A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Masters of Science in Physiotherapy. Johannesburg, 2015 / Patients 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.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg in partial fulfillment of the requirements for the degree of Master of Science in Nursing Johannesburg, 2017 / South Africa has emerged as the rainbow nation. The Changing demographics within the country has resulted in cultural diversity within the health care system, including the Critical Care units. The purpose of this study was to investigate the level of cultural competence of Critical Care nurses working in culturally diverse Critical Care units in South Africa, in order to make recommendations of whether the skills of cultural competence can assist Critical Care nurses in caring for the needs of culturally diverse patients and their family members. The setting for the study is the members of the Critical Care Society of Southern Africa (CCSSA). A non-experimental, exploratory, descriptive and cross-sectional survey design was used in this study. A non-probability convenience sampling method was utilised. Data was collected by means of a self-administered questionnaire developed by Schim, Doorenbos, Benkert and Miller (2007) which explored the knowledge, feelings and actions of Critical Care nurses’ and skills of cultural competence, inclusive of cultural awareness and sensitivity and cultural behaviour. The questionnaire was administered via an on-line survey using RED CAP with feedback responses from participants via email. Findings in the study revealed 43.6% of the nurses rated themselves as very competent, 42.3% as somewhat competent and 17% as somewhat incompetent. In regard to the nurse respondent’s cultural awareness and sensitivity, the total mean score was 5.29 (SD 0.60), which showed a moderately high level of cultural awareness and sensitivity. In regard to the nurse respondent’s cultural behaviours, the total mean score was 4.06 (SD 1.30), which showed a moderate level of cultural competence. Cultural competence may well be the solution to improving quality of health care, improving patient outcomes and decreasing health care disparities. / MT2017

ABSTRACT Background: About 90% of women in Kenya report at least one antenatal care (ANC) visit yet maternal mortality rate remains high at 414 per 100,000 live births. Only 40% of childbirths occur in health facilities. A previous study of Nairobi slums in 2000 indicated that only 10.3% of women initiated ANC visits in the first trimester. High incidence of maternal deaths in Kenya especially among the very poor has been attributed to inadequate emergency obstetrical care. Decreasing numbers of women are initiating ANC within the first trimester and this may be affecting the ability of the health system to identify and cater for women whose health conditions can be effectively managed through ANC. This study aimed to determine the proportion of women initiating ANC in the first and last trimesters and the background characteristics associated with these women in two slums of Nairobi, Kenya. It also sought to determine if timing of initial ANC visit was associated with number of visits and choice of place of delivery in a slum setting. Materials and methods: This research report is a secondary data analysis of the World Bank funded Maternal Health Project conducted between 1st April and 30th June, 2006 by the African Population and Health Research Center. Participants were women 12 to 54 years, enumerated in the Nairobi Urban Health Demographic Surveillance System living in two slums of Nairobi, who had a pregnancy outcome between January 2004 and December 2005. Women 15 to 49 years were included in this analysis. Analysis of the data was done using STATA 9.2. Findings: Only 7.3% of women initiated ANC in the first trimester, with 52% making four or more visits. In the third trimester 22% of women initiated ANC. Although 97% of women reported receiving their first ANC from a skilled health professional, only 48.4% delivered in well equipped health care facilities. The median number of months pregnant at first ANC was six and median number of visits was four. Women who were most likely to initiate early ANC had secondary school or higher level of education (p=0.055) and were in a union (p=0.008). The least likely to initiate care in the first trimester were of minority ethnicity (0.011) and high parity (p=0.019). As educational level and wealth status rise, the likelihood of late ANC initiation declines. Women living with unemployed partners were less likely to initiate care in the first trimester compared to those living with employed partners (OR 0.2, p=0.046). Only women with educated partners initiated care during the first trimester. Women who initiated ANC in the first trimester were more likely to have 4 visits and more likely to deliver in appropriate facilities than those who initiated care in the third trimester. Those who initiated care to obtain an ANC card were less likely to have 4 visits than those who initiated care to verify that pregnancy was normal (OR 0.5, p=0.000). Women who initiated care in first trimester were 1.5 and 5.0 times more likely to deliver in good health facilities than those who initiated care in third trimester (p=0.040) and those who had no ANC (p=0.000), respectively. Conclusion: Women in Korogocho and Viwandani may have better chances of delivering in appropriate facilities if they have low parity and secondary level education. The presence of a partner with a means of steady income may also make it easier for women to access delivery care in good facilities. Interventions to improve the level of educational attainment among women and provide affordable family planning are necessary to increase early ANC attendance and subsequently delivery in well equipped facilities.

Training and support for community health workers is envisaged to positively shape a better effective health care system at the grass root level. All community health workers need adequate resources as they scale up treatment and support for people living in poor resource settings. The aim of this research report is to explore how the preparation and support processes for Community Health Workers influences their role in delivery of home-based care services in the Bushbuckridge Sub district during the period of April- July 2010.

