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 Physiotherapists' experiences of interactions with inter-professional team members in the adult intensive care unit (ICU) setting(2017) Ntinga, Mahitsonge NomusaIntroduction: Inter-professional team collaboration allows for enhanced patient safety, better use of resources by avoiding duplication of treatment, and improved standards of patient care as the time and skills of the professionals is efficiently utilised. In environments where the patients are highly dependent on the caregiver such as the intensive care unit (ICU), patient safety is of utmost priority and ensuring this safety requires collaboration of all professionals attending to the patient. The willingness to follow evidence based practice (EBP) and inter-professional team collaborative protocols become tools to ensure the ICU patients’ survival. Physiotherapists, through respiratory therapy, help reduce rates of ventilator associated pneumonia, time spent on mechanical ventilation and early mobilisation exercises aid in preventing ICU acquired weakness, which is a consequence of prolonged bed rest, and therefore reduces length of stay (LOS) in ICU and in hospital. There is evidence that using inter-professional team inclusive weaning protocols results in a shorter, more effective weaning process, which is most beneficial to patient outcomes and implementing interactive learning/education inclusive of all members. This allows for auditing and feedback and continuous professional development of the team. There is currently no research done in South Africa that explores, from the physiotherapist’s perspective, the collaboration, interactions and communication between physiotherapists and the interprofessional team members in the ICU setting. This study was conducted to establish physiotherapists’ experiences of interactions with the inter-professional team members in an adult ICU setting.Item Malaria at Chris Hani Baragwanath academic hospital intensive care unit: comparing outcomes between quinine and artesunate therapy(2017) Mathiba, RofhiwaBackground Malaria is a preventable and treatable disease that is a major burden in the African sub-region, accounting for 75% of malaria related deaths globally. Prior to December 2009, quinine has been the therapeutic option of choice for the management of Malaria in our unit. In the non-intensive care unit setting a mortality benefit of artesunate over quinine has been shown by two major trials and thus artesunate is currently therapy of choice for severe malaria. There is paucity of South African data regarding the outcomes of severe malaria patients treated w ith quinine compared to those treated with artesunate in the intensive care unit (ICU). Objectives The aim of this study was to compare the outcomes of patients treated with artesunate versus those treated with quinine, over a four-year period in our ICU. The primary outcome variables were length of stay and mortality, secondary outcomes where hypoglycaemia episodes and neurological outcome as measured by GCS on admission and on discharge. Methods This was a retrospective cohort study of patients with severe malaria treated at Chris Hani Baragwanath Academic Hospital with artesunate or quinine. The study was done in an ICU setting. This included a review of patients treated in the unit from 1st January of 2008 to 31st December 2012. A p value of<0.05 was chosen as a measure of statistical significance. Results The sample consisted of 92 patients. Forty three percent (n=40) received quinine and 57% (n = 52) received artesunate. There was no statistically significant difference between the two drugs in the treatment of severe malaria in our ICU with regards to length of stay (p=0.738), mortality (p=0.246), hypoglycaemia (p= 0.246) and neurological outcome as measured by GCS on admission and discharge (p= 0.357). Conclusion In our intensive care population the difference in outcomes between artesunate and quinine were not statistically significant. Artesunate did not confer an obvious benefit over quinine. Considering the differences in cost, logistical differences associated with the use of the two drugs as well as the emergence of artesunate resistance, we suggest that outcomes of artesunate versus quinine be investigated in other non-endemic regions.Item Effects of the stress management intervention amonsgt intensive care nurses in a Gauteng public hospital(2017) Haarde, MarliseBackground: South African professional nurses, working in an Intensive Care Unit (ICU) experience many physical and psycho-social hazards and risks. Stress, provoked by failure to meet work demands, leads to illness, injury and psychological suffering. This in turn may result in absenteeism and to the nurse abandoning the profession. It is therefore necessary for healthcare administrators to address the aspects leading to nurse stress and work burnout. Setting: The study was conducted in the adult intensive