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.

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 and Child Health 29 May 2017 / Introduction Sepsis, and in particular, severe sepsis, remains a major cause of death in children worldwide. One of the areas where the burden of sepsis is keenly felt is in the paediatric intensive care unit (PICU) setting, contributing significantly to childhood mortality. Fungal organisms have emerged as a major organism contributing to nosocomial sepsis in PICU. No local data regarding nosocomial fungal sepsis in the non-neonatal, PICU population exists regarding this matter. This study describes the characteristics of patients with nosocomial fungal sepsis in the PICU at South Africa’s largest hospital Chris Hani Baragwanath Academic Hospital (CHBAH). Methods This study was a retrospective review of patient records. All patients aged 0-16 years admitted to the PICU at Chris Hani Baragwanath Academic Hospital (CHBAH) from January 2008 through December 2011 were assessed. A total of seventeen patients who developed nosocomial fungal sepsis were included in this study. Results The incidence of candidaemia was reported to be 3.2 per 100 cases. The major age group affected by nosocomial fungal sepsis was the under one age group. The most common diagnoses on admission were lower respiratory tract infection (LRTI) followed by haematology-oncology and acute gastroenteritis cases. ICU factors found to commonly co-­‐exist with proven nosocomial fungal sepsis were presence of a central venous catheter (100%), mechanical ventilation (82%), arterial line (70%), and systemic corticosteroid use (47%). The penicillin class was the most common antimicrobial that patients were found to be on at the time of nosocomial sepsis. The most common fungal organism as a cause for nosocomial sepsis was C. parapsilosis rather than C. albicans. Furthermore, the majority of this study’s isolates were susceptible to voriconazole rather the current empiric antifungal of choice, namely fluconazole. Conclusion The presence of central venous catheters, arterial lines, mechanical ventilation and systemic corticosteroid use is common in paediatric patients with nosocomial fungal sepsis. However, this study was unable to determine statistically significant factors associated with fungal sepsis in a tertiary PICU due to the surprisingly small number of cases (n=35) detected over a four-year period. This perhaps represents the most striking finding of the study together with a concerning pattern of fluconazole resistance (14%) among isolated organisms. / 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 Masters of Science in Physiotherapy. Johannesburg 2017 / Background: There is limited research available on the use of outcome measures in intensive care units (ICU) in a South African setting.The Chelsea Critical Care Physical Assessment tool (CPAx) is a measure of morbidity related to physical function and assesses respiratory function and functional abilities of critically ill patients. Objectives: The objectives of this study were to establish the effect of the use of the CPAx tool on ICU and hospital length of stay (LOS) in the care of critically ill patients; to establish the usefulness of the CPAx tool according to patient admission diagnosis; to determine if a relationship exists between CPAx scores and severity of illness or general morbidity during ICU admission; and to establish physiotherapists’ perceptions and views towards the use of the CPAx tool in their daily clinical practice in ICU. Design: The study consisted of two parts. Part one was a quasi-experimental design with a historical matched control group. Part two was a survey-based design. Methods: The study took place in a South African public sector hospital. Twenty six participants each were recruited into the experimental and control groups. Participants from the control group were matched with participants in the experimental group according to age, gender, diagnosis and acute physiology and chronic health evaluation (APACHE) II scores. CPAx scores and sequential organ failure assessment (SOFA) scores were calculated for participants in the experimental group on alternate weekdays during their ICU stay. Comparisons of ICU and hospital LOS between the study participants and historical control group were done using an independent t-test. Pearson’s correlation coefficient was used to determine if a relationship existed between CPAx scores, APACHE II scores or SOFA scores. A p-value ≤ 0.05 was deemed statistically significant. A questionnaire was developed and was completed by the research assistants who administered the CPAx tool to participants in the experimental group in order to determine their perceptions of the tool. Results: The mean age for the CPAx group was 37.88 (±13.37) years and for the control group was 37.81 (±12.21) years. The CPAx group consisted of 14 (53.8%) participants who underwent surgical procedures and 12 (46.2%) participants with traumatic orthopaedic injuries. The control group consisted of 14 (53.8%) participants who underwent surgical procedures and 12 (46.2%) participants with traumatic orthopaedic injuries. The mean initial SOFA score for the CPAx group was 2.42 (±1.79) and for the control group was 4.15 (±2.6). A p=0.03 indicates that there was a statistically significant difference between the two groups with regards to initial SOFA scores. The mean SOFA score at ICU discharge for the CPAx group was 1.80 (±0.42) and for the control group was 2.87 (±1.81). A p=0.05 indicates that there was a statistically significant difference between the two groups with regards to SOFA scores at ICU discharge. The mean initial CPAx score for the experimental group was 29.73 points (±14.81) and the mean CPAx score at ICU discharge was 36.15 (±8.33). The mean CPAx scores changed by 9.45 points between admission and discharge from ICU for participants who underwent surgical procedures and the mean CPAx scores changed by 3.9 points between admission and discharge from ICU for participants who sustained traumatic orthopaedic injuries. The mean ICU LOS for the CPAx group was 5.84 days (±7.43) and for the control group was 4.56 days (±5.25). The mean hospital LOS for the CPAx group was 17.43 (±16.68) days and for the control group was 19.31 days (±15.79); however, in both cases differences were not statistically significant. APACHE II scores had a very weak negative correlation with initial CPAx scores. APACHE II scores had a very weak positive correlation with CPAx scores at ICU discharge. There was a statistically significant difference between the two groups with regards to initial SOFA scores (p=0.05). Initial SOFA scores had a statistically significant moderate negative correlation with initial CPAx scores (r=-0.45, p=0.02). Initial SOFA scores had a weak negative correlation with CPAx scores at ICU discharge. Initial CPAx scores had a moderate positive correlation with SOFA scores at ICU discharge. CPAx scores at ICU discharge had a very strong statistically significant positive correlation with SOFA scores at ICU discharge (r=0.80, p=0.05).The CPAx tool proved to be more responsive in a surgical population than in a trauma population. Clinicians had positive perceptions of the CPAx tool in the management of critically ill patients. Discussion: Participants in the CPAx group were well matched with those in the historical control group with regards to age, gender, diagnoses and severity of illness. Those in the CPAx group had lower extent of organ dysfunction than those in the control group which might account for their shorter period of hospitalisation. Patients with a higher risk for mortality on admission into the ICU displayed lower functional abilities and, in turn, lower CPAx scores were measured. A greater change in CPAx scores was observed for participants recovering from surgical interventions compared to those recovering from traumatic orthopaedic injuries. Participants with low morbidity at the time of ICU admission seemed to have a greater ability to perform functional activities during their ICU stay. Limitations of the study included a small patient sample, a limited number of research assistants as well as lack of content validation of the questionnaire used. A multi-centre trial on the use of CPAx in ICU patient management could yield a wider perception of physiotherapists regarding the usefulness of the tool in daily clinical practice. Measuring the effect of the CPAx tool on participants’ length of mechanical ventilation could also be an interesting clinical outcome to consider. Conclusion: The data presented in this study show that the use of the CPAx tool does not have an influence on ICU and hospital LOS in a small sample of surgical and trauma participants. The tool appears to be more useful when used in the care of patients who are recovering from surgical procedures rather than those who sustained complex traumatic injuries. Physiotherapy clinicians that participated in the study supported the use of the CPAx tool in this single-centre trial and generally had positive perceptions towards the use of the tool. / MT2017