MDent, Faculty of Health Sciences, University of the Witwatersrand, 2009 / An analysis of the patterns of dental treatment delivered over a period of time provides administrators with data from which they can assess the quality of service delivery being delivered so that they can make improvements where necessary. This may be referred to as a situation analysis. Oral Health surveys on the other hand drive policy decisions. The oral health needs of a population are identified in the surveys thus allowing the formulation of an oral health care policy for the country. In Mauritius neither situation analyses nor oral health surveys have been conducted. The only study into this oral health status of the population in Mauritius has been a DMFT study carried out by the WHO - 1989) 1990 Objectives of this study Little data exists at a local/district level on the patterns of dental care provided over a long term basis at individual clinics. This study sought to compare patterns of dental treatments at a selected clinic over a six year period. The aims were to (1) To investigate the pattern of treatment delivered at a particular dental clinic (Chemin Grenier Dental Clinic) in Mauritius over a period of seven years from year 2000 to year 2006. (2) Determine whether the package of care offered has changed over the study period. (3) To provide recommendations on how to improve the delivery of oral health care at dental clinics in Mauritius. Materials and methods The research location was Chemin Grenier, a village in Mauritius, an island state in the middle of the Indian Ocean. It has a state funded dental clinic, where all treatment is free of charge. All the data for the purpose of this study has been obtained from this clinic. Since the introduction of free oral health care in Mauritius, extractions have been most common dental treatment offered in the public service. The treatment offered were divided into three categories, namely, Dental extractions Conservative procedures aiming at preserving dentition, that is restorative work Preventive work which included scaling and fissure sealant placements The data was collected from monthly summary sheets of treatment performed at the clinic. They were compiled and the results were showcased by graphs and tables. Results The results show that patient attendances have gradually increased placing additional pressure on a already overloaded system. The treatment delivered has changed over the period of the survey with a decrease in the relative percentages of extractions done and a concomitant increase in restorative procedures. Preventative treatment has remained relatively constant over the period analysed. Conclusion If significant changes are to be affected in the oral health status of the population in Mauritius prefer planning a necessary. The following strategy is recommended A - Carry out an assessment of the oral health status of the community. (Natural Oral Health Survey ) which will provide quantitative data and also of the perceptions of oral health in terms of it being a priority in their lives which will provide the quantitative data. P - Develop a National Oral Health Policy basal on this data. A - Ensure that the dental service are delivered in terms of this policy.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfillment of the requirements for the degree of Master of Medicine in Obstetrics and Gynaecology MMed (O&G) Johannesburg January 2017 / Background and objectives Pregnancy can be associated with life threatening complications of pregnancy specific disease and delivery, as well as the exacerbation of preexisting comorbid disease, which requires multidisciplinary critical care. Studies have shown that advancement in medical care and access to intensive care units have been instrumental in the global decline in maternal mortality rates, particularly in developed countries. The aim of this study was to describe the admissions to ICU of all pregnant women including those with pregnancy related complications at CHBAH tertiary hospital in South Africa. Methods The study was a retrospective review of pregnant women, including pregnancy related complications, admitted to CHBAH ICU for the year of 2012. Baseline demographic data, admission diagnosis, laboratory information and acute physiological and chronic health evaluation score (APACHE II), intervention and outcomes were recorded using ICU records and general hospital records. Descriptive statistical analysis employed. Results In 2012 there were 21765 deliveries at CHBAH with 76 pregnancy related admissions to the ICU. Complete ICU data was available in 73 women. The incidence of ICU admission at the hospital was 3.5 per 1000 deliveries. The mortality rate in this group in ICU was 8.2%. The most common indication for admission was haemorrhage (43.8%) followed by medical and surgical disorders (23.3%), then sepsis (21.9%) and hypertensive disorders of pregnancy (11%). The majority of the women (98.3%) were admitted in the postpartum period. Mechanical ventilation was required in 77% of the women, inotropic support in 29% and 59% received blood transfusion products. APACHE II scoring system overestimated the possible mortality rate giving a predicted mortality rate of 15%. Conclusion Haemorrhage was the most common indication for admission to ICU. This does not concur with previous South African studies where hypertension was the most common reason for admission followed by haemorrhage. The study showed an overall mortality concurrent with some first world studies and significantly lower than cited South African studies. / MT2017

