Few studies have explored how medical ethics works in practice specifically in terms of the social processes that result in a decision regarding an ethical problem. This is particularly so in the case of children’s intensive care. More than a decade of teaching healthcare ethics to both nurses and doctors prompted a study to examine how ethical problems are resolved in a children’s intensive care unit. This qualitative study addressed this question in a single large children’s intensive care unit in England. The study was guided by grounded theory in examining via individual face to face unstructured and semi-structured interviews what ethical problems were encountered and how they were resolved. Interviews were conducted mainly with doctors and nurses working on an intensive care unit. Two admitting consultant doctors and three parents were also interviewed. The analysis of data gathered in 20 interviews was developed using Strauss and Corbin’s (1998) framework. A theory emerged from the analysis of the data that revealed the most prominent ethical problems in children’s intensive care related to end-of-life situations. Most significant among these was the decision to withdraw life-preserving interventions from a child. The theory outlines a process by which health professionals involved in the care and treatment of a child in intensive care negotiated a consensus on the point at which it was no longer appropriate to continue life-preserving interventions. This consensus was then presented to parents. Parental assent to withdrawal was facilitated, when not immediately forthcoming, by a process of persuasion.

D.Cur. / Please refer to full text to view abstract

>Magister Scientiae - MSc / Functional genomics determines the biological functions of genes on a global scale by using large volumes of data obtained through techniques including next-generation sequencing (NGS). The application of NGS in biomedical research is gaining in momentum, and with its adoption becoming more widespread, there is an increasing need for access to customizable computational workflows that can simplify, and offer access to, computer intensive analyses of genomic data. In this study, the Galaxy and Ruffus frameworks were designed and implemented with a view to address the challenges faced in biomedical research. Galaxy, a graphical web-based framework, allows researchers to build a graphical NGS data analysis pipeline for accessible, reproducible, and collaborative data-sharing. Ruffus, a UNIX command-line framework used by bioinformaticians as Python library to write scripts in object-oriented style, allows for building a workflow in terms of task dependencies and execution logic. In this study, a dual data analysis technique was explored which focuses on a comparative evaluation of Galaxy and Ruffus frameworks that are used in composing analysis pipelines. To this end, we developed an analysis pipeline in Galaxy, and Ruffus, for the analysis of Mycobacterium tuberculosis sequence data. Furthermore, this study aimed to compare the Galaxy framework to Ruffus with preliminary analysis revealing that the analysis pipeline in Galaxy displayed a higher percentage of load and store instructions. In comparison, pipelines in Ruffus tended to be CPU bound and memory intensive. The CPU usage, memory utilization, and runtime execution are graphically represented in this study. Our evaluation suggests that workflow frameworks have distinctly different features from ease of use, flexibility, and portability, to architectural designs.

