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 perceptions of occupational performance priorities for adolescents with learning difficulties(2017) Marx, LoaniOccupational therapy for adolescents with learning difficulties (LDs) is still a relatively undeveloped area of practice in contrast to paediatric services for younger populations. The purpose of the study was to explore the perceptions of adolescents with learning difficulties and their parents regarding their most important current and future occupational performance priorities (OPPs), current occupational difficulties as well as intervention and supports that have been helpful thus far. A descriptive, explorative, qualitative study design was utilised. Eighteen adolescents aged 13 – 21 years with LD and nine parents were interviewed or included in a focus group. Data was inductively coded and analysed, identifying three main themes. The main needs in terms of OPPs included understanding the adolescent perspective and developmental needs, occupational needs and preparing for the future. Occupational difficulties included developmentally-related difficulties, occupational difficulties and intervention-related difficulties. Current and previous effective support and interventions as reported by the participants entailed support and mentoring, direct interventions and the promotion of self-determination. Recommendations for implementing occupation-based practice for this population are made.Item Routine measurement of outcomes for mental health care users attending occupational therapy(2016) Silaule, OlindahIntroduction: The lack of accurate routinely collected data regarding mental health services is one of the several ongoing challenges facing healthcare services in South Africa. The increasing emphasis on routine outcome measurement within the field of mental health has urged occupational therapists to demonstrate the impact of their intervention on mental health care users. Therefore, the aim of this study was to implement routine outcomes measurement in the occupational therapy department in order to describe and document changes in activity participation in MHCUs at Tintswalo Hospital situated within a rural site of Mpumalanga province. Methodology: Quantitative methods were employed in this study with a sample size of 64 MHCUs. One group pre/post- test design was used in order to collect data using an Activity Participation Outcome Measure (APOM). Results: The key findings demonstrated that the majority of participants improved significantly across all of the APOM domains during hospitalisation. A decline in the APOM domains was noted in the follow-up stages yielding insignificant results as demonstrated by the value of the effect sizes. Conclusion: Results of this study demonstrate the relevance of routinely measuring outcomes in mental health. The study generated evidence of change in activity participation during hospitalisation and follow-up and emphasised the need for future research in this regard.Item Occupational therapy reports: exploring best practice(2017) Jay, JulieIntroduction: Communicating about patient assessment and intervention is accepted as an essential requirement of the health professional’s role. Current research indicates that this area of professional practice is the most routinely neglected. There is anecdotal evidence that reporting by occupational therapists, especially novice clinicians in South Africa, is of a poor standard, but as yet, there is limited research into this field. This study aimed to establish what occupational therapists view as current and best practice regarding report writing and the factors that influence their ability in writing profession specific reports. Method: The study was completed in two phases. The first phase included six focus groups, carried out with occupational therapists in a variety of clinical and discipline specific contexts. The qualitative data were analysed to determine specific themes using an inductive approach. Several conflicts emerged leading to the second phase; a nominal group with subject matter experts where data were analysed using deductive content analysis. Results: Three themes emerged. Generic occupational therapy reporting issues identified that therapists are subject to generic barriers that influence their report writing. The occupational therapy identity, highlighted that profession specific challenges, such as professional identity and the use of professional language are causing a disconnect in occupational therapists reporting on what they actually do. Thirdly, who is the audience, identified that the heterogeneous audience for occupational therapy reports can influence how findings are communicated. The disagreement as to how to overcome these challenges, lead to the subject matter experts in the second phase to provide recommendations to support best practice. Conclusion: Several recommendations surfaced, including creating a protocol and training to aid occupational therapists in complying with regulations. Ensuring reports are occupational in nature was deemed as important. Further research to establish a bank of explanations for occupational therapy language in South Africa to support the professions identity and to ensure service user involvement was recommended.Item Occupational therapy practice used for children diagnosed with a dual diagnosis of cerebral palsy and visual impairment in South Africa(2016-11-04) Van Rensburg, Zone JanseOccupational therapy aims to assist children diagnosed with cerebral palsy (CP) to achieve independence in their occupational performance areas. Treatment includes the use of sensory stimulation but when a child’s vision is impaired the use of visual stimulation becomes difficult. Research guiding occupational therapists on how to combine treatment methods successfully when treating children with CP with a co-morbid diagnosis of visual impairment is limited(15)(16). This study aims to determine the occupational therapy practice used, including the therapists’ knowledge; skill and perceived