjustment of mechanical ventilation settings for respiratory muscle training (n=76, 70.4%). Physiotherapists working in the private sector made up 60.2% (n=65) of the respondents. An afterhours physiotherapy service was provided to ICU patients by 78 (72.2%) of the respondents during the week. One hundred and five (97.2%) of the respondents provided a physiotherapy service for ICU patients over the weekend. When comparing the results of the current study to the studies by Norrenberg and Vincent (2000) and Van Aswegen and Potterton (2005), there was a significant difference (p < 0.05) in the usage of IPPB/NIPPV, weaning patients from MV, adjustment of MV settings and IS between the studies. Results from the current study showed a significant difference (p < 0.05) in the involvement of respondents in suctioning, extubation and adjustment of MV settings compared to that reported by Norrenberg and Vincent (2000). Conclusion: Physiotherapists in this study performed a multisystem assessment of their patient’s which is important since physiotherapists are first line practitioners in South Africa. Physiotherapists play an important role in treating and preventing respiratory and musculoskeletal complications that occur in ICU. The results from this study showed that physiotherapists in South Africa are treating their patient’s according to evidenced based practice but due to the high nonresponse bias these results should be interpreted with caution. The results from this study can be used to develop preliminary clinical practice guidelines for physiotherapists working in ICU in South Africa.Item The nature of involvement of physiotherapists in South Africa in the weaning of mechanically ventilated patients(2014-09-11) Morar, DipnaMechanical ventilation (MV) is the defining event of intensive care unit (ICU) management. Although it is a lifesaving intervention in patients with acute respiratory failure and other diseases, a major goal of critical care clinicians should be to liberate patients from MV as early as possible to avoid the multitude of complications and risks associated with prolonged MV. Such complications include an increase in mortality, morbidity and ICU length of stay (LOS), as well as reduced functional status and quality of life (Moodie et al 2011; Gosselink et al 2008). Rapid weaning however has its own potential problems such as fatigue or cardiovascular instability, either of which may ultimately delay the weaning process. Premature extubation, leading to reintubation, is associated with increased risk of pneumonia and mortality (Brown et al 2011; Meade et al 2001 (a)). In view of this, there has been increasing interest in delivering more consistent practice in ICUs by developing weaning protocols that provide structured guidelines to achieve prompt and successful weaning. Many studies have shown the benefit of allied health care worker (nurses and physiotherapists) driven weaning protocols in decreasing MV days and costs (MacIntyre 2005; Dries et al 2004; Ely et al 2001). Objectives: The objectives of this study were to determine a) if the number of patients in the ICU has an influence on physiotherapists’ involvement in the weaning of patients from MV, b) if the type of ICU has an influence on physiotherapists’ involvement in the weaning of patients from MV, c) if physiotherapists are involved in the development and implementation of weaning protocols for mechanically ventilated patients in their ICUs, d) if physiotherapists are involved in titration of ventilator settings for patients during the weaning process, e) what modalities physiotherapists in South Africa use to facilitate respiratory muscle strengthening to assist weaning of patients on MV, f) if physiotherapists in South Africa are involved in the extubation of ventilated patients, g) if there is a difference in involvement in weaning of mechanically ventilated patients between newly qualified physiotherapists and experienced physiotherapists. The last objective of this study was to determine if current physiotherapy involvement in the weaning of patients from MV in South Africa is in line with international physiotherapy practice according to the literature. Method: A questionnaire was developed by the researcher using available literature on the nature of involvement of physiotherapists in the weaning of mechanically ventilated patients. Content validation of the questionnaire was achieved after a panel of senior cardiopulmonary physiotherapists analysed each question and their recommendations and adjustments were implemented. Physiotherapists who practice cardiopulmonary physiotherapy in adult ICUs of hospitals in the public and private sectors in South Africa were sought and targeted for the study. The self-administered questionnaire was then posted or emailed to the physiotherapists identified for inclusion into the study. Results: A total of 425 questionnaires were distributed to physiotherapists who practice cardiopulmonary physiotherapy in adult ICUs of hospitals in South Africa. Of the 425 questionnaires distributed, 200 questionnaires were sent via the postal system and 225 were sent via email with a link to an online survey. The response rate for the postal questionnaires was 54.5% (n=109) and 33.3% (n=75) for the emailed questionnaire, giving a combined response rate of 43.3%. The results showed that 76% of South African physiotherapists are not or are seldom involved in the weaning of mechanically ventilated patients in adult ICUs. They are not involved in the development of weaning protocols (74%, n=51), titration and adjustment of MV settings (>80%, n=154), spontaneous breathing trails (67%, n=119) and non-invasive ventilation (58%, n=101). Physiotherapists working in South Africa are somewhat involved in extubation (16%, n=28). The most common physiotherapy modalities used in ICU to facilitate respiratory muscle strengthening are exercises (81%, n= 138), early mobilisation out of bed and deep breathing exercises. (77%, n=134). Physiotherapists’ involvement in the weaning of mechanically ventilated patients are not influenced by the type of ICU they work in (p>0.05), type of physiotherapy degree they have (p=0.24) or whether they are newly qualified physiotherapists or experienced physiotherapists (p=0.43). Conclusion: This survey shows that most physiotherapists who work in adult ICUs in South Africa are not involved in the weaning of mechanically ventilated patients. The survey does show that there is a need for physiotherapists to reconsider their role in ICU with regards to weaning patients from MV as current practice is not in keeping with the international practice of respiratory therapists in the United States of America (USA) and physiotherapists in the United Kingdom (UK), Australia and Europe.Item Nurses' and physicians' attitudes toward physician-nurse collaboration in private hospital critical care units.