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Continuous professional development (CPD) is used to support the development and progression of professions. As nursing regulated by the South African Nursing Council (SANC), has no CPD system, the study’s aim was to describe critical care nurses opinions regarding CPD, their current participation in CPD programs and what they perceive as their potential barriers to CPD. It is envisaged that this study will provide information to consider in developing a CPD framework to support critical care nurses with life long learning. The research design was quantitative using a non experimental, descriptive survey approach, comprised of two phases using Lynne’s model (1986). Data results showed similarity with international literature: significant needs for knowledge and skills related to new technology, attitudinal improvement and professional networking with critical care nurses internally driven to participate in CPD programs and significant barriers to being lack of knowledge in how to access CPD events communication and a lack of communication.

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, 2014 / Discrepancies exist between how pain is assessed in ICU patients able and unable to self report. There are pain assessment scales and guidelines that have been developed over the years for pain assessment. However, little is known regarding ICU nurses’ knowledge and current practices in the provision of pain management in the critically ill. The purpose of this study was to investigate intensive care nurses’ knowledge and practices related to pain assessment for critically ill patients. A quantitative non-experimental, descriptive cross-sectional design was used to achieve the objectives. ICU nurse participants (n=79) were drawn from the five (5) adult ICUs in a public tertiary hospital. Data were collected using a self-administered questionnaire by Rose et al. 2011. Descriptive and inferential statistics were used to analyze the data.

Mechanical ventilation (MV) is the defining event of intensive care unit (ICU) management. Although it is a lifesaving intervention in patients with acute respiratory failure and other diseases, a major goal of critical care clinicians should be to liberate patients from MV as early as possible to avoid the multitude of complications and risks associated with prolonged MV. Such complications include an increase in mortality, morbidity and ICU length of stay (LOS), as well as reduced functional status and quality of life (Moodie et al 2011; Gosselink et al 2008). Rapid weaning however has its own potential problems such as fatigue or cardiovascular instability, either of which may ultimately delay the weaning process. Premature extubation, leading to reintubation, is associated with increased risk of pneumonia and mortality (Brown et al 2011; Meade et al 2001 (a)). In view of this, there has been increasing interest in delivering more consistent practice in ICUs by developing weaning protocols that provide structured guidelines to achieve prompt and successful weaning. Many studies have shown the benefit of allied health care worker (nurses and physiotherapists) driven weaning protocols in decreasing MV days and costs (MacIntyre 2005; Dries et al 2004; Ely et al 2001). Objectives: The objectives of this study were to determine a) if the number of patients in the ICU has an influence on physiotherapists’ involvement in the weaning of patients from MV, b) if the type of ICU has an influence on physiotherapists’ involvement in the weaning of patients from MV, c) if physiotherapists are involved in the development and implementation of weaning protocols for mechanically ventilated patients in their ICUs, d) if physiotherapists are involved in titration of ventilator settings for patients during the weaning process, e) what modalities physiotherapists in South Africa use to facilitate respiratory muscle strengthening to assist weaning of patients on MV, f) if physiotherapists in South Africa are involved in the extubation of ventilated patients, g) if there is a difference in involvement in weaning of mechanically ventilated patients between newly qualified physiotherapists and experienced physiotherapists. The last objective of this study was to determine if current physiotherapy involvement in the weaning of patients from MV in South Africa is in line with international physiotherapy practice according to the literature. Method: A questionnaire was developed by the researcher using available literature on the nature of involvement of physiotherapists in the weaning of mechanically ventilated patients. Content validation of the questionnaire was achieved after a panel of senior cardiopulmonary physiotherapists analysed each question and their recommendations and adjustments were implemented. Physiotherapists who practice cardiopulmonary physiotherapy in adult ICUs of hospitals in the public and private sectors in South Africa were sought and targeted for the study. The self-administered questionnaire was then posted or emailed to the physiotherapists identified for inclusion into the study. Results: A total of 425 questionnaires were distributed to physiotherapists who practice cardiopulmonary physiotherapy in adult ICUs of hospitals in South Africa. Of the 425 questionnaires distributed, 200 questionnaires were sent via the postal system and 225 were sent via email with a link to an online survey. The response rate for the postal questionnaires was 54.5% (n=109) and 33.3% (n=75) for the emailed questionnaire, giving a combined response rate of 43.3%. The results showed that 76% of South African physiotherapists are not or are seldom involved in the weaning of mechanically ventilated patients in adult ICUs. They are not involved in the development of weaning protocols (74%, n=51), titration and adjustment of MV settings (>80%, n=154), spontaneous breathing trails (67%, n=119) and non-invasive ventilation (58%, n=101). Physiotherapists working in South Africa are somewhat involved in extubation (16%, n=28). The most common physiotherapy modalities used in ICU to facilitate respiratory muscle strengthening are exercises (81%, n= 138), early mobilisation out of bed and deep breathing exercises. (77%, n=134). Physiotherapists’ involvement in the weaning of mechanically ventilated patients are not influenced by the type of ICU they work in (p>0.05), type of physiotherapy degree they have (p=0.24) or whether they are newly qualified physiotherapists or experienced physiotherapists (p=0.43). Conclusion: This survey shows that most physiotherapists who work in adult ICUs in South Africa are not involved in the weaning of mechanically ventilated patients. The survey does show that there is a need for physiotherapists to reconsider their role in ICU with regards to weaning patients from MV as current practice is not in keeping with the international practice of respiratory therapists in the United States of America (USA) and physiotherapists in the United Kingdom (UK), Australia and Europe.

