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.

Making the transition to an area of specialist nursing practice is challenging for both the learner and staff who are responsible for education and skill development. This study uses grounded theory methodology to explore the question: "How do nurses learn critical care nursing?"The eight registered nurses who participated in this study were recruited from a range of intensive care settings. The criteria for inclusion in the study included the participant having attained competency within the critical care setting. Data was collected from individual interviews. The findings of this study developed during the coding and comparative analysis process, and subsequently theoretical sampling was used to further explore the identified concepts.This study found that nurses' focus on two main areas during their orientation and induction into critical care nursing practice. These are learning to do (skill acquisition) and learning to be (professional socialisation). The process of transition involves two stages: that of learning to do the tasks related to critical care nursing practice, and the ongoing development of competence and confidence in practice ability. The relationship of the learner with the critical care team is a vital part of the transition to competency within the specialist area.This study identifies factors that influence the learner during transition and also provides an understanding of the strategies used by the learners to attain competency. These findings are applicable to educators and leaders responsible for the education and ongoing learning of nurses within critical care practice. The use of strategies such as simulated learning and repetition are significant in skill acquisition. However attention must also be paid to issues which influence the professional socialisation process, such as the quality of preceptor input during orientation and the use of ongoing mentoring of the learner.

published_or_final_version / Nursing Studies / Master / Master of Nursing

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are together known as venous thrombo-embolism (VTE), one of the most common complications after surgery and trauma injury. In the case of critically ill patients, it is also a significant medical and financial burden, associated with high mortality and morbidity. In recent years, much evidence has come to light showing that DVT prophylaxis can effectively reduce DVT, and it has been incorporated into various evidenced-based guidelines (Geerts et al., 2008; Nicolaides et al., 2006). The objectives of this study are to examine, through a comprehensive literature review of published studies, the effectiveness of various means of DVT prophylaxis aimed at reducing DVT, and to develop an evidence-based guideline for the use of DVT prophylaxis in surgical intensive care unit (ICU) settings. Keywords related to DVT prophylaxis were used in conducting the search in electronic bibliographic databases like MEDLlNE, CINAHL, PubMed and the Cochrane Library. A total of 110 articles were identified, and seven studies fulfilled the inclusion criteria of the study. Data from the seven studies have been extracted to form tables of evidence; the qualities of the studies were then rated, and the levels of evidence assigned according to SIGN 50: A guideline developer’s handbook (Network, Harbour & Forsyth, 2011). Three studies attained a higher level of evidence with strong methodological design and demonstrated a statistically significant reduction in the incidence of DVT. The implementation potential of DVT prophylaxis was examined in terms of target setting, target audience, transferability of findings, feasibility and cost-benefit ratio. And it was found that the development of evidence-based guidelines for DVT prophylaxis was feasible, cost-beneficial and transferable in current settings. The findings of the seven reviewed studies have been translated into an evidence-based DVT prophylaxis guideline. The main focuses of the guideline are the choice of prophylaxis used with surgical ICU patients and the strategies for improving adherence and prophylaxis monitoring. Combined pharmacological and mechanical DVT prophylaxis is recommended for ICU patients who are at high risk of DVT. For patients with active bleeding or high risk of bleeding, mechanical prophylaxis like intermittent pneumatic compressor (IPC) or gradual compression stocking (GCS) should be used first, followed by a review for pharmacological prophylaxis when the risk of bleeding has decreased. In addition, routine assessment of thrombosis and bleeding risk for high-risk ICU patients and regular checking of fitting and functioning of the DVT prophylaxis are recommended. An implementation plan consisting of communication, pilot and evaluation plan was developed. A 12-month programme including communication with stakeholders, marketing of the innovation, training of frontline staff, a five-week pilot study and implementation of the guideline followed by evaluation will be carried out. In the evaluation, programme effectiveness was assessed in terms of patient outcome (e.g. incidence of DVT), process outcomes (e.g. level of knowledge related to DVT, compliance with the guideline and level of staff satisfaction) and system outcome (e.g. financial cost reduction). / published_or_final_version / Nursing Studies / Master / Master of Nursing