care units of a public sector hospital. Purpose of the study: The purpose of the study was to develop and pilot test a stress management intervention for professional nurses practising in ICUs. Method: A quasi-experimental non-equivalent control group design was selected for this study. It comprised of pre-testing, development and implementation of the intervention and post testing. Both groups of professional nurses were recruited from the same hospital by means of convenience sampling. Each group was asked to complete the Expanded Nurses Stress Scale (ENSS). The Intervention group participated in the educational intervention on stress management. The control group received no form of any intervention. Both groups completed the ENSS, four weeks after completion of the intervention. The intervention group of participants also completed a stress management intervention assessment form in order to collect feedback for the evaluation of the workshop and the researcher. The quantitative data was analysed by means of descriptive summary statistics. Results: There was clear evidence of significant differences (p=0.000) emerging in all 9 subscale total average scores with respect to level of stress when considering the pre-test score and the post-test score. This indicates the stress management intervention had an effect on the stress levels of nurses practicing in the ICUs at the selected study sites. Evaluation of stress management intervention workshop also revealed that an overwhelming (>87%) number of nurse participants experienced all activities as meaningful, with contributory worth. Recommendations arising from the study findings are put forward for intensive care nursing practice, occupational health nursing, executive hospital management and further research. Key words: intensive care, nurses, stress management intervention.Item Family members of Intensive Care Unit patients' perceptions of psychosocial support received in a Tertiary Hospital in Johannesburg(2017) Direng, Tlamelo LebitsangAdmission to an Intensive Care Unit can be intimidating to both the patient and family. The literature reviewed, suggested that the psychosocial care and support needs of family members are frequently overlooked, leaving them frustrated and vulnerable to emotional distress. Thus, the study intended to describe the family members’ perception of psychosocial support received in Intensive Care Units. The purpose of the study was to describe the perceptions of psychosocial support received in a tertiary academic hospital in Johannesburg of family members’ of Intensive Care Unit patients. This study utilised a non-experimental, descriptive quantitative survey and cross-sectional design. Non-probability purposive sampling was used, and the sample comprised of 100 (n=100) family members. Data was collected using a survey instrument developed by Hariharan et al. (2015), and analysed using descriptive and comparative statistics to describe the family members of Intensive Care Unit patients, perception of psychosocial support received in the Intensive Care Unit. Statistical tests included the Cronbach’s reliability coefficient, Proportions and Chi-square tests; testing was done on the 0.05 (p<0.05) level of significance. The results revealed a significant positive perception toward psychosocial support received in Intensive Care Units. Some inconsistencies were noted on the frequencies with which psychosocial support was provided. There was a significant disagreement in three priority items in the domain of transparency in decision-making and continuity of care; female family members or patients admitted for medical reasons were more likely to be in disagreement of items in this domain (p<0.05). Similarly, there was a significant disagreement to two priority items in the domain protection of human rights and dignity; family members’ in the age category of 43 to 48 years, or a sibling relationship to the patient, were more likely to be in disagreement of items in this domain (p<0.05). Recommendations are made for improvement in the provision of psychosocial support for family members in clinical practice and education of Intensive Care nurses.Item The usage of antibiotics in paediatric patients while admitted to the intensive care unit at a public tertiary hospital(2018) Sinyela, NkhumiseniBackground: The overuse and misuse of antibiotics decreases their effectiveness and results in increasing bacterial resistance which is considered an international public health crisis. Antibiotics are one of the most commonly used groups of medicines in peadiatric patients however there are limited data available on the usage of antibiotics in paediatrics globally but especially in South Africa. The aim of this study was to conduct a retrospective review of antibiotics used in paediatric patients in intensive care. Method: This study reviewed antibiotic therapy from patient charts in the Intensive Care Unit at Charlotte Maxeke