Decision support systems (DSS) are traditionally designed to optimise the outcomes of a decision. This thesis explores how DSS design can also be driven by the optimisation of the decision process leading to the decision, and how it may enhance the human uptake and use of DSS. It identifies which tasks could be simplified by decision support, and how to build DSS that are likely to be readily adopted and so improve decision outcomes. It tests the hypotheses that: (a) The analysis of specific process attributes of a given clinical decision task, as well as the information needs of its users, improves the design of DSS and enhances systems?impact and acceptance. (b) The complexity of the decision task is the key process attribute that, in conjunction with the information seeking of users, shapes the outcome of the design process. The work is applied to the domain of antibiotic prescribing in critical care. To explore the first hypothesis, the key attributes of prescribing decisions associated with specific prescribing subtasks and different decision-makers and decision contexts are identified and then analysed. Based on our findings, an information-processing model of decision support for an antibiotic-prescribing task is proposed. The second hypothesis is addressed by applying and comparing metrics for decision complexity including minimum message length, cognitive effort assessment and clinical algorithm structure analysis to the prescribing task. A framework is developed to select clinical decision tasks that may benefit from automation, by characterizing decision support as a process of complexity reduction for users, and these ideas are tested in the context of antibiotic prescribing for ventilator-associated pneumonia. The hypotheses are then tested by applying the task complexity framework to the design of a DSS for antibiotic prescribing in critical care. A web-based experiment and a clinical trial of the DSS are described, both of which study the acceptability and effectiveness of the system and verify the usefulness of the design framework. Specifically, in a before-after controlled trial, with no difference in patient mortality or severity of presentation between the two periods, the use of the DSS was associated with statistically significant improvements in patient outcomes and a reduction in antibiotic usage. The length of stay and total consumption of antibiotics decreased respectively from 7.15 to 6.22 days (P=0.02) and from 1767 to 1458 defined daily doses/1000 patient days (P=0.04). The introduction of a hand-held computer-based DSS was associated with less administration of ???broad-spectrum?antibiotics. The relative impact of the uptake of the DSS on the prescribing quality was quantified. Clinicians chose to use guidelines for one third, and pathology data or the DSS for about two thirds of cases for which they were available to assist their prescribing decisions. When used, the DSS plus pathology data improved the agreement of decisions with those of an expert panel - from 65% to 97% (P=0.002). The impact of the DSS was more significant on prescribing decisions of higher complexity. The level of decision complexity appeared to affect the choice of decision support type. Prescribing guidelines were accessed more often for lower complexity decisions, whereas the infection risk DSS plus pathology data were preferred for decisions of higher complexity. The need for measurement of the effectiveness of a DSS in improving decisions, as well as their likely rate of adoption in the clinical environment, was demonstrated. The thesis concludes with a proposal to apply the framework described to the modelling of the DSS adoption and to include task complexity and user information seeking as determinants of the design and evaluation of clinical DSS.

