The aim of this study was to explore the experience of carers of family members dying at home with particular reference to their expectations and preparedness for the dying process. It was a qualitative, longitudinal study which initially followed a grounded theory approach. However, as a theatrical metaphor became apparent from the data the approach changed to dramaturgical analysis. Face to face semi-structured interviews were conducted with fifteen carers before and after the death of their family member. Carers were found to be performing a leading role in home palliative care but they experienced a universal sense of uncertainty and of being unrehearsed for their role in the dying process. They were reluctant to seek information to give them a script for their performance because it was painful and difficult to contemplate their family member dying. They needed the direction of health professionals and the support of paid carers but had variable experiences of these services. Carers’ performance types were also variable but tended to be towards the combative or the pragmatic end of a continuum. Their experience was illuminated through the dramaturgical metaphor of a play called the Carer’s Initiation. The climax of the play was the death of the family member followed by the finale in which they watch over the body until it is removed and they finally face a future without their family member. The carer’s initiation highlighted policy and practice implications for improving the preparation and support of carers for the dying process.

Magister Scientiae (Physiotherapy) - MSc(Physio) / An increase of cardiac surgeries globally has been associated with an increasing number of people with cardiovascular disease in both developed and developing countries. Following cardiac surgery, pulmonary complications are an important cause of morbidity leading to significant prolonged hospitalisation, mortality and overall hospital costs. Physiotherapists have been part of cardiac multidisciplinary team playing a role in prevention and managing respiratory complications post-operatively. Numbers of studies have investigated on the efficacy of physiotherapy interventions in managing patients following cardiac surgery. However, there is no consensus in the literature with regards to intensity, duration of the session and content of therapy in this specialised area of cardio-pulmonary. These variations of physiotherapy intervention have made difficult to find agreement on the necessity of physiotherapy care in the post-operative management of patients following cardiac surgery. To date, however, there have been limited or no studies done on the role of physiotherapy in the Cardiac Unit setting. Thus, the aim of the study was to investigate the role of physiotherapy in the post-operative management of patients following cardiac surgery at Muhimbili National Hospital (MNH), Tanzania. An explanatory sequential mixed method study design was used. A descriptive retrospective study design was chosen for the quantitative phase using a convenient sample of all 105 patients’ records operated from January 2010 to 31st December 2013. With regards to the qualitative phase, 2 Cardiac Surgeons and 10 Physiotherapists working at MNH were conveniently sampled to explore their perceptions on the post-operative role of physiotherapy in the management of patients following cardiac surgery at MNH. Ethical clearance was obtained from the University of the Western Cape and Muhimbili National Hospital to conduct the study. Anonymity and confidentiality was ensured for all participants and their participation was voluntary. They were allowed to withdraw from the study anytime without any negative consequences. Following ethical issues; quantitative data (i.e. profile and process of care of patients) was collected by means of a data extraction sheet while the two separate semi-structured interview guides were used for qualitative data. A total of 105 patients’ records were obtained. Quantitative data was analysed using SPSS 22.0 version. A descriptive statistics was used. The mean age of the study sample was 30.6 (SD=10.5). More than half (54.3%) were females and males 45.7% of the sample. The results show that Rheumatic Heart Disease (RHD) accounted for the majority (74.3%) of cardiac diseases. Double valve repair accounted for 71.4%. A decline in the number of surgeries performed were noted from 2010 (48.6%) to 2013 (10.5%). The mean number of days spent in Intensive Care Unit (ICU) were 6.4 (SD=5.3) and in the ward 12.2 (SD=7.8). A total of 21.4% of the sample developed post-operative complications and 10.5% of the total sample died. A substantial number of patients (77.7%) were referred for physiotherapy treatment post-operatively, with most of these referrals (70.0%) on the first day post-operatively. The majority (37.8%) of the patients received 3 physiotherapy sessions in the ICU with most of these patients (79.3%) being seen once a day in the ICU and (65.8%) in the ward. Physiotherapists prescribed (53.7%) a combination of breathing exercises, active limb mobilisation, incentive spirometry and progressive ambulation in the ICU. A combination of breathing exercises, active limb mobilisations, endurance training and posture correction was frequently (89.5%) prescribed in the ward. Content analysis was used to analyse qualitative data. Cardiac Surgeons were aware of the role of Physiotherapists on the post-operative management of patients following cardiac surgery. They also identified shortcomings on the side of Physiotherapists’ in terms of poor co-operation, inadequate skills and a lack of motivation to work in the Cardiac Unit. On the other hand, Physiotherapists revealed that there was communication breakdown between them and Cardiac Surgeons. They added that they were not motivated to work in the Cardiac Unit due to their inadequate skills in the area of investigation, training and lack of working facilities. Although they had consensus on different techniques, they had variations on the application procedure, intensity and frequency. Cardiac Surgeons and Physiotherapists agreed that hospital management should motivate Physiotherapists by opening a Physiotherapy Unit within the Cardiac Complex and train Physiotherapists in the area of cardio-pulmonary. From these findings it can be concluded that, poor communication and lack of trained Physiotherapists in the field of cardio-pulmonary is a setback which need to be addressed. Also, lack of standard treatment procedure among Physiotherapists brings variations in this world of evidence based practice.