Johannesburg Academic hospital. The review was done from 15 January 2016 to 15 February 2016 and 15 January 2017 to 15 February 2017. Results: There were 40 files reviewed for 2016 and 55 files for 2017. Most patients (2016: 78% and 2017: 60%) were neonates aged between 0 -3 months. There were 15 antibiotics prescribed in 2016 and 2017 that differed between the two study periods. The most frequently prescribed antibiotics in 2016 were: vancomycin (19%), imipenem (18%), ampicillin (11%) and gentamycin (11%). In comparison in 2017, the most frequently prescribed antibiotics were meropenem (21.7%) vancomycin (20.8%) and co-amoxiclav (11.7%). In both periods majority of patients received two antibiotics as therapy during their ICU stay, 47.5% in 2016 and 40% in 2017. The average numbers of days in ICU were 5 days in 2016 and 4 days in 2017. Diagnosis classifications were similar between the two study periods. Cultures (blood) were ordered in 73% (2016) compared to 75% (2017). C-reactive protein samples were taken from 85% of patients in 2016 and 82% in 2017. In 2017, there were 46.2% (n=36) of doses with a hang time less than 60 minutes and 32.5% (n=26) in 2016. Conclusion: This study showed that most antibiotics were prescribed empirically with imipenem and vancomycin the most used combination antibiotic therapy in 2016, meropenem and vancomycin in 2017. Majority of patients received two antibiotic therapies during their ICU stay. CRP and cultures (blood) were frequently ordered and hang time mostly documented. Prescription of antibiotics was mostly compliant with the unit antibiotic prescription guidelines.Item The attitudes and opinions of intensive care nurses on the use of physical restraints(2018) Maleho, Mabona EdnahBackground: Despite the uncertainty over the ability of physical restraints to maintain patient safety, as well as the potential for undesirable psychological and physical patient outcomes and ethical concerns, physical restraints use is still common in many ICUs in different countries. Physical restraints are prescribed by the physician but the ICU nurse remains the decision maker responsible in assessing the need, application and removal of physical restraints on patients in the ICU setting. Purpose of the study: The purpose of this study was to describe nurses’ attitudes and opinions on the use of physical restraints in adult ICUs of a tertiary academic hospital in Johannesburg, with the intention to suggest and create awareness to nurse educators on what needs to be included in the curriculum on topic of physical restraints. This may also provide guidance to policy makers on the best practice that need to be considered when implementing a policy in the clinical setting. Method: A descriptive, non-experimental, quantitative survey design was used. Data was collected using an eighteen (18) item questionnaire developed by Freeman, Hallett and McHugh (2015) titled “Attitudes and opinions of ICU nurses on the use of physical restraints’’. The questionnaire was divided into four sections. Convenience sampling was used and a sample size of 113 was used. Descriptive and comparative statistics were used for data analysis. The statistical test used includes Chi-square test and Fisher’s exact test and testing was set at 5% level of significance Results: Most nurses indicated that there is a need for physical restraints use in the ICU setting in order to provide an environment that is safe for the patient. Physical restraints as a management option were preferred over sedation. There was no consensus about the maximum time that an individual patient can be restraint, agitated behaviors such as pulling of endotracheal tubes and medical devices has been noted as the most reason for exceeding the maximum time that an individual patient can be restraint. Nurses were happy to discuss the use of physical restraints with relatives. There was a perceived need for training on use of physical restraints, availing a written policy on physical restraints and support from the medical staff. There was association between ICU nurses’ years of experience, report on availability of written policy on the use of physical restraints, reports on having training on the application of physical restraints and their attitudes and opinions on the use of physical restraints in some statements regarding such. Conclusion: Nurses need support and guidance from other health care workers in cases of using physical restraints. There is need for availability of physical restraints policy to aid nurses’ clinical decision making. Relevance to clinical Practice: There have to be alternative methods and thorough patient assessment of managing agitated patients before implementation of physical restraints, these methods can be pain management and allowing relatives to be at the patient bed side. Key words: Physical restraints, Attitudes, Opinions, Intensive Care, Nurses, Clinical decision makingItem Delirium assessment in adult intensive care units: do nursing practices hinder or help?