Samfattning   Bakgrund: I vår vardag världen över drabbas människor oavsett kön och ålder av olyckor, dödsfall och andra traumatiska händelser. Vissa yrken medför en större risk att utsättas för traumatiska händelser. Exempel på dessa är ambulans, räddningspersonal, polis och vårdpersonal inom främst akutsjukvård. Dessa händelser kan ibland bli personen övermäktigt. Ett sätt att motverka bl.a. utbrändhet och posttraumatiskt stressymptom (PTSD) hos vårdpersonalen är att genomföra debriefingsamtal. Detta genomförs med den vårdpersonal som varit delaktig i en traumatisk händelse.     Syfte: Syftet med denna studie var att beskriva erfarenheten av debriefing hos vårdpersonal inom akutsjukvården i samband med traumatiska händelser i sin yrkesutövning.   Metod: Litteraturstudie som totalt innehåller 10 vetenskapliga artiklar varav fem är kvalitativa och fem är kvantitativa.   Resultat: Studieresultatet påvisar att debriefing uppfattas som ett positiv redskap när det gäller avlastning efter en traumatisk händelse för vårdpersonalen inom akutsjukvården. De främsta faktorerna som lyfts i studien är tid och plats för debriefing, debriefingens inverkan på kommunikationen mellan vårdpersonalen, val av debriefingledare och behovet av väl utformade riktlinjer för debriefingen.   Slutsats: I föreliggande studie påvisas att debriefing bör betraktas som ett effektivt verktyg att motverka psykisk ohälsa hos vårdpersonalen och att debriefing även förstärker kommunikationen mellan de olika professionella yrkesgrupperna inom akutsjukvården. Studien visar även att det är viktigt med väl utformade riktlinjer för att debriefingens syfte skall uppnås. / Abstract Background: In our everyday lives worldwide, people are affected regardless of gender and age by accidents, deaths and other traumatic events. Some professions involve a greater risk of being exposed to traumatic events. Examples of these are ambulance, emergency personnel, police and health care personnel, primarily in emergency care. These events can sometimes become overpowering. One way to counteract burnout and post-traumatic stress symptom (PTSD) in healthcare professionals is to carry out debriefing talks. This is done with the healthcare staff who has participated in a traumatic event.   Aim: The purpose of this study was to describe the experience of debriefing in healthcare professionals in emergency care in connection with traumatic events in their professional practice.   Method: Literature study that contains a total of 10 scientific articles, five of which are qualitative and five are quantitative.   Results: The study results show that debriefing is perceived as a positive tool when it comes to unloading after a traumatic event for the healthcare staff in emergency care. The main factors raised in the study are time and place for debriefing, debriefing impact on the communication between the healthcare staff, the choice of debriefing leader and the need for well-designed guidelines for debriefing.   Conclusion: The present study demonstrates that debriefing should be regarded as an effective tool for counteracting mental illness in the healthcare staff and that debriefing also reinforces communication between the various professional occupational groups in emergency care. The study also shows that well-designed guidelines are important for achieving the purpose of the debriefing.

The volumes of data which Big Data applications have to process are constantly increasing. This requires for the development of highly scalable systems. Microservices is considered as one of the solutions to deal with the scalability problem. However, the literature on practices for building scalable data-intensive systems is still lacking. This thesis aims to investigate and present the benefits and drawbacks of using microservices architecture in big data systems. Moreover, it presents other practices used to increase scalability. It includes containerization, shared-nothing architecture, data sharding, load balancing, clustering, and stateless design. Finally, an experiment comparing the performance of a monolithic application and a microservices-based application was performed. The results show that with increasing amount of load microservices perform better than the monolith. However, to cope with the constantly increasing amount of data, additional techniques should be used together with microservices.

Thesis submitted in fulfillment of the requirements for the degree of Masters of Science in Nursing, Faculty of Community and Health Sciences, Department of Nursing Education, University of the Witwatersrand Johannesburg, 2012 / Studies generally agree the survival of the mechanically ventilated patient in the ICU is largely reliant upon the competence of the nurse undertaking this highly specialized role (Alphonso,Quinones,Mishra,et al. 2004; Burns 2005) However, an audit undertaken by the Critical Care Society of Southern Africa (2004) revealed that 75 % of nurses working in ICU are inexperienced and do not hold an ICU qualification, and as such are unlikely to have acquired the level of competency required to care for the mechanically ventilated patient (Binnekade 2004). A high index of suspicion exists around the competence levels of nurses‟ currently working in ICU in SA as revealed by local studies (Khoza & Ehlers 1998; Scribante & Bhagwanjee 2003; Moeti, van Niekerk, van Velden, 2004; Morolong & Chabeli 2005; Windsor 2005; Perrie & Schmollgruber 2010). The purpose of the study was to determine and describe the level of competence with regard to mechanical ventilation, of nurses working in ICU, who have varying years of experience and training backgrounds, using study specific designed clinical vignettes, in two tertiary healthcare institutions in Gauteng. A descriptive two phase design was utilized for the study. Phase one comprised the development and validation of three clinical vignettes to determine the level of competence of nurses working in ICU‟s with regard to mechanical ventilation. A modified Delphi technique technique using purposively sampled experts from medical technical and nursing backgrounds was used to validate the three clinical vignettes. Content validity was strengthened by computing CVI of the instrument. In Phase two consecutive sampling was used, and data collection comprised of participants (n=136) completing three validated clinical vignettes in the ICU‟s of two tertiary healthcare institutions in Gauteng. All nurses who participated in the study completed the same three clinical vignettes and demographic data. Nurses‟ perceptions regarding their own level of competence with regard to mechanical ventilation were quantified and compared with actual scores achieved in the clinical vignettes. Descriptive and inferential statistics were used to analyse the data. The level of significance was set at <0,05 and confidence levels at 95%. The competency indicator for the vignettes was set at 75% by the expert group, and nurses‟ level of competence was graded according to vignette score outcomes using a grading scale. Statistical assistance was obtained from a statistician from the Medical Research Council (MRC). Results: Results of the study showed that nurses regardless of training background, age, or experience showed a poor level of knowledge, the average score being 48% for ICU qualified nurses and 31% for non-ICU qualified nurses. There was a small significant difference between ICU qualified and non-ICU qualified nurses‟ competence levels in mechanical ventilation when analysed using a two tailed- t- test (p=0.039). Nurses also experienced a misperception regarding their own competence levels in mechanical ventilation when compared to their actual competence levels as determined by three clinical vignettes.