Background Severe impairment of physiologic functioning brings the focus of intensive care unit (ICU) on the reversal of acute organ failure which will threaten one’s survival if it is left untreated (Morris, 2007). Providing respiratory support to majority of ICU patients, mechanical ventilation (MV) is a life saving intervention. MV patients constitute one-third of ICU patients worldwide and 46% of them are put on ventilator support more than 24 hours having the mean duration ranged from 15.4 to 33.2 days (Adler & Malone, 2012). The aim of ICU care places most of the attention on resuscitation and survival while the neuromuscular functioning is often overlooked as raised by a number of recent studies. Poor physical functioning was reported by all the patients due to loss of muscle mass, muscle weakness and fatigue (Herridge et al., 2011). Only 50% of them got employed 1 year after recovery while the rest of them were still unemployed because of persistent fatigue, poor functional status like foot drop and large joint immobility (Herridge at al., 2011). ICU-acquired weakness accounts for neuropathies and myopathies after recovery from critically illness and respiratory failure as manifested by loss of body mass, severe weakness and physical dysfunction (Cheung et al., 2006). De Jonghe and colleagues (2002) found that 25% of MV patients developed the ICU-acquired weakness and they determined MV as one of the key etiologies. Kasper and colleagues (2002) stressed that muscle atrophy happens within a few hours of bed rest having 4% to 5% depreciation of muscle strength for one week bed rest. Moreover, insulin resistance appears after merely 5 days of bed rest. On the other hand, immobility interferes baroreceptors bringing hypotension and tachycardia, giving rise to reduced cardiac output and gaseous exchange therefore deterioration of cardiac function (Convertino, Bloomfield & Greenleaf, 1997). It is obvious that a viscous cycle is present while leaving survivors from recovery of critical illness immobilized. Mobilizing MV patients can train up their limb power and their ADL ability (Burtin et al., 2009; Chiang, Wang, Wu, Wu, & Wu, 2005; Martin, Hincapie, Nimchuk, Gaughan, & Criner, 2005). Burtin and colleagues (2009) illustrated that patients receiving mobilization program had a better score in SF-36PF showing the attainment of better quality of life (QOL). Early mobilization can increase the number of day of ventilator free (Schweickert et al., 2009) and shortening ICU and hospital length of stay (Morris et al., 2008). Purpose The dissertation is aiming at seeking for the best evidence to establish an evidence – based mobilization guideline for those mechanically ventilated patients. The goal is to optimizing the physical outcomes of mechanically ventilated critically ill patients. Method The three electronic databases including Medline (Ovid SP), CINAHL (Ovid SP), PudMed and Cochrane Library were searched through while doing the systematic search of scientific literature. Subsequently, five articles confining to the inclusion criteria were sieved in the literature review and evidence extraction was performed. Quality assessment of the 5 studies was done using a critical appraisal tool derived by Scottish Intercollegiate Guideline Network (SIGN) (2008) and thereafter an evidence-based guideline for early mobilization of the mechanically ventilated patients was established. An implementation plan was then set up which comprised of the communication plan between different level of stakeholders of ICU and the pilot testing. Apart from communicating with the stakeholders, the plan also delineated the way of initiating, guiding and sustaining the change. A pilot study was planned to execute in order to test the sufficiency of training workshop, determine the feasibility of the mobilization protocol and the evaluation plan. Lastly, an evaluation plan was considered to assess the success of mobilization guideline in terms of patient outcomes, healthcare provider outcomes and organizational outcomes. / published_or_final_version / Nursing Studies / Master / Master of Nursing

Ventilator-associated pneumonia (VAP) is a kind of frequently hospital-acquired infection that increases morbidity and mortality in patients in intensive care units (ICU), which would in turn increase length of ICU stay, cost of hospital stay, and duration of mechanical intubation. Pneumonia appeared within 48 hours before onset of infection in people whose respiration is mechanically supported through endotracheal tube or tracheostomy is ventilator-associated pneumonia. Combating VAP is a major challenge in ICU as almost all ICU patients require mechanical intubation. Development of evidence-based methods to reduce the incidence and prevalence of VAP becomes an important issue in ICU. The objectives of this dissertation are to conduct a thorough search of current evidence on the effectiveness of using different concentration, frequency of application, method of application and amount of chlorhexidine gluconate solution for oral care of adult intubated patients in reducing VAP incidence rate. MEDLINE (OvidSP), CINAHL PLUS (EBSCOhost), PubMed and British Nursing Index were used to conduct electronic search using keywords related to VAP. A total of 99 studies were identified and seven were selected according to inclusion criteria. The quality of the seven selected studies was tested using The Scottish Intercollegiate Guidelines Network (2008) tools for randomized controlled trials, and the evidence level coding from Scottish Intercollegiate Guidelines Network was used in grading of recommendations. Six studies were rated as high quality, which oral care using chlorhexidine gluconate solution had shown statistically significant VAP incidence rate reduction or VAP-related parameters improvement. Analysis on the implementation potential, transferability of findings, feasibility of implementation and cost-benefit ratio was conducted and the oral care guideline was beneficial to intubated patients. Implementation plan, communication plan and evaluation plan about oral care guideline application was formulated. The program designed to apply the new oral care guideline would last for one year, which includes communication with stakeholders, publication of the guideline, training of staff and a one month pilot test. The primary outcome was the decrease in VAP incidence rate and the process evaluation outcome were compliance and acceptability of the guideline, satisfaction and knowledge level of staff, and hospital cost reduction. The attainment of primary outcome and process evaluation outcome would be used to evaluate the effectiveness of the program. / published_or_final_version / Nursing Studies / Master / Master of Nursing

No description available.

This study, drawing on the work of van Manen and based on hermeneutic phenomenological principles, sets out to lay open an ontological substance of emergency nursing-as-caring work by exploring the experiences and lived realities of eleven emergency nurses engaged in nursing practice in emergency departments within South Australia. / Thesis (PhD)--University of South Australia, 1998

Making the transition to an area of specialist nursing practice is challenging for both the learner and staff who are responsible for education and skill development. This study uses grounded theory methodology to explore the question: "How do nurses learn critical care nursing?"The eight registered nurses who participated in this study were recruited from a range of intensive care settings. The criteria for inclusion in the study included the participant having attained competency within the critical care setting. Data was collected from individual interviews. The findings of this study developed during the coding and comparative analysis process, and subsequently theoretical sampling was used to further explore the identified concepts.This study found that nurses' focus on two main areas during their orientation and induction into critical care nursing practice. These are learning to do (skill acquisition) and learning to be (professional socialisation). The process of transition involves two stages: that of learning to do the tasks related to critical care nursing practice, and the ongoing development of competence and confidence in practice ability. The relationship of the learner with the critical care team is a vital part of the transition to competency within the specialist area.This study identifies factors that influence the learner during transition and also provides an understanding of the strategies used by the learners to attain competency. These findings are applicable to educators and leaders responsible for the education and ongoing learning of nurses within critical care practice. The use of strategies such as simulated learning and repetition are significant in skill acquisition. However attention must also be paid to issues which influence the professional socialisation process, such as the quality of preceptor input during orientation and the use of ongoing mentoring of the learner.

This study, drawing on the work of van Manen and based on hermeneutic phenomenological principles, sets out to lay open an ontological substance of emergency nursing-as-caring work by exploring the experiences and lived realities of eleven emergency nurses engaged in nursing practice in emergency departments within South Australia.