M.Sc. (Nursing), Faculty of Health Sciences, University of the Witwatersrand, 2009 / The purpose of this study is to undertake an interpretive, descriptive meta synthesis of available literature of primary qualitative research findings on patient satisfaction with nursing care of adult patients in hospitals across the world. The study addresses the question about the experiences and expectations of adult patients regarding nursing care. It is argued that patient satisfaction provides a meaningful focus for improving quality of care, planning and evaluation of health care services. The data collected in this study were from the identified articles from a range of databases including Science direct, PubMed, CINAHL and EBSCO host. The findings reveal that 13 studies met the inclusion criteria. Four of these were undertaken in the Sweden, two in the USA, two in the UK, and one each from China, Iceland, Ireland, Greece and Western Australia. The population study sampled was 341 adult patients in the included primary research reports. The total population comprises of 132 males and 166 females. In the literature 49 themes were derived which were synthesised to four new themes namely: Caring, quality of care, communication and information, professional technical skills and competence, organizational and environmental factors. Therefore, this study focuses on these five themes that contribute to patient satisfaction. In conclusion, this study points out that despite the dissatisfaction with nursing care, some satisfaction were experienced and that these should be used for those considering whether or not to use patient satisfaction views and opinions in the care.

South African medical schemes (health insurance or medical aid) companies offer insurance to the general public in the form of a multitude of different schemes. Each scheme has its own unique range of benefits, but certain exclusions apply across the board in respect of all schemes operated by a medical aid. In this research report, I investigate the rationale and necessity, as well as some of the ethical and legal implications of numerous notable exclusions. I further make relevant recommendations with respect to their application within the legal and ethical framework of the South Africa’s Consumer Protection Act, No. 68 of 2010.

A Research Report submitted to the Faculty of Health Sciences of the University of the Witwatersrand in partial fulfillment of the requirements for the degree of Master of Public Health (Hospital Management) Johannesburg 2011 / With the exception of emergency cases most patients should first be seen at the Primary Health Care(PHC) level where a decision is made by a doctor or nurse as to whether they should be referred to a higher level of care or not. Such referral would be referring to a district hospital, from there to a regional hospital then eventually to a central hospital. Over the last five years the argument from Pelonomi Regional Hospital (PRH) casualty department doctors has been growing louder and louder about patients they see which should be seen at PHC level. It was for this reason that this study was found to be necessary in order to put the arguments to a scientific test and be certain that the complaints are valid i.e. Are the majority of patients seen inappropriate for this level of care?

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg in partial fulfilment of the requirements for the degree of Master of Science in Nursing Johannesburg, 2015 / Collaboration is an interpersonal relationship among colleagues sharing the same goal, power, authority and decision making (Dougherty & Larson, 2010). Collaboration is described as a marker of a nurses’ ability as well as a professional obligation. However, current clinical practice indicates that, as nurses attempt to collaborate with each other, they also employ aggressive, hostile and intimidating behaviours that may result in tension among senior and junior nurses. This carries the risk of medical errors that will lead to poor patient outcomes and job dissatisfaction. This study sought to determine the extent and nature of collaboration practices among nurses in the intensive care settings, with an intention of making recommendations for clinical practice and education. The setting for the study was the Intensive Care Units (ICU’s) (n=5); trauma, cardiothoracic, coronary care, general and neurosurgical units of a public sector and tertiary level hospital in Johannesburg. A non-experimental, descriptive and quantitative study design was utilized in the study. The sample comprised of 112 (n=112) nurses working in the intensive care setting. Non-probability, convenience sampling was employed in this study. Data was collected using a structured questionnaire developed from the Nurse-Nurse Collaboration Scale, which has 35 items on a four-point Likert type scale. The instrument is divided into five subscales of problem solving, communication, coordination, shared process and professionalism. Data was analyzed using factor analysis and descriptive statistics. The data was then analyzed using descriptive and inferential statistics. Statistical assistance was sought from the biomedical statistician at the Medical Research Council (MRC) South Africa. Generally, in this study the results have shown that nurses have more positive perceptions and attitudes about collaboration in the Intensive Care Units, as evidenced by the frequency scores with nurses responding more positively to the five subscales even though some missing data was identified on some of the responses. However, the subscales of communication, shared process, coordination and professionalism scored higher; most of the participants either agreed or strongly agreed to all these items compared to conflict management in item 1.1, where the majority disagreed ignoring the issue pretending it will go away. In item 1.2, the majority agreed to withdraw from conflict; similarly for item 1.5 disagreements between nurses were ignored, or avoided. Correct conflict management amongst nurses is very important for effective delivery of care and collegial working relationships; nurses’ are urged to learn the skills of resolving conflict amicably by compromising in order to consider the interests of all parties. These results showed that females dominate the nursing profession with males being a minority and no differences in collaboration were observed. Participants’ responses for work experience were examined to determine if there was any impact on how nurses perceive collaboration between senior and junior nurses. However, the study results indicated there was a statistically significantly (p<0.05) difference in perceptions of collaboration practices in two of the five subscales; namely communication and shared process between junior and senior nurses in the Intensive Care units. In their responses to an open-ended question, nurses felt that some of their roles overlapped creating confusion as to who was supposed to do what and as a result, it became difficult to maintain effective collaboration amongst team members, compromising the delivery of patient care.