MSc (Nursing), Faculty of Health Sciences, University of the Witwatersrand / The purpose of this study was to elicit and compare nurses’ and families’ perception of family needs in intensive care unit. A quantitative non-experimental, comparative and descriptive research design was used to achieve research objectives. Participants (nurses, n= 65; family members, n= 61) were drawn from three intensive care units. Data were collected using a questionnaire developed from the Critical Care Family Needs Inventory (CCFNI). Descriptive and inferential statistics were used to analyze the data. Majority (more than 50%) of both groups agreed with 42 out of 45 family need statements. All the nurses (100%, n=65) agreed with the need ‘to have explanations that are understandable’ while most family members (98%, n=58) agreed with the need ‘to feel that health care professionals care about the patient’. Seven out of ten statements agreed by majority of both groups were similar. Most of these statements were related to assurance and information need categories. In addition, both groups scored high on the two categories, assurance and information. However, family members scored higher than nurses in two categories, assurance and proximity with statistically significant difference (p-value < 0.05). Based on the research findings, it can therefore be concluded that generally there were similarities between nurses’ and families’ perception of family needs. These findings support evidence in literature resulting from previous studies.

Purpose: To introduce the simplified therapeutic intervention scoring system (TISS-28), the original therapeutic intervention scoring system (TISS-76) and simplified acute physiological score (SAPS) version II in critically ill adult patients, in order to describe the validity and reliability of TISS-28 as a suitable measure of quantifying nursing workload in the adult intensive care units (ICU) of a public sector hospital in Johannesburg. Objectives: To describe the profile of patient admissions to the intensive care units, to investigate the impact of the patients’ profile on the requirements for nursing workload and to validate the use of TISS-28 as a measure of quantifying nursing workload in this setting. Design: A non-experimental, comparative descriptive, correlational and prospective two-staged design was utilized to meet the study objectives. Stage I involved face and content validation of TISS-28 by a panel of ICU nurse experts (n=6). Stage II involved assessment of concurrent and construct validity as well as inter-rater reliability of TISS-28 using participants (n=105) drawn from trauma, cardiothoracic and multidisciplinary ICUs. Data necessary for the calculation of TISS-28, TISS-76 and SAPS II were recorded for each patient in the ICU at 24 and 48 hours after admission and in the wards after discharge within 24-48 hours. Descriptive and inferential statistics were used to analyze data. Results: Content Validity Index (CVI) of 0.93 was found for TISS-28. A significant positive correlation was found between TISS-28 and TISS-76 scores (r = 0.7857, p = 0.0001) as well as TISS-28 and SAPS II scores (r = 0.2098, p = 0.0317). A significant difference was found between TISS-28 scores among patients in the ICU and patients in the ward (t = 25.59, p = 0.0001; t = 21.48, p = 0.0001) respectively. A significant correlation was found between the data collected from a sample of patients by the researcher and the expert assistant researcher with an intra-class correlation coefficient of 0.99 and a p-value of 0.0001. Conclusions: The findings support validity and reliability of TISS-28 hence its feasibility for use in South African ICUs. Recommendations for nursing education, practice, management and research are proposed.

