M.Cur. / The neonate has the right to quality nursing care and the Neonatal Intensive nursing care practitioner is personally and professionally-ethically liable for quality nursing care. The process of quality improvement is a structured, planned and purposeful action where standards are set and the nursing care is evaluated after which remedial steps are taken to improve quality nursing care. In this study the focus is on the first step in the quality improvement cycle; the setting of standards. The central theoretical statement is as follows: standards for Neonatal Intensive nursing care facilitate quality nursing care in the Neonatal Intensive Care unit. The purpose of the study is to describe and formulate standards for Neonatal Intensive nursing care which can be utilised as an accreditation instrument for institutional self evaluation to improve quality nursing care. The aim of the study is justified by means of a descriptive, explorative, contextual research design. Standards for Neonatal Intensive nursing care were developed and validated by utilising a threephase research method. In phase one subjects for standards were identified by a panel of six experts. They were chosen according to their academic qualifications and nursing experience. The identification was done by means of a critical debate, after which a preliminary conceptual framework was formulated. During the second phase a comprehensive literature control was undertaken to refine the preliminary conceptual framework. The final conceptual framework, that was formulated during phase two, served as a basis for the description and formulation of standards. The standards were divided as unit management standards and clinical nursing care standards. During the third phase a final validation of the standards occured by means of a consencus debate between the experts that were used in the first phase. An accreditation instrument was developed to be utilised for institusional self evaluation in order to facilitate quality nursing care. The standards comply with content validity within the context of a Neonatal Intensive Care unit in a private hospital in Gauteng. It is recommended that the standards are validated nationally in the Neonatal Intensive Care practice in order to be implemented after inservice training to the different role players. The following hypotheses is set for testing: standards for Neonatal Intensive nursing care improve quality nursing care in the Neonatal Intensive Care unit.

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Long-term outcomes for patients admitted to intensive care units (ICUs) are recognised to be of increasing importance. Published studies indicate that ICU survivors have significant physical impairment, impaired quality of life, and excess mortality during the post-ICU period. The period of excess mortality has been variously estimated as lasting from one to 16 years after ICU discharge. Remarkably little information about long-term mortality and healthcare resource use exists for critical care populations, and outcomes relative to a non-ICU control population are unknown. The aims of the studies presented in the thesis were (i) to describe long-term (five year) mortality and identify factors associated with mortality for patients admitted to ICUs in Scotland (ICU admission cohort) and those surviving to be discharged from hospital alive (ICU survivor cohort); (ii) to compare mortality rates with control populations after adjustment for relevant confounders; (iii) to evaluate the extent of, and factors associated with, long-term (five year) major healthcare resource use of survivors of critical illness (ICU survivor cohort); and (iv)to compare major healthcare resource use with a control hospital inpatient population. I undertook a detailed systematic review of the international literature relating to healthcare resource use in ICU survivors to inform the design of the part of the study relating to resource use. This revealed a paucity of high quality studies but led to recommendations for improving the conduct and reporting of future research in this field. Using both retrospective cohort and matched cohort study designs, I analysed data relating to all patients admitted to Scottish ICUs in 2005 from the Scottish Intensive Care Society Audit Group (SICSAG) database. Two cohorts were defined: an ICU admission cohort, representing all ICU admissions, and a subcohort of those who survived to hospital discharge (ICU survivor cohort). Matched control cohorts of non-ICU hospital inpatients were selected from national datasets. The main outcomes were five-year mortality and major healthcare resource use obtained from linkage to national datasets. Major healthcare use was measured by number of hospital readmissions, number of days spent in hospital and hospital costs during the five years after hospital discharge. Five year mortality was 53% in the ICU cohort compared with 27% for the matched control hospital cohort and 16% for an age/sex-standardised general population. Among hospital survivors, ICU patients had higher five year mortality after adjustment for confounders (HR 1.3, 95%CI 1.2 to 1.4, p<0.001). Age, comorbidity, ICU admission diagnosis and deprivation quintile were independently associated with five-year mortality. The ICU diagnosis with greatest five year mortality (relative to self-poisoning) was variceal bleeding (HR 3.9, 95%CI 2.2 to 6.7, p<0.001). The readmission rate for the 5259 ICU patients surviving to hospital discharge declined from 1.7 readmissions per person in the first year to 0.9 in the fifth year of follow-up. Overall, ICU survivors spent a mean of 29 days in hospital over the five year follow up period, at a cost of £14593 per person. Previous number of admissions was the factor most strongly associated with resource use. ICU patients had a significant increased rate of hospital admission compared with the control cohort throughout the five year follow up period (admission rate ratio 1.21 (95%CI 1.14 to 1.29, p<0.001)). In the programme of work presented in this thesis, I have systematically reviewed evidence for resource use following critical illness, and have demonstrated that ICU patients are more likely to die compared with other hospital inpatients over a five-year horizon, even when only hospital survivor cohorts are considered. Furthermore, I have demonstrated that ICU survivors utilise a significant amount of excess acute hospital resource, which is relevant to health service planning and economic evaluations.

