A RESEARCH REPORT SUBMITTED TO THE FACULTY OF HEALTH SCIENCES, UNIVERSITY OF THE WITWATERSRAND, IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF PUBLIC HEALTH IN THE FIELD OF HOSPITAL MANAGEMENT Johannesburg, September 2014 / Background: Although the Free State Psychiatry Complex has collected information on adverse events, the reporting processes have not been consistent, systematic or transparent and this information was not used in the planning process. In addition, there is also a perception that the rate of adverse events is increasing, that these adverse events are not managed adequately and the extent of the problem could not be determined. It was for this reason that this study was found to be necessary to investigate further on patterns of serious adverse event occurrence, to put the argu-ments to a scientific test and be certain about the extent to which contributory factors were associated with the occurrence of these events in the Free State Psychiatry Complex. Aim: The aim of the study was to describe the inpatient-related adverse events and factors contributing to these adverse events reported at the Free State Psychiatry Complex in order to develop effective strategies to prevent and reduce these ad-verse events. Methodology: This was a cross sectional study design based on a retrospective re-view of records of patients who were involved in these adverse events. The study was undertaken at Free State Psychiatric Complex which is a specialized Mental Health Care Establishment from 1 April 2008 to 31 March 2010. All records of re-ported adverse events of all inpatients at Free State Psychiatry Complex were re-viewed and no sampling was done. The study included review of routinely collected hospital information on patients’ records and registers and from the Advance Incident Management System (AIMS). Results: There were 419 Serious Adverse Events reported during 1 April 2008 to 31 March 2010. The most commonly reported SAE’s included Aggressor-Aggressor, Aggression-victim, Behaviour/Human Performance, Accident/occupational health and safety and falls. The Aggression related adverse event type was one of the most common types of SAE’s, constituting 40% of the Serious Adverse Events reported. The Behaviour /Human Performance adverse event type was second in frequency. Other common SAE’s reported during the study period included Medication, Pres-sure ulcer, Clinical Management and Organisation Management. These Serious Ad-verse Events occurred in 5% of the inpatients at Free State Psychiatry Complex and the findings showed an increase rate of 3.3%. Although more than 80% of the ad-verse events gave rise to moderate disability, 2% caused permanent disabling inju-ries and 2% led to death. However, only 15% of the SAE’s caused minor harm to pa-tients. The most Serious Adverse Events occurred in the months of March, Decem-ber and November which indicate that seasonal changes are associated with in-creased risk for Serious Adverse Events. Most SAE’s happened during the day-shift which might be ascribed to the organisational routines such as medication rounds, handover periods and mealtimes. Human and System Adverse Event Error Types accounted for more than 70% of these SAE’s. The study revealed a positive relationship between the patients in the Intellectual disability and Psycho-geriatric specialities and Accident/occupational health and safety as well as falls related adverse event types. There was also a posi-tive correlation between male patients in the age group of 9-38 in the Acute and Fo-rensic Specialities and Aggression- as well Behaviour Performance related Adverse Event Types. The patients diagnosed with Schizophrenia, Substance Induced Psy-chosis and Intellectual Disability was mostly associated with an increased risk for Se-rious Adverse Events. The results showed that co-morbidity, the patient’s disease profile, age, admission classification, organisational routines and seasonal changes are associated are contributory factors too Serious Adverse Events. It supports the premise that human and system errors as well as the profile of the patient are con-tributing to SAE’s. Conclusion: Safety issues in mental health are unique and are in that way different to the safety issues in medical care. Both the patient population and the environment make patient safety in mental health unique. The uniqueness is associated more with the diagnosis, the patient population and with the mental health setting. SAE’s included Aggressor-aggression, Aggressor-victim, Behavior Performance (abscond-ing, self-harm, suicide); Occupational health and safety, falls and other injuries are particularly prominent to mental health patients. Although patient safety in mental health was considered a field of importance, there is still a lack of awareness of the issues as well as a shortage of research and readily available information to guide patient safety systems, practices, policies, and care delivery in mental health. Work is required to establish a clear definition, set priorities, and develop strategies for re-sponding to patient safety concerns. Models of quality improvement are being uti-lized in psychiatry hospitals but the need for evidenced-based quality improvement models for inpatient psychiatric care still exist. Findings from my study showed that Serious Adverse Events are prevalent in Free State Psychiatry Complex and factors significantly associates with the frequency of aggression-, behavior/occupational health and safety and falls related adverse event types. Advancing a quality and safety research agenda for inpatient psychiatric care will guide practice, improve care, and help ensure efficient and effective care. Complicated problems such as the provision of acute psychiatric hospital services require solutions that incorporate depth of understanding the complexities of acute mental illness as well as changes in prevailing attitudes and systems. This study has also highlighted that Serious Adverse Events are contributed by a varied set of contributing and interacting elements, including patient factors, human factors, system factors, and environmental factors. A complex interaction between the mental health environment and the diagnosis/patient population was found which differentiates patient safety from other health sectors is. Understanding this interac-tion and its relationship to patient safety is very important. It is believed that research in scientific advances, systems analysis, education and development, dissemination of guidelines and improved standard of practice is required for reduction of SAE’s (Leappe et al. 1991) This was the first study to systematically evaluate adverse events in a mental health establishment in the Free State province. The researcher hopes that the Department of Health in the Free State Province would utilise the findings of this study to review and to improve the safety programmes on the care, treatment and rehabilitation of the mental health care services.

