The 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.

MSc (Med), (Bioethics and Health Law), Faculty of Health Sciences, University of the Witwatersrand / Access to health care is a constitutionally recognized right, under section 27 of the South African Constitution. Fifteen years post the first democratic election in South Africa the realization of this right is the focus of this research report. In 1997 the South African Human Rights Commission (SAHRC), a statutory body assigned to evaluate the realization of access to health care, held a public enquiry into the matter. The report was released in early 2009. The public health care system was found to be in a „lamentable state‟. South Africa faces a number of challenges that complicate the progressive realization of access to health care . For example, the country is currently in recession; the HIV / AIDS statistics is among the highest in the world placing a huge burden on public health; South Africa has the highest income inequality globally and the gap between public and private health care, with regards to affordability and quality of service remains a great concern. A way of addressing this problem is to engage ethical principles such as beneficence, non-maleficence, autonomy and (distributive) justice. Each of these in application can argue a case for the moral obligation to initiate a more effective national health care system. Rawls1 (1999) emphasized the centrality of justice in consideration of the bio-medical principles. 1 Rawls, J. 1999. A Theory of Justice. Revised edition. Cambridge, Mass.: Harvard University Press., 1971. Oxford: Clarendon Press, 1972. The principle of justice and its derivative, distributive justice, is of importance when making a moral argument for equal access to health care for all. Farmer and Campos (2004:28) rightly asks2: “What does it mean, for both bioethics and human rights, when a person living in poverty is able to vote, is protected from torture or from imprisonment without due process, but dies of untreated AIDS? What does it mean when a person with renal failure experiences no abuse of his or her civil and political rights, but dies without ever having been offered access to dialysis, to say nothing of transplant?” There is a need for ethicists to become more involved in arguments pertaining to the inequalities in distribution of social goods. Legislation and case law in South Africa also affirm the right to access health care services and have as their grounding normative ethical tenets. The recommendations made by the SAHRC, together with the planned national health insurance aimed at addressing the gap between public and private health care, can only become a reality through successful implementation of a monitored process based on ethical principles. There is a need for a practical implementation of current ethico-legal and human rights principles through every phase of the health care system to serve as monitors to ensure the success of this guaranteed right that so few people have genuinely seen realized. The findings of the SAHRC, together with the response from the Department of Health, serve as a basis for planning towards successful 2 Farmer, P. and Campos, N.G. 2004. Rethinking Medical Ethics: A view from below. In: Developing World Bioethics, 4 (1), 17-41 implementation of an equitable health service system that is of an excellent standard. To aid in this process an ethical framework could be of use to assess the policies formed along the way as well as the practical implementation thereof. This research report is an analysis of current literature and data available on access to health care in South Africa in light of human rights and ethical arguments for its provision. The aim is to reflect on the realization of greater access to health care since 1994, identifying current hampering factors in achieving this and proposing a broad set of guidelines that can be applied to the reform process already underway in South African health care.

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 Public Health (MPH) School of Public Health Faculty of Health Sciences University of the Witwatersrand 19 June 2017 / Background In order to achieve the Millennium Development Goals, South Africa embarked on a strategy in 2011 to re-engineer its Primary Health care (PHC) system. This included the creation of Ward-based Outreach Teams (WBOTs). Each team comprises six community health workers (CHWs) led by a professional nurse linked to a clinic. The national guidelines prescribe that each municipal ward should have at least one WBOT to improve access to health care and strengthen the decentralised district health system. Implementation of the WBOT policy has varied across the country. Methodology This qualitative study explored WBOT staff and manager views on initial WBOT implementation in the Ekurhuleni health district. Research methods included five focus group discussions with CHWs; 14 in-depth interviews with team leaders and managers; and ethnographic observations. Using the framework analysis approach, data were coded based on themes relevant to the National Implementation Research Network’s (NIRN) Implementation Drivers’ Framework, including: competency, leadership and organizational drivers of the initial implementation processes. The context in which implementation occurred was also an important theme, as derived from the NIRN formula for successful implementation. Results There were significant weaknesses underscoring the current implementation of WBOTs in the district. The experiences of WBOT staff and managers illustrate that competence to perform the ideal roles was compromised by poor staff selection, inadequate training and limited coaching. CHWs complained of precarious working conditions, payment delays and uncertainty of employment contracts. Within the community context, CHWs experienced both positive and negative attitudes from the community and clinic staff from inter alia: traditional beliefs; stigma; and, the perception that CHWs were increasing clinic workloads. Despite this, CHWs valued their expanded role, including the ability to refer to services beyond the clinic such a social services, police and home affairs, and felt motivated by the impact of their work in the communities they serve. Weak organisational processes, compounded by poor planning, budgeting and rushed implementation, resulted in problems with procurement of resources. The lack of support for robust data management led to poor data verification, quality and use for decision-making. Communication challenges revealed leadership deficiencies at the national and implementation levels. This led to confusion about the ownership of the programme and poor integration of WBOT into the service delivery package in traditional clinic settings. Conflicting departmental mandates (between provincial and municipal departments), fragmented leadership and accountability, all lack of insight into the policy objectives and a disabling and ill-prepared context, constrained efforts of WBOTs at the local level. This also affected the embeddedness and acceptance of the programme in clinics and the community, impacting on implementation fidelity. Conclusion Sustainable systemic change requires clear, detailed planning guidelines, defined leadership structures, budgetary commitments, and continuous communication strategies. Furthermore, successful change is dependent on the on-going commitment to human resources development and capacity building, including investment in supervision, quality training, organisational support and competent staff. This study highlights the critical importance of organisational readiness that includes health systems and actor readiness when implementing policies across decentralised systems. Furthermore, adaptation to local contexts must be heeded in policy processes. This study further illustrates that in order to re-engineer PHC, to achieve the vision and values set out by the Alma Ata Declaration, and, to strengthen outreach services across relevant sectors, participation of all relevant actors in the implementation process. / MT2017