published_or_final_version / Nursing Studies / Master / Master of Nursing

published_or_final_version / Nursing Studies / Master / Master of Nursing

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The aim of this study was to describe and compare the needs of families of critically ill patients in two adult ICUs from both the family and the nurses' perspectives. A non-experimental descriptive survey design with a quantitative approach was used to explore the family members' needs in an ICU situation. For this study, a non-probability convenience sample of 50 critical care nurses and 50 family members from adult Intensive Care Units (ICUs) in two tertiary hospitals was used. The Critical Care Family Need Inventory (CCFNI) (Molter, 1979) was used as a data collection instrument. There were different perceptions of family needs between families and nurses. Nurses were accurate with 21 (47%) of the 45 families' need items which was less than half of their perceived family needs compared to family members' perceptions despite the fact that the two groups were in agreement with 5 of the first 10 most important needs. Recommendations for future practice included incorporation of educational programmes for critical care nurses concerning family needs in ICU settings, and the provision of specific in-service training to improve communication skills. Critical care unit, critical care nurse, critically ill patient, family, family member, needs, perception, critical care nursing. / Thesis (M.A.)-University of KwaZulu-Natal, Durban, 2010.

The management of critically ill patients at end-of-life (EOL) is concerned with shifting the focus of care from curing disease to maximizing comfort and ensuring the needs of the patient and family (Carey & Cosgrove 2006). Despite the availability of a wide range of EOL care studies, there appears to be inadequate knowledge of how best intensive care nurses can cope and provide ethical, quality, humane, holistic and comfort care for the dying patients including these patients’ family members in the ICU. Purpose: To develop best practice guidelines for end-of-life care for intensive care nurses in adult intensive care units at three tertiary level III hospitals in Gauteng province. Objectives: 1) To search and analyze for quality research discourse on EOL care by means of a systematic review, 2) To search for evidence on EOL care through interviews with family members, interviews with critically ill patients and focus group discussions with intensive care nurses. 3) To develop best practice guidelines for intensive care nurses on EOL care. 4) To verify the tentative best practice guidelines using an Appraisal of Guidelines Research and Evaluation (AGREE) II instrument. Design: Both quantitative and qualitative approaches were used to achieve the aim of the study. Systematic review, semi structured interviews and focus group discussions were utilized during data collection in the various steps of the study. During data analysis, meta-synthesis was utilized for systematic review; Tesch’s (1992) eight steps of analysis were used for semi structured interviews whereas the long-table approach was used to analyze transcripts from focus groups. The process of guideline development was divided into three stages: Stage I involved the search for quality research evidence on EOL care (this was conducted in 4 steps: In step 1, a systematic review of both qualitative and quantitative articles on EOL care was conducted yielding 23 articles, step 2 included individual interviews with 17 purposively selected family members, step 3 involved individual interviews with 16 purposively selected critically ill patients whereas step 4 included three focus group discussions with 24 purposively selected intensive care nurses). Stage II involved development of best practice guidelines in form of recommendations by means of synthesising and integrating conclusions from stage I. stage III involved verification of the guidelines by four purposively selected verifiers using the AGREE II instrument. Findings: The main findings obtained from the four steps in stage I of the study were as follows: step 1) the findings from systematic review were grouped as factors that enable or complicate EOL care, patients’/family members’/nurses’ experiences of EOL care and decision making processes at EOL. Step 2) Five major themes emerged from the experiences of family members on EOL care. These included: “most of the time we are in darkness”, “emotional support”, “involvement”, “you feel you should see her face more often” and “spiritual support”. Step 3) Five major themes were identified from the experiences of critically ill patients on comfort care and they included: “being in someone’s shoes”, “communication”, “trust”, “presence” and “religion and spirituality”. Step 4) Focus group discussion with the intensive care nurses led to five major themes including: “difficulties we get”, “discussion and decision making”, “support for patients”, support for families” and support for nurses. Conclusions drawn from stage I provided evidence for the development of best practice guidelines. Based on the conclusions drawn, guidelines developed were divided into three categories related to: communication, caring and negative aspects impacting on EOL care. The tentative guidelines were verified by a panel of four experts. The verifiers’ feedback, recommendations, criticisms and suggestions were analysed and incorporated into the guidelines. Conclusions: Guidelines were developed to inform nursing practice, nursing management and nursing education. Communication recommendations focused on how to effectively communicate as a health care team as well as instituting communication strategies in dealing with dying patients and their families. Caring recommendations were intended to promote quality care for patients and families at EOL and more so, the care needed by nurses in order for them to continue rendering holistic nursing care. Negative factors impacting on EOL care reflected on what need to be improved so as to ensure quality EOL care. In general, the guidelines were rated to be of high quality and were recommended for use by the verifiers.