MPH, Faculty of Health Sciences, University of the Witwatersrand / Introduction: VCT services are a meaningful entry point to a continuum of care, in treatment and prevention of HIV/AIDS and related illnesses. Although VCT has been available at some sites across the country even before 2000, there have been very few studies conducted to evaluate its implementation at local municipality level. This study describes the status of VCT implementation in the Ekurhuleni Metropolitan Municipality between January 2004 and March 2007. Methods: Using a questionnaire, checklist and data collection sheet, data was collected between April - May 2007 in a sample of 14 VCT sites. These were government funded sites that included three hospitals, three community health centres, three clinics, three non governmental organisations and two hospices and were selected from all three service delivery regions in Ekurhuleni. Areas assessed were demographics of facility managers, staff and training, referral system, guidelines, supervision and support and VCT registers. Results: Over ninety percent of the VCT sites had closed areas for HIV counseling and testing. Majority of the VCT service providers were lay counselors (52.9%) and others were nurses, doctors, dieticians, social workers and health promoters. Most of the counselors had received both formal and in-service training. Almost all sites (92.8%, N=13) had the relevant guidelines in place and in-service training and use of checklist were methods used to ensure adherence to guidelines. The majority of the sites (71.4%, N=10) regularly evaluated the quality of counseling offered to clients through direct observation (50.0%), exit interviews (20.0%), self evaluation (10.0%) and combination of direct observation and interviews (20.0%). Close to two thirds of the sites (64.3%, N=9) were satisfied with supervision received from the district office. All the sites used a formal letter to refer clients to other outside facilities. There was no uniformity in the data elements of VCT registers across sites and the registers had many gaps. iv Conclusions: The VCT sites in this study had the necessary set up for the implementation of basic VCT services. However, because of the small sample size, this conclusion may not be true for the whole of Ekurhuleni. There needs to be improvement in VCT record keeping and data management in the sites. Further studies are needed to evaluate factors influencing uptake of VCT services.

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.

Thesis advisor: June Horowitz / Pain in extremely low gestational age (ELGA) infants remains under-assessed and poorly managed despite the fact that pain may have profound consequences with regard to infants' neuro-development (Als, 1982). Pain prevention is a critical goal of pain assessment, yet barriers exist. Most critical is the lack of valid, reliable, and clinically useful pain tools. This observational descriptive study focused on the development of a gestational age appropriate instrument for 24-29 6/7 week infants and evaluation of the new instrument, Pain Assessment and Care for the Extremely Low Gestational Age Infant Focused Instrument (PACEFI). Additionally, differences in behavioral cues and physiologic indicators were evaluated for ELGA infants and very low gestational age (VLGA) infants for non-invasive and invasive procedures. Nurse raters used the PACEFI to rate these infants during both procedures at baseline, during, and recovery to assess variation in expected pain. The PACEFI demonstrated a high internal consistency (.879) and appeared to be contributing to the measurement of pain. A RANOVA found a significant difference in rating scores ( p < .001) for both procedures. Baseline and recovery scores were lower than during scores. ELGA infants demonstrated a dampened response (p < .023) as compared to the VLGA infants during the invasive procedure. Alternatively, ELGA infants demonstrated a more vigorous response for non-invasive procedure and dropped below baseline scores at recovery. The whole care experience during the non-invasive procedure may have led to sensitization for the VLGA infant and overwhelming energy expenditure for the ELGA infant. Furthermore, physiologic indicators and behavioral cues were inconsistent arguing for independent assessment of these parameters. Knowledge gained from this study: 1) provides information regarding gestational age differences in pain behaviors; and (2) clarifies if the measurement of these behaviors addresses the immediate need for pain assessment for this vulnerable population. / Thesis (PhD) — Boston College, 2012. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