Os eventos adversos, devido à grande ocorrência, são considerados um importante problema de saúde pública além de elevarem os custos com a saúde. Dessa forma, existe a necessidade de um sistema eficiente de farmacovigilância para prevení-los sendo a monitorização intensiva uma excelente estratégia para se alcançar este objetivo, pois permite a identificação e o conhecimento dos eventos adversos, além de medir sua incidência e melhorar as notificações voluntárias. Por esta razão, o presente estudo propôs a avaliação deste método em eventos adversos relacionados ao antimicrobiano vancomicina. As informações coletadas, provenientes dos bancos de dados e dos prontuários do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto (HCFMRP-USP), são referentes aos pacientes internados no hospital em tratamento com vancomicina no período de 01/09/2008 a 31/08/2009. Identificou-se 1719 tratamentos de 1302 usuários. Destes tratamentos, 521 foram excluídos por serem profiláticos. A idade média dos 1198 pacientes monitorados foi de 39,33 (± 27,66) anos e 58,68% pertenciam ao gênero masculino. Os diagnósticos infecciosos prevalentes para o tratamento com vancomicina foram pneumonia (18,95%), sepse (11,19%) e infecção relacionada a cateter (10,27%) com período médio de duração do tratamento de 11,47 (±7,79) dias geralmente na dose de 2000 mg ao dia (35,98%). Foram identificados indicadores de eventos adversos em 85,81% dos tratamentos, sendo a incidência de eventos adversos de 7,18%. A incidência de reações adversas (RAM) foi de 5,93% e de erros de medicação 2,57%. A causalidade das RAM foi prevalentemente provável (49,29%) e a gravidade moderada (54,93%). As RAM foram essencialmente do tipo B (81,69%) e os erros de medicação relativos à prescrição (87,10%). A comparação entre os grupos controle e estudo não apresentou diferenças significativas, demonstrando a necessidade de monitorização de todos os parâmetros relacionados a eventos adversos com a vancomicina. Dessa forma, fica evidente a importância da monitorização intensiva e da presença dos farmacêuticos clínicos na equipe de saúde para melhorar a eficiência da farmacovigilância, como demonstrado por este estudo. Diante dos resultados, conclui-se que o método de monitorização intensiva utilizando base de dados e prontuários, além da participação de um farmacêutico clínico, promove o conhecimento, a avaliação e a compreensão dos eventos adversos presentes em uma instituição, permitindo a esquematização de estratégias para a sua prevenção. / Adverse events, due to the high occurrence, are considered an important public health problem in addition to driving up health care costs. There is therefore a need for an efficient system of pharmacovigilance to prevent them being the intensive monitoring an excellent strategy for achieving this goal because it allows the identification and knowledge of the adverse events, in addition to measuring its incidence and improve spontaneous reports. For this reason, the present study evaluated this method in adverse events related to antibiotic vancomycin. The informations collected from databases and records of the Hospital of the Medical School of Ribeirão Preto-SP (USP-HCFMRP), refers to hospital patients treated with vancomycin for the period 01/09/2008 to 31/08/2009. We evaluated 1719 treatments in 1302 users, of which 521 were excluded because they were prophylactic. The average age of 1198 patients was 39.33 years (±27.66) and 58.68% were males. Prevalent infectious diagnoses for treatment with vancomycin were pneumonia (18.95%), sepsis (11.19%) and catheter-related infection (10.27%) with mean duration of treatment of 11.47 days (± 7.79) usually at a dose of 2000 mg daily (35.98%). We identified indicators of adverse events in 85.81% of treatments, and the incidence of adverse events was 7.18%. The adverse drug reactions (ADR) incidence was 5.93% and 2.57% of medication errors. The causality of ADR was probable (49.29%) and severity was moderate (54.93%). The ADR were mainly of type B (81.69%) and medication errors related to prescription (87.10%). Comparisons between the study and control groups showed no significant differences, demonstrating the need for monitoring of all parameters related to adverse events with vancomycin. Thus, it is clear the importance of the intensive monitoring and the presence of clinical pharmacists in the health team to improve the efficiency of pharmacovigilance, as demonstrated by this study. Before the results, we conclude that the method of intensive monitoring using the database and records, plus the involvement of a clinical pharmacist, promotes knowledge, assessment and understanding of adverse events presents in an institution, enabling the layout of strategies to prevention.