(2018) Kandindi, KamandaBackground: Delirium is a well-recognised and severe problem in adult intensive care units. With a reported incidence as high as 80%, it has been associated with increased length of stay, higher costs of care, on-going cognitive impairment and increased mortality. International best practice guidelines recommend nurses perform frequent delirium assessments using validated screening tools for all intensive care patients. Lack of data exists in the South African context regarding nurses’ current sedation and delirium practices and their perceptions towards delirium assessments. Setting: The settings for the study were five adult intensive care units (ICUs) at one academic hospital in Johannesburg. These intensive care units were: trauma ICU, cardiothoracic ICU, coronary care, neurosurgical ICU and General ICU. Purpose: The purpose of this study was to determine nursing practices regarding delirium assessments in the adult intensive care units of an academic hospital in Johannesburg, to make recommendations for clinical practice and education. Design: A quantitative-descriptive and cross-sectional design was utilised in this study. The total sample (n = 105) of registered nurses from the adult intensive care units (n = 5) between the period of 1.08.2017 to 1.09.2017 was used. Non-probability convenience sampling was utilised and data were collected using a questionnaire developed by (Devlin et al., 2008). Results: Overall 100 (n = 100) nurses responded, which yielded a response rate of 95.2% for the study. Delirium assessment was less frequent than sedation assessment (20% vs. 51%; p<0.001). Only 21%, ranked delirium as the most important condition to evaluate, compared with the altered level of consciousness (41%), improper placement of invasive lines (18%) and presence of pain (16%). Preferred methods for assessing delirium included assessing the ability to follow commands (51%), checking for agitation-related situations (41%), the Confusion Assessment Method for the Intensive Care Unit (24%), the Intensive Care Delirium Checklist (15%) and psychiatric consultation (12%). The barrier to assessment included intubation (57%), sedation level (21%) and lack of confidence to use delirium assessment tools (22%).The majority of participants never received an education (56%) or attended a lecture (19%) on delirium. Conclusion: These findings provide further evidence of a theory-practice gap that is likely to exist in South Africa where best practice guidelines in the management of delirium in the ICU settings are not implemented. Recommendations are made for clinical practice and education of intensive care nurses. Key words: delirium assessment, CAM-ICU, intensive care unit, intensive care nurseItem Antibiotic usage in an intensive care unit of a tertiary level public hospital(2018) Ejike, Antonietta ChidimmaIntroduction: Antibiotic resistance presents a great challenge as the World Health Organization declared antibiotic resistance a global threat. Considering the high disease burden, prescribers are pressured to treat empirically rather than definitively especially in the intensive care units (ICU) where critically ill patients need rapid treatment. Aim: The aim of this study was to document the utilization of antibiotics in a tertiary level hospital intensive care unit. Method: This was a retrospective record review and data was collected for a two-month period in 2016 and 2017. Information was transcribed from the ICU charts. Variables included antibiotic chosen, number of antibiotics per patient, duration and frequency of treatment as well as information on the microorganisms involved. Data was analysed quantitatively using mean, median and frequency. Result: The majority (67% in 2016 and 75% in 2017) of patients admitted to the Helen Joseph Hospital (HJH) ICU during the study period were on antibiotics and the majority were treated empirically. The most frequently used antibiotics were amoxicillin/clavulanic acid followed by piperacillin/tazobactam. The majority of antibiotics stocked in the ICU were started on day zero of admission compared to the restricted antibiotics. The average antibiotic per patient was one and a maximum of three antibiotics was used concurrently. The average length of stay in HJH ICU was two days. Klebsiella pneumoniae (17%), Enterobacter cloacae (15%), Staphylococcus aureus (11%), Escherichia coli (9%) and Pseudomonas aeruginosa (6%) were the frequently most isolated pathogens. Conclusion: The study concluded that restriction of antibiotics does improve antibiotic utilization. Also the length of stay in the HJH ICU is short. Concurrent use of antibiotics was low. Furthermore, there were some antibiotics utilization patterns seen which are not supportive for a successful antibiotic stewardship. If there are no interventions informed by utilization studies, same patterns will continue.