1.1 The focus of this thesis will be the nexus of statistical methods and clinical practice, as it applies to Critical Care Medicine and is reflected in the literature ( for instance : Anaesthesia and Intensive Care ( Anaesthesia and Intensive Care 2005 ) and Critical Care & Resuscitation ( Critical Care and Resuscitation 2005 ) in Australia ; and internationally : Critical Care Medicine ( Critical Care Medicine 2005 ), Intensive Care Medicine ( Intensive Care Medicine 2005 ), Chest ( Chest 2005 ), American Journal of Respiratory and Critical Care Medicine ( American Journal of Respiratory and Critical Care Medicine 2005 ) and Journal of the American Medical Association ( JAMA 2005 ) ). 1.2 Altman has documented the career of statistics in medical journals over a 20 year period and has lamented the general state of affairs ( Altman 1982 ; Altman 1991b ; Altman 1994 ; Altman 2000 ). The transfer of statistical techniques into medical literature is characterised by a significant lag - time ( Altman et al. 1994b ) and statistical input into medical research and publication, although " widely recommended ... ( is ) ... inconsistently obtained " ( Altman et al. 2002 ), perhaps reflecting an undervaluation of statistical contributions to medicine, as articulated by one of the doyen ' s of biostatistics, Norman Breslow ( Breslow 2003 ). The latter observed that, as opposed to the awarding of a Nobel Prize ( in 2000 ) to econometricians Daniel McFadden and James Heckman for work on discrete choice models and selection bias, similar contributions to medicine by statisticians and epidemiologists have been, as yet, unrecognized. 1.3 Our comparators in statistical " critique " ( Berk 2004 ; BROSS 1960 ) are drawn from analytic approaches, more than thirty years apart. First, the lucid contributions of Jerome Cornfield ( Greenhouse 1982 ) ; in particular : the classic intervention ( in 1959 ) into the tobacco smoking / lung cancer debate " Smoking and lung cancer : recent evidence and a discussion of some questions " ( Cornfield et al. 1959 ) ; and " Further statistical analysis of the mortality findings " of the University Group Diabetes Program ( Cornfield 1971 ), which was an elegant response to the controversy which raged ( for some years ( Kolata 1979 ) ) over the discontinuance of tolbutamide and diet arm in that trial. The textual lucidity to which we refer was presumably a function of the literary background of Cornfield, as documented in the classic review by Salsburg of the rise of the modern statistical paradigm in the twentieth century ( Salsburg 2001 ). Second, the muscular re - examination, or rather, dissection, by Freedman et al ( Freedman et al. 2004 ) of the controversy surrounding breast cancer screening and its efficacy ; being a detailed reading of the meta - analysis by Gotszche and Olsen ( Gotzsche et al. 2000 ), who had questioned the role of mammography in breast cancer screening in terms of potential lives saved. Third, the subtle 1994 reappraisal by Petitti of the mortality treatment effect of patient " compliance " in randomized trials, as it related to both therapy and placebo groups in the Coronary Drug Project ( The Coronary Drug Project Research Group 1981 ) and the Beta - blocker Heart Attack Trial ( Byington 1984 ). The demonstration that the ( cardiovascular ) mortality reduction of compliance with placebo was of the same magnitude as that experienced by users of oestrogen replacement therapy, followed the publication of a quantitative assessment of the of the efficacy of oestrogen on coronary heart disease by Stampfer and Colditz, in which a relative risk of 0.56 ( 95 % CI 0.5 - 0.61 ) was postulated ( Stampfer et al. 1991 ). Petitti ' s review anticipated the null effects ( of replacement oestrogen ) demonstrated in the subsequent randomized trials of the Women ' s Health Initiative ( The Women ' s Health Initiative Study Group 1998 ). These null effects caused extensive debate and some degree of angst in the epidemiological literature and the consequent death of observational epidemiology was rhetorically announced ( Lawlor et al. 2004 ). 