A palavra estresse tem sido muito utilizada, sendo associada a sensações de desconforto em diversas situações, dependendo do ponto de vista de cada um. O estresse está relacionado à enfermagem principalmente pelo fato do enfermeiro trabalhar com pessoas doentes, em sofrimento físico e psíquico, que requerem grande demanda de atenção, compreensão e empatia. Lidando com as referidas pessoas e com as diversas situações, os sentimentos que desenvolve podem levá-lo a estados de irritação, desapontamento, e, até mesmo, à depressão. O trabalho na enfermagem, por si só, constitui-se em fonte de estresse decorrente do sofrimento dos pacientes, principalmente dentro de uma Unidade de Terapia Intensiva (UTI), onde os mesmos necessitam de cuidados diretos e intensivos e estão sujeitos a mudanças súbitas no estado geral. Devido à importância do tema, este estudo, seguindo uma metodologia quanti - qualitativa, objetivou caracterizar os enfermeiros que desenvolvem suas atividades em UTI, verificar como associam o estresse a suas atividades, e, também, verificar a presença de estresse entre eles. Para tal, participaram do estudo 21 enfermeiros de UTIs de 5 hospitais do interior do Estado de São Paulo, que responderam a um roteiro de perguntas direcionadas a sua caracterização, um questionário com 2 perguntas sobre estresse e o Inventário do Estresse em Enfermeiros. Os resultados mostraram que a maioria dos participantes é do sexo feminino, na faixa etária dos 24 aos 50 anos, casados, com tempo de formação entre 1 e 16 anos e com curso de especialização. A falta de recursos humanos e materiais, o relacionamento interpessoal entre a equipe, o excesso de atividades e a rotatividade de leitos, foram alguns dos aspectos que os enfermeiros relataram relacionados à presença de estresse associados as suas atividades e que se manifestaram através de sintomas físicos e psíquicos. Dos enfermeiros pesquisados, 57,1% consideraram a UTI um local estressante e 23,8% deles apresentaram um escore elevado indicando a presença de estresse, o que leva a consideração de que este estudo evidenciou o fato de que o estresse, mesmo sendo discutido desde longa data, acomete, de certa forma, esses profissionais, e, as instituições, ainda não oferecem atenção especial aos seus profissionais no sentido de promover sua saúde integral. / The word stress has been frequently used, being associated with sensations of discomfort in many situations, depending of the point of view of each one. The stress is related to nursing mainly because the nurses have to work with sick people, suffering physically and psychologically, that requires a lot of attention, comprehension and empathy. Dealing with the referred people and with the diverse situations, the feelings that they develop can let them to irritating, disappointing states and, even, to depression. The work in the nursing area, for itself, it\'s a source of stress caused by the patient\'s suffering, mainly inside the Intensive Therapy Unit (ITU), where they need straight and intensive care and they are subjected to sudden changes in the general state. As the importance of the theme, this study, following a quantitative and qualitative methodology, aims to describe the nurses that developed their activities in the ITU, verifying how they associated the stress with their duties, and, also, identifying the stress presence among them. For that, 21 ITU nurses from 5 hospitals of the inner State of São Paulo participated of the research, answering a list of questions related to their description; one questionnaire with 2 questions about stress and the Inventário do Estresse em Enfermeiros. The results showed that most of the professionals are women, between 24 to 50 years old, married, graduated for 1 to 16 years and with specialization course. The lack of human resources and materials, the relationship interpersonal among the staff, the exceeding activities and the rotation of the hospital bed, were some of the aspects that the nurses said associated with their activities and that were caused by the physical and psychological symptoms. Among the interviewed nurses, 57,1% considered the ITU a stress local and 23,8% presented a high score that indicates the presence of stress, that takes into consideration that this study reveals the fact that the stress, even being considered since a long time ago, it affects, in some way, these professionals, and, the institutions don\'t offer special attention for their professionals to promote their integral health yet.