confidence, for children with a dual diagnosis of CP and visual impairment in South Africa. It uses a descriptive, non-experimental, cross-sectional framework within a quantitative research approach. Purposive sampling was used to select participants. This study finds uniformity in the approaches occupational therapists use when managing these children, but these approaches are not always based on best practice. Therapists use clinical expertise and integrate evidence based practice rather than the other way around. This study demonstrates a need for clear protocols on how to manage these children and more accessible postgraduate training in the management of them.Item Sensory modulation deficits and anxiety symptoms in children receiving occupational therapy(2016-10-12) Tauby, Michal ChavaThis study aimed to identify the association between observable sensory behaviours and anxiety symptoms in school-aged children. The children were between the ages of 8-10 years and attended Remedial Schools. The participants were receiving occupational therapy and were identified as having a Sensory Modulation Disorder (SMD). Parents rated their children on the Sensory Profile, and scores were correlated to the Spence Children’s Anxiety Scale, completed by the children. Participants showed high quadrant scores indicating “low registration” and sensory “over-responsivity” (avoidance and sensitivity to sensory input). Further, the participants were identified to be an “at risk” population for anxiety disorders, as scores of elevated anxiety exceeded normal populations. Although total anxiety scores correlated with only avoidance quadrant scores (and not sensitive scores as predicted,) other scores indicating emotional behaviours correlated moderately with total anxiety scores. It is concluded that children with SMD are at risk of presenting with anxiety disorder symptoms, and must thus be monitored for these.Item A study to determine which motor deficit has the strongest association with an improvement in functioning in activities of daily living in stroke patients(2015-09-07) Muller, CaitlinStudies to determine which underlying motor deficits have the greatest impact on improvement in functioning within activities of daily living in stroke patients are nonexistent with regard to the South African context. Effective stroke rehabilitation is essential due to rapid discharge rates and therefore it is important to focus on the motor deficit that will contribute most significantly to function. Patients from the ages of 35 to 85, who had suffered a stroke and were admitted to a private, neurological, rehabilitation facility in Johannesburg gave consent to participate in three outcome measures determining adequacy of balance (Berg Balance Scale), upper limb movement (Frenchay Arm Test) and gait (Timed Up-and-go Test) as well as one outcome measure determining level of functioning within activities of daily living (Functional Independence Measure). Results from the pre- and post-tests indicated that all participants improved during the time of rehabilitation. The findings of the outcome measures for each of the three different motor components were correlated with functioning in ADLs for each patient. The results showed that balance had the strongest correlation with functioning in ADLs, followed by upper limb movement, and then gait. The use of the FIM as a functional measure appeared to have some limitations and is not standardised to be used within the South African context.Item Convergent validity of the occupational therapy adult perceptual screening test with two other cognitive-perceptual tests in South Africa(2014) Razemba, FadzaiIn previous research done, convergent validity was not established for OT-APST with two cognitive-perceptual tests. In this research, the DLOTCA and RPAB were used as reference tools to determine the convergent validity of the OT-APST using Spearman’s correlation. The aim was to ascertain whether the three tests when administered at the same time would yield the same result. This was a quantitative cross-sectional study that was mainly correlative and comparative in nature. Convenience sampling was used (n=32). The tools compared evaluate similar constructs and were expected to have strong correlations. This current research revealed that six subscales of the OT-APST had significant correlations with similar cognitive areas from the DLOTCA and the OT-APST subscales often correlated with an appropriate item from the RPAB. This study provides sufficient evidence of the convergent validity of the OT-APST when compared to the DLOTCA and RPAB. The OT-APST proved useful in identifying patients with visual perceptual problems in a population not standardised for.Item A study of the effectiveness of certain occupational therapeutic group techniques in the assessment of the acutely disturbed adult psychiatric patient(2015-02-17) Crouch, Rosemary BarncastleItem The effect of neoprene thumb abductor splints on upper limb function in children with cerebral palsy.(2014-04-25) Hughes, Ashleigh AnnHand function deficits are associated with Cerebral Palsy (CP), and lead to diminished participation in activities of daily living (ADL’s), play and school. A longitudinal experiment incorporating a pre-test-post-test design was used with a convenience sample of 28 children with spastic quadriplegic CP randomly assigned to two groups. Both groups received monthly occupational therapy and a home programme over the three month period, the intervention group received an additional neoprene thumb abductor splint. The Quality of Upper Extremity Skills Test (QUEST) was administered at baseline and again at 3 months to assess changes in underlying impairments contributing to hand function. There were no statistically significant differences between final scores in the control and intervention groups, but a clinically significant improvement in score with the splint on for the intervention group was found. Wearing the splint during functional tasks may be beneficial in improving underlying impairments.