Doctor Scientiae / Following the introduction of the Health Act of 1995, the Primary Healthcare Package for South Africa, a set of norms and standards was developed in 2000, to ensure good quality of care and to act as a guide to provide good service at this level of care. Related to this, and bringing health services to the people, was the aspect of rehabilitation. It was highlighted that rehabilitation services should be restructured and strengthened in order to improve access to these services for those who did not have them before. This led to the development of the National Rehabilitation Policy in 2000, which focused on improving accessibility to all rehabilitation services, in order to facilitate the realisation of every citizen’s constitutional right to have access to healthcare services, but this policy was not implemented. During 2002, the Department of Health produced a strategic plan for the reshaping of public health services in the Western Cape. This initiative, Healthcare 2010, the Future for Health in the Western Cape 2020, mapped the way forward to improve substantially the quality of care provided by the health service. This plan was based on the primary healthcare approach and aimed to shift patients to more appropriate levels of care. It became evident that in order to move forward with the 2020 vision, there needed to be a greater understanding of the current situation. This study focused primarily on the aspect of rehabilitation, with a specific focus on systematic review and three dimensions of the process of care, namely patient information; service provider information; and realised access. These dimensions assisted in evaluating the rehabilitation service in order to understand what was happening in the delivery of rehabilitation services, focusing on the experiences of patients with physical disabilities, as well as service providers and caregivers, and realised access that included satisfaction of all participants in the rehabilitation centres. Hence the aim of this study was to evaluate the process of care at three selected rehabilitation centres in the Western Cape Province within the contextual framework of the National Rehabilitation Policy (NRP) and the United Nations Convention Rehabilitation Policy for People with Disabilities (UNCRPD). To assist in achieving this aim, objectives were developed as follows: to determine the reported barriers and facilitators to rehabilitation services through a systematic review; to determine the profile of patients with disabilities accessing rehabilitation services at three rehabilitation centres in the Western Cape Province; to determine the profile of service providers providing rehabilitation service to patients with disabilities attending rehabilitation centres in the Western Cape Province; to explore clients’ perceptions of and satisfaction with the rehabilitation services; to explore caregivers’ perceptions of and satisfaction with the rehabilitation services; to explore the experiences of service providers with the rehabilitation services; and to map the links between the experiences and perceptions of the key stakeholders. This was an evaluation study, which was primarily descriptive, with the focus on process evaluation. Process evaluation provides an indication of what happened, and why. The study was conducted at three rehabilitation centres in the Western Cape Province. Voluntary participation of patients, service providers and caregivers was gained by signing a consent form. Both qualitative and quantitative methods of data collection were used in this study. Questionnaires were used for quantitative data collection and SPSS version 17 and 21 was used to analyse the data. Focus group discussions and in-depth interviews, which were based on interview guides and tape recorded, were used to gather information on experiences and perceptions of all the participants. Quantitative data capturing was checked for errors by using excel spread sheets, where data was entered twice in two different spread sheets and checked for differences, as responses were coded by using numbers. Qualitative data was checked for errors by following the trustworthiness process where data was transcribed verbatim, and where necessary translated by two different translators to ensure accuracy. The researcher consulted with the supervisors during data analysis to enhance quality in the coding process and identification of themes and relevant quotations. Results showed that barriers to rehabilitation outnumbered facilitators of the rehabilitation process. There was a gap identified in the profile of the patients with regards to their rehabilitation needs. Records of the patients had missing information posing a challenge to data collection and possible presenting a distorted picture of service provision. However, records showed that not all rehabilitation professionals were not consulted during the rehabilitation process of care. Ninety-five percent (95%) of the clients consulted with physiotherapists, whereas only 4% consulted social workers. Rehabilitation service providers did not reflect a rehabilitation team. There was a shortage of rehabilitation service providers, in that some centres had full time staff while other centres only had sessional rehabilitation professionals. Service providers were negligent with some of the processes to be followed when consulting clients, such as getting consent to treat the patient and educating patients regarding their ailments, which then affected satisfaction of the patients. However, there were also positive aspects like treating patients with respect and allowing patients to ask questions during consultation. Caregivers on the other hand were satisfied with the rehabilitation process, as they found the centre easily accessible for their family members and were involved in the rehabilitation of the patients. In conclusion, the rehabilitation process was satisfying to the participants of this study. The main challenge that patients and caregivers experienced was financial constraints. Staffing remains a problem in rehabilitation centres in the Western Cape Province, as there were not enough staff for rehabilitation service delivery at these selected rehabilitation centres. Other staff members were not utilised during the rehabilitation process. These findings raise issues for the Western Cape Department of Health to consider regarding rehabilitation, as people with disabilities are not receiving optimal care. The study makes recommendations to the Department of Health in the Western Cape Province regarding the improvement of the rehabilitation process of care.