The state of Oregon, like many states, requires its districts’ teacher evaluation systems to include measures of student learning as well as a measure of teachers’ professional practice. State guidelines require use of state test data in assessed grades as one of the measures, but allow districts flexibility in which additional assessments to use and which source of information to prioritize when evaluating teachers. This study used existing data from one school district to compare students’ performance on a state reading and literature assessment to their performance on reading curriculum-based measures, and the degree to which measures of teaching practices relates to both types of student outcomes. Results are interpreted with consideration of how the district implements their measure of teaching practice. Results from this study may help inform decisions the district will face as they continue to refine their teacher evaluation system in accordance with state guidelines, while elucidating challenges that such systems pose.

This research explores learning and democratic values in the peer-coaching service at the Institute of Education (IOE). The service, set up seven years ago, adopted a learning-centred model of coaching (Carnell, MacDonald and Askew 2006). An initial evaluation of the service focused mainly on benefits to the coachee (Hargreaves 2007). To date, there has been no study into how learning is understood and facilitated by the coaches. This study builds on the work of the initial facilitators of the coaching group, Askew and Carnell 2011, by providing a detailed study into how learning is interpreted in practice. The study is set in the context of Adult Learning. In particular, aspects of Mezirow’s Theory of Transformative Learning are applied to illuminate the learning process. Six audio-recorded coaching conversations are analysed. A system of analysis is borrowed and developed from Conversation Analysis. The conversations are presented and analysed sequentially, before discussing approaches to learning, and values that appear to underpin practice. Findings suggest that despite following the same programme of professional development, coaches seem to understand learning differently resulting in diverse practice. Some appear to facilitate reflection on self. Connections between current and previous behaviour patterns are explored together with developing an understanding of where embedded beliefs and attitudes have originated. In other conversations, a goal-centred approach, focusing on completing specific tasks, is dominant. This research advances the argument for a learning-centred model of coaching leading to individual development, fulfilment and possibly better working practices. The thesis addresses a gap in research by exploring the practice of coaching as a model for supporting adult learning, identifying democratic values that underpin and give strength to, the transformative learning model. The thesis concludes with suggestions for coaches’ professional development and thoughts for future research.

by Chan Kwai-Ming, Evan. / Thesis (M.B.A.)--Chinese University of Hong Kong, 1989. / Bibliography: leaves 45-47.