(2014-04-25) Le Roux, LynnIn the setting of the critical care unit, the nurse is caring for the critically ill patients and is the care giver who is present at the bedside for 24 hours. The nurse comes into contact with all other disciplines attending to the patient and is thus often the common link in the multidisciplinary team. It is therefore essential that there is effective collaboration between the physician and the nursing practitioner.With the world-wide shortage of skilled nurses worsening, it is imperative that we look at a means of retaining our current nursing personnel and attracting new nurses into the profession. Many studies examining the relationship between a healthy work environment and the retention of nurses have rated collaboration as a key aspect. The setting for this study was five critical care units within the private health care sector. The study investigated both nurses’ and physicians’ attitudes towards collaboration in critical care units, as well as identifying factors which facilitate and constrain effective physician-nurse collaboration. Recommendations for enhancing collaboration within the critical care unit were explored. In this study a non-experimental descriptive design was be used. The Jefferson Scale of Attitudes toward Physician-Nurse Collaboration, a 15 statement Likert scale, was utilized to collect data from both the nurses and the physicians. The data was analysed using factor analysis and descriptive statistics. The results showed that nurses had a slightly more positive attitude toward collaboration as compared to the physicians, however the difference in the overall scores was not statistically significant.Item Perceptions and opinions of critical care nurses regarding family presence during resuscitation(2012-01-10) Le Goff, ChanelThe concept of family witnessed resuscitation in South African critical care areas is one that is rarely practiced. In the majority of cases family members are ushered away from the resuscitation area, and this task is usually one that is performed by the critical care nurse. Consequently, the critical care nurse in the South African public health sector is relatively inexperienced in family witnessed resuscitation. In addition to this, few institutions have written policies with regards to family presence. Hence, the importance of uncovering critical care nurses opinions and perceptions of family presence during resuscitation. Therefore, the aim of this study was to explore and describe a select group of critical care nurses perceptions and opinions regarding family presence during resuscitation. A qualitative study was undertaken in which one-on-one semi structured interviews were conducted as a means of data collection. The following question was asked of the participants, ‘As a critical care nurse, if your patient was been resuscitated, and the family members requested to be present, how would you feel?’. In addition to this the following question was asked of the participants with regards to written policy within the institution used in this study, ‘Is there a policy in place in this institution regarding family presence?’. A total of 11 interviews were conducted including participants of various cultures and previous experiences of family witnessed resuscitation. The data collection and analysis processes were integrated as each interview was directly transcribed following the interview. The data analysis process was guided by Tesch’s method for qualitative data analysis. Four nurses interviewed in this study felt that family witnessed resuscitation is unacceptable, and two were unsure. However, these nurses did waver with regards to this. Nine participants expressed reservations regarding family witnessed resuscitation including the potential traumatic effects that it could have on the family. In addition to this, four participants had concerns that family members might interfere with resuscitation efforts came to light. Six participants also feared that their own shortcomings might be exposed to family members should they observe resuscitation attempts. Three nurses in this study believe that family members may misinterpret issues pertaining to resuscitative efforts, and that the physical space at the bedside would be inadequate. Six participants pointed out that it is norm to ask family members to leave the resuscitation area, in part due to habit, and thus could be preventing family members being invited to the bedside. In addition to this, lack of policy guidelines may be acting as a barrier to allowing and facilitating nurses to invite family members to witness resuscitation. In contrast, five nurses in this study had accepting views on family witnessed resuscitation. This, despite the lack of previous experience these nurses had with regards to family witnessed resuscitation. And as mentioned, nurses did waver with regards to this. Psychological pre-preparation of the family emerged as a concern for three participants. Three of the eleven nurses interviewed would extend an offer to family members to be at the bedside during resuscitation. Four participants felt that a benefit to family witnessed resuscitation is the opportunity it may offer for closure for the family should the resuscitation attempt be unsuccessful. In concluding, the participants in this study are inexperienced in the field of family witnessed resuscitation, and most participants wavered with regards to their perceptions with regards to family witnessed resuscitation.