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 Medicine in the branch of Paediatrics. Johannesburg, 2015. / Background: Organisms causing neonatal sepsis differ in different regions and also change with time in the same area. The antibiotic susceptibility of microorganisms also changes with time, with emergence of multidrug resistant organisms. A periodic survey of the causes of sepsis and their antibiotic sensitivity patterns is essential in the design of effective infection control programs and in guiding empiric antibiotic therapy. Aim: To evaluate the epidemiology of culture-proven neonatal sepsis and to describe the clinical characteristics of patients with neonatal sepsis at a tertiary care hospital in South Africa over a one year period. Methods: This was a retrospective descriptive study conducted in the neonatal unit at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Clinical and laboratory data of patients, admitted to the CMJAH neonatal unit between 1 January 2012 and 31 December 2012 with positive blood cultures were reviewed. Results: During this time there were 196 patients with blood-culture proven neonatal sepsis (NNS). This gave an incidence of 10.26 per 100 admissions. Late-onset sepsis (LOS) accounted for 83.7% of cases of NNS. Of the 196 patients with NNS, 117 (59.39%) were males. The median gestational age for patients with NNS was 30 weeks and the median birth weight was 1300g. HIV exposure was present in 30.67 % of patients. Predominant isolates were Klebsiella pneumioniae (32.20%), coagulase-negative staphylococci (23.72%) and methicillin-resistant Staphylococcus aureus (13.13%). The majority of the isolated K.pneumoniae were extended beta-lactamase-producing (ESBL) with resistance to ampicillin and gentamicin. Conclusion: Neonatal sepsis is an important cause of mortality at CMJAH neonatal unit. Compared to previous audits in the unit, the incidence of NNS in the unit is on the increase while mortality from NNS has remained relatively constant. LOS was more common than EOS at CMJAH. A changing pattern of bacteria isolated has been observed. Gramnegative microorganisms comprised the majority of the neonatal sepsis, with ESBL Klebsiella pneumoniae and A. baumannii being the most prevalent. Coagulase negative staphylococcus remains an important cause of NNS, and is the most prevalent grampositive organism isolated. Resistance to the first-line antibiotic regimen for both EOS and LOS is significant. Due to the changing pattern of bacteria isolated and changing patterns in antibiotic sensitivity, recommendations are made regarding early empiric antibiotic therapy.