Existing literature has identified that health care providers significantly shape the experiences of parents at the end-of-life in the pediatric intensive care unit. However, there is a gap in the literature of the specific nursing influence on parental experiences of a child’s death in this context. Employing the interpretive descriptive methodology, this qualitative study was designed to explore parents’ moral experiences of nursing care at the end-of-life in the pediatric intensive care unit, and was analyzed through a lens of nursing ethics. Face-to-face, semi-structured interviews were conducted with eleven parents (six mothers and five fathers) of six children who died in a pediatric intensive care unit at a university-affiliated tertiary hospital in Eastern Canada. Study results revealed close connections between parents’ abilities to meaningfully parent a child through their death and the nursing care that they received at the end-of-life, and highlighted the varying helpful guiding roles that nurses adopted at different moments in parental experiences. Results also indicated that parents attributed immense value to feeling that nurses cared-for-and-about their child and the parents themselves, since this made parents feel that their child’s death mattered to the nurses whom they had formed relationships with. This study enhances our understanding of the individualized nature of parents’ moral experiences of nursing care at the end-of-life in the pediatric intensive care unit, and study results suggest implications for nursing practice, education, and research.

Essa dissertação tem o objetivo de analisar a complexidade do vínculo entre as indústrias eletrointensivas e o setor elétrico brasileiro, depois da década de 70, buscando responder à pergunta formulada no próprio título. 0 consumo de energia elétrica nas indústrias eletrointensivas teve um peso significativo na estrutura do consumo industrial, motivando análise por se tratar de um segmento industrial com demanda elevada de energia elétrica, exigindo consequentemente crescentes investimentos no setor de energia elétrica. Para efeito de análise, o trabalho está dividido em duas partes: a primeira aborda as questões relativas às indústrias eletrointensivas; a segunda analisa a indústria do alumínio primário brasileiro, simulando o cálculo do valor aproximado da \"perda potencial de receita\" do setor elétrico, ao fornecer energia elétrica com tarefas especiais para as duas empresas localizadas na região norte do país. Ao enfocar a implantação das duas indústrias de alumínio primário na região norte, o objetivo foi de mostrar um exemplo de decisão governamental que favoreceu investimentos pesados no Setor Elétrico, sem levar em conta o seu próprio planejamento. É bem verdade que a própria configuração do setor favoreceu esse tipo de decisão. A crise macroeconômica, que marcou a década de 80, provocou tanto a estagnação na produção e a retração do mercado interno, como o esgotamento na capacidade de financiamento do setor de energia elétrica. As indústrias de bens intermediários, como as eletrointensivas, conseguiram sobreviver graças ao mercado externo, ganhando competitividade mesmo com perda do dinamismo econômico. Num contexto de redefinição do papel do Estado, em que faltam recursos para o setor elétrico ampliar seus parque de origem hidráulica, é necessário analisar como se deu o vínculo entre o consumo de energia elétrica e as indústrias de bens intermediários, buscando respostas às necessidades do momento atual. / The aim of this study is to verify the amount of subsidie given by the electricity sector to Northern Region, as well as, the brazilian\'s option of the electricityintensive, mainly in the aluminium industry. In 1995, the Brazilian Primary Aluminium Industry consumed 18.189,5 GWh of electrical energy to produce 1188,2 thousands tons. Its growth occured after the establishment of the projects Albras and Alumar, in the Northern Region of Brazil. These two projects pay \"special tariffs\" for the electricity consumed which is generated by the Tucuruí Hydroelectric Power Plant in the State of Pará, for 20 years. When the Brazilien Government decided to build the Tucuruí Hydroelectric Power Plant, it did not take into account the criterion of lower cost projects. It has started giving incentives and allowing tariff discounts to new projects which aimed at exploring mineral reserves located in the Northern Region. The establishment of Primary Aluminium Industries in the Northern Region are typical examples of industrial policy decision, favouring heavy investments in the electricity sector without a coordinated process in its decision.