by Lo Po Hung, Gordon. / Thesis submitted in: December 1998. / Thesis (M.Phil.)--Chinese University of Hong Kong, 1999. / Includes bibliographical references (leaves 94-107). / Abstract and questionnaire also in Chinese. / ACKNOWLEDGMENTS / ABSTRACT (ENGLISH & CHINESE VERSION) --- p.ii / LIST OF TABLES --- p.vi / CHAPTER / Chapter 1. --- INTRODUCTION --- p.1 / Chapter 2. --- LITERATURE REVIEW --- p.3 / Nursing Assessment --- p.3 / Purpose of Nursing Assessment --- p.4 / The Importance of Nursing Assessment --- p.5 / The Influence of the Concepts of Health and Holism on Comprehensive Nursing Assessment --- p.7 / Philosophical Perspectives on Nursing Assessment --- p.8 / The Incorporation of Nursing Theories or Models into Nursing Assessment --- p.10 / Implementation of Comprehensive Nursing Assessment --- p.12 / Areas Included in the Comprehensive Nursing Assessment --- p.13 / Biophysical Assessment --- p.14 / Psychological Assessment --- p.16 / Sociocultural Assessment --- p.19 / Spiritual Assessment --- p.21 / Summary --- p.24 / Chapter 3. --- METHOD --- p.25 / Design --- p.26 / Sampling --- p.28 / Data Collection Methods --- p.32 / Data Collection Procedure --- p.37 / Pilot study --- p.39 / Reliability --- p.41 / Ethical Considerations --- p.43 / Data Analysis --- p.44 / Chapter 4. --- RESULTS --- p.47 / Sample Characteristics --- p.47 / Mean Scores for Comprehensive Assessment --- p.50 / Items with Higher and Lower Scores in the Questionnaires and the Checklists of Nursing Records --- p.53 / Items with Higher and Lower Means in Each Category in Comprehensive Assessment Questionnaire --- p.57 / Differences in the Total and Category Assessment Mean Scores --- p.59 / Factors Affecting the Implementation Comprehensive Nursing Assessment --- p.64 / Suggested Interventions to Enable Nurses to Perform Comprehensive Nursing Assessment --- p.67 / Chapter 5. --- DISCUSSION AND CONCLUSION --- p.71 / The Performance of Comprehensive Nursing Assessment --- p.71 / The Focus of the Assessment within Each Component of Nursing Assessment --- p.74 / Factors Affecting the Implementation of Comprehensive Nursing Assessment --- p.81 / Limitations --- p.87 / Implications for Practice --- p.89 / Recommendations for Future Research --- p.91 / Conclusion --- p.92 / REFERENCES --- p.94

It was hypothesised that previous experience of working with issues concerning sexuality and clients with learning disabilities, knowledge, and overall experience of working with the client group would influence decisions professional staff made concerning sexuality and risk. A questionnaire was devised comprising the following four sections: 1. Demographic details. 2. Changes in levels of promotion / protection of clients since qualifying in a profession. 3. Knowledge questions concerning issues of sexuality. 4. Scenario based questions relating to sexuality and relationship issues- The questionnaires were completed by 78 professional members of community learning disability teams. A significant positive correlation was found between knowledge scores and scenarios cores, indicating that the more knowledgeable the individual is the more protective they are of clients. Additionally, a significant positive correlation was found between the amount of experience dealing specifically with sexual relationships and knowledge scores. A significant negative correlation was found between the amount of experience gained in dealing with clients experiencing heterosexual relationships and the score gained in the scenario concerning that issue. A significant negative correlation was also found between the amount of experience gained in dealing with sexual health issues and the score in the relevant scenario. This indicates that the more experience the participant has in dealing with heterosexual relationships and issues around sexually transmitted diseases, the more promoting they are when assessing the risks in a related scenario. A polarisation of views was noted in the scoring of some of the scenarios. The clinical implications are discussed as well as possible improvements in questionnaire design. Suggestions are made concerning directions for future research.

This qualitative study, carried out in an early learning center in an international school in Japan, aims to examine the place, meaning, and practice of assessment of young children’s learning through the methodology of documentation as defined and developed by the educators of the Reggio Emilia Approach. Whereas most aspects of instruction and assessment practices focus on individual performances and achievements, this study looks at the learning strategies of young children within the group and the learning of the group and the complexities of assessment practices assigned to socio-cultural theory. The focus of this study, therefore, is framed within socio-cultural theory to look at the intersection of the two, that of group learning and documentation, where the systematic and purposeful documentation of the ways in which groups develop ideas, theories and understanding is given space as being critical to learning of individuals as well as of groups towards building an understanding of assessment from a socio-cultural perspective. Learning is viewed as relevant to experience where the relations between the social and personal (cultural) are shared and that each person learns autonomously and through the ways of learning of others. The study was carried out in the form of action research in the course of one academic year, with the researcher acting as an active participant observer to a group of 4 children and a teacher who formed a learning group through a yearlong project on the concept of color. The teacher was asked to document the process of the salient paths of learning of the children through the project, becoming the ‘documentor’ of the project, and the researcher ‘documenting the documentor’. The main findings suggest to view learning of young children as a web of reciprocal expectations and possibilities of engagement built upon children’s constant mediation between scientific and everyday concepts with and through others.