BACKGROUND: Maternal health care in South Africa is based on the District Health System model which includes public health facilities (such as primary health care clinics, community health centers and district hospitals) as well as private health facilities. The majority of uncomplicated deliveries are expected to happen at community health centers and only complicated cases are expected to be referred to district hospitals. But in reality, the majority of deliveries in a health district happen in district hospitals. This often results in increasing utilisation of resources and decreased quality of care at these hospitals. The Ganyesa District Hospital, situated in Dr Ruth Segomotsi Mompati District in the North West Province has been facing similar challenges. Although the Hospital has been collecting routine information for the District Health Information System, it has never been analysed systematically to understand the impact of the current referral system on the performance of this Hospital. Aims: To compare maternal and neonatal profiles and outcomes between referred and self-referred patients delivered at the Ganyesa District Hospital during one year study period (1st April 2008 to 31st March 2009). Methodology: The setting of this study was Ganyesa District Hospital, in the Dr Ruth Segomotsi Mompati District in the North West Province. A Cross sectional study design was used utilising retrospective data, from the Hospital information systems. The MS excel software based data extraction tool was designed to obtain data from Hospital Information System. The variables used for this study included socio-demographic and clinical profiles of patients. A comparative statistical analysis were done to compare the profile of two groups of patients: (Referred and Self-referred) Results: The majority of the subjects were black. Most of the patients were, single and unemployed. The majority of the patients were multigravidae. The most common past and current medical disorders were diabetes and pregnancy induced hypertension (PIH). The prevalence of pre-term deliveries of the subjects was 14.8%. The majority of the subjects delivered normally (86.5%) followed by CS (13.2%). The majority of CSs were performed as emergency. PIH and previous CS were common maternal indications whereas fetal distress and mal-presentation were common fetal indications. Prolonged labour and Intra-partum haemorrhage were common maternal complications whereas fetal distress and fresh still-birth were common fetal complications. There were 26 (4.3%) post-partum maternal complications. There were 3 (4.6%) deaths during this period among the patients (Maternal mortality rate of 501/ 100,000). The incidence of low birth weight (less than 2.5 kg) was 23%. The fresh and macerated stillbirths and low Apgar score were common neonatal complications. The majority of the patients (374, 62.5%) arrived after-hours. The majority of the patients arrived by ambulance (87.3%). The median distance between places of residence and PHC facilities (Clinic and CHC) was 12 km. The median distance between places of residence and the Hospital was 45 km. There were no significant differences in socio-demographic (age, ethnicity, marital and employment status) and obstetric profiles (gravidity, prevalence of past medical disorders and antenatal disorders, prevalence of pre-term deliveries, mode of deliveries, intra-partum or post-partum complications and maternal outcomes.) between referred and self-referred patients. The two groups were not significantly different in terms of birth weight, the incidence of low birth weight, and Apgar scores (at 1 minute and 10 minutes) and neonatal complications. More referred patients arrived after hours in comparison to self-referred patients More referred patients arrived with ambulance in comparison to selfreferred patients. The self-referred patients stayed closer to health facilities. This was probably the reason these patients decided to come to Hospital instead of going to their nearby PHC clinics. Conclusion: Findings of this study will be reported to the district and provincial department of health and hopefully will be used for improvement of maternal health services in the Dr Ruth Segomotsi Mompati District.

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No description available.

Thesis advisor: Andrea Vicini / Thesis advisor: James Keenan / In this thesis, I am going to explore some of the significant legal and medical activities that have had a great influence on the healthcare delivery in the United States of America, focusing on the care of people that are severely sick or those whose death is imminent. Then I will discuss how the application of virtues, particularly the cardinal virtues, can inspire people not to neglect the needs of patients whenever some helpful procedures could be done, and also to enable people to desist from engaging in medical procedures that could be deemed futile. Patients and their caregivers can all benefit from cultivating virtue and hence create a way of life that respects the human dignity of patients and also uses the available resources prudently for the sake of the common good. Ultimately, I hope to suggest some theologically sound proposals that are helpful to a patient, the patient’s family and the rest of the country’s health system, with a particular focus on an ethical way of delivering healthcare services. I will show how the developments in the Western world can be applied to develop some protocols of healthcare delivery that could be helpful to Kenya. It is my belief that the universal applicability of virtues can ensure that healthcare activities uphold the human dignity of patients, provide respect for healthcare work, and also use a country’s limited resources prudently. / Thesis (STL) — Boston College, 2016. / Submitted to: Boston College. School of Theology and Ministry. / Discipline: Sacred Theology.

Thesis advisor: Andrea Vicini / Thesis (STL) — Boston College, 2015. / Submitted to: Boston College. School of Theology and Ministry. / Discipline: Sacred Theology.

The growing older adult population, their age-related morbidities, and lifelimiting chronic illnesses increase the demand for quality yet cost-effective end of life (EOL) care. Losing a loved one creates emotional turmoil, heightened uneasiness, and EOL uncertainties for family members. Understanding the complex needs of family members and supportive actions deemed most significant to them can guide nurses to enhance EOL care, encouraging palliation and peaceful death experiences. This study used a qualitative descriptive exploratory design guided by story theory methodology to explore the dimensions of the health challenge of losing a loved one who had been in an acute care setting during the last three months of life, the approaches used to resolve this health challenge, and turning points that prompted decisions about a loved one’s care with 15 older adults residing in a Continuing Care Retirement Community (CCRC) in Southeast Florida. Theoretical grounding for this study was Watson’s (1988, 2002) theory of human caring and Smith and Liehr’s (2014) story theory. Older adults’ stories were analyzed through theory-guided content analysis. Themes that describe the health challenge include moving from painful holding on to poignant letting go, uneasiness that permeates everyday living and precious memories, patterns of disconnect that breed discontent, and pervasive ambiguity that permeates perspectives about remaining time. Approaches to resolve this challenge include active engagement enabling exceptional care for loved ones, appreciating the rhythmic flow of everyday connecting and separating to get by, and embracing reality as situated in one’s lifelong journey. Failure to establish normalcy, coming to grips with abrupt health decline/demise, and recognition – there’s nothing more to do – were the turning points identified by CCRC residents. Older adults’ vivid recollections of losing a loved one and willingness to share EOL concerns as well as recommendations regarding support of family members who are facing this challenge serve as invaluable guidance for improving EOL care for dying patients and their family members. / Includes bibliography. / Dissertation (Ph.D.)--Florida Atlantic University, 2016. / FAU Electronic Theses and Dissertations Collection