1.4 The thesis is divided into two parts: 1.4.1 First, a detailed expository analysis of various questions relating to the interpretation of the results of recent noteworthy trials in the medical and Critical Care literature. Initially we come to terms with the seemingly intractable P - value question which has regularly surfaced in the literature over the years. We also address the thorny but perennial parametric versus non - parametric test controversy. Next we look at the methodology of recent trials in Critical Care and find some problematic areas in terms of interim analyses and the reporting of results. These concerns are expanded into a detailed consideration of the issues surrounding group sequential and equivalence trials. The subsequent section analyses particular aspects of ( i ) effect size ( ii ) prognostic factors and responsiveness ( iii ) sample size, power and interpretation of trials and we conclude ( iv ) with a critique of various aspects of Critical Care practice, as it relates to certain key trials and overviews ( meta - analyses ) of these trials : the PROWESS trial of activated protein C in sepsis ; hypothermia as therapy in cerebral injury ; selective decontamination of the digestive tract ; and nutrition as therapy. 1.4.2 Second, concrete focused analyses are performed on particular datasets and particular statistical techniques are subject to scrutiny. The first encompasses multivariate analysis of phosphate metabolism in ICU patients ; in particular, issues relating to regression to the mean, appropriate estimators ( ordinary least squares or generalized linear models ), model and variable selection, and missing data. The second looks at the analysis of cost data and explores the use of generalized linear models as appropriate estimators. The third introduces time - to - event analysis in and reviews the use of the Cox model and random effects estimators in a data set of patients with malignancies. The fourth is a in depth analysis of three aspects of meta - analysis as it applies in the Critical Care field : heterogeneity, publication bias and metaregression. 1.5 In this endeavour, we are mindful of certain cautions regarding treatment effects : ( i ) it is reasonable to find odds ratio ( s ) below 0.6 " extremely surprising " ( Speigelhalter et al. 2004 ) ( ii ) " If a result appears too good to be true, it probably is " ( Yusuf 1997 ) and ( iii ) we may " require that data indicate an increased relative risk for a characteristic of at least 50 percent, on the assumption that an excess of this magnitude would not arise from extraneous factors alone " ( Mantel et al. 1959 ). The latter proposition was first articulated in 1959 by Mantel and Haenszel, but needed to be reiterated ( by Mantel ) some thirty four years later ( Mantel 1993 ). Finally, we endorse the admonition of Jerome Cornfield that " Any set of hospital or clinical data that is worth analysing at all is worth analysing properly " ( Cornfield 1951). 1.6 The importance of statistical principles in both the interpretation and conduct of analysis would seem to be obvious and we must " grapple " with statistics in the same manner as Appleby urged with respect to health economics ( Appleby 1987 ). To this extent, the evidence - based - medicine movement has mandated " critical appraisal ", which incorporates, to varying degree, statistical methods ( Morris 2002b ) and at least one prominent medical journal has recently welcomed papers " detailing important contributions in the design of studies or analysis of epidemiological data " ( Dominici et al. 2004 ). Thus statistics is increasingly engaged with " front - line science " ( Efron 2005 ) and these recent trends prefigure the overall thrust of the sections below. / Thesis (M.D.) -- University of Adelaide, School of Medicine, Discipline of Medicine,

Thesis (MVoeding)--University of Stellenbosch, 2006. / Bibliography.

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Thesis (Ph. D.)--University of Oklahoma, 1994. / Includes bibliographical references (leaves 110-129).

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