Quality of care is identified as a major problem in the current health care system. Multidisciplinary teamwork has been proposed to address quality-of-care problems because, theoretically, a health-care team can expand knowledge and follow up patients more efficiently. However, questions about how to successfully implement team-based care in ambulatory settings and its long-term costs are still unanswered. The first objective of this dissertation is to estimate the marginal effects of process measures including number of counseling sessions about lifestyle modification and number of specified-dose antihypertensive medications provided by a physician-pharmacist collaborative intervention and usual care on blood pressure reduction and direct treatment costs by comparing the results from as-treated and instrumental variable methods. The second objective is to estimate the long-term cost changes attributable to the physician-pharmacist collaborative intervention by considering costs related to coronary heart disease, stroke, and heart failure. To accomplish both objectives, data from two prospective, clustered randomized controlled clinical trials implementing a physician-pharmacist collaborative intervention in the Midwest were used. In the first study, multiple linear regression models included blood pressure reduction and costs as outcome variables, and the two process measures and other control variables as explanatory variables. As-treated methods revealed insignificant associations between the two process measures and blood pressure reduction outcomes. On the other hand, both process measures were significantly associated with the costs. By using instrumental variable methods, utilizing two instruments of randomization and the trial indicator, the models were unidentified and showed no significant associations between the process measures and all of the outcomes. However, the post-hoc analysis of the instrumental variable models, evaluating one process measure at a time without controlling for the other process measure, showed significant associations between the process measures and all of the outcomes. The estimates from instrumental variable methods were larger than the estimates from the as-treated methods. The second study used a Markov model cohort simulation in a 10-year timeframe, transition probabilities estimated by several risk estimation systems and published statistics, and published event costs. The reference case employed a sample of patients aged 30 to 74 years from the trials and assumed that blood pressure after the intervention was constant. The total costs of the intervention for hypertension care and the costs related to the vascular diseases in the intervention group were shown to be lower than the usual care group at 6.5 years. However, cost-savings by the intervention were sensitive to patient risk profiles and sustainability of blood pressure after the intervention. To conclude, from the first study, combining multiple studies and using instrumental variable methods may be useful for evaluating marginal effects of the care process but further research is needed to address under-identification problems. The results of the second study suggested that it was likely that the physician-pharmacist collaborative intervention to treat hypertension was appropriate for high-risk patients.

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Patient safety is one of the top priorities of anesthesia and perioperative care in the operating room. The patient safety is greatly compromised due to administered medication and the actual operating performance in the perioperative care. The risks of anesthesia and the operational performance are many, starting with the fall of the patient, the possible wrong- site, wrong-procedure, wrong-patient errors, adverse reactions to administered medication, difficult airway management or an unexpected perioperative bleeding. Patient harm in hospital care leads not only to increased costs for additional treatment, prolongation of the hospitalization time, but also significantly affects the subsequent quality of life. Most adverse events are preventable, since most of them are caused by susceptible factors, such as incomplete or incorrect information or the lack of communication between the members of the operating team. Due to the increasing number of such adverse events around the world, including those of the most serious, The World Health Organization has created a program called The Save Surgery Saves Lives, whose aim was the identification of key risk areas in ensuring the safety of patients. On the basis of the identified risk areas the Surgical Safety Checklist was introduced in 2008. It is aimed...