Thesis (Master of Emergency Medical Care (MEMC))--Cape Peninsula University of Technology, 2019 / Introduction: Road traffic injuries are the ninth leading cause of death globally. Projections indicate that without new and sustained commitment globally to preventing such injuries, the situation will only worsen. Motor vehicle rescue does not lend itself to the prevention of road traffic incidents but through ensuring that all incidents are managed using sound evidence could contribute in positive outcomes for victims. It is unknown what contribution rescue education makes to the body of medical rescue knowledge in South Africa. Aims: The aim of this research was to investigate the relevance and scope of the principles of physics within medical rescue specifically in the context of motor vehicle rescue. It appears that current traditional methods of presenting rescue training, which is mainly procedural and technical, may contribute to 'segmented' learning. Research Methodology: Using an interpretive research design, multiple qualitative methodologies were employed. This methodological triangulation was intended to improve construct validity and trustworthiness of findings. A modified Delphi process through which questionnaires was repeatedly distributed to rescue experts was employed. Process tracing was used to evaluate the developed typical motor vehicle rescue case scenario narrative for underpinnings of the principles of physics. The Bachelor Emergency Medical Care Physics and Extrication subject guides was evaluated for its educational alignment during the document analysis. Legitimation Code theory as a theoretical framework was utilised to appraise the knowledge gap. Results & Discussion: Motor vehicle rescue incident may not always present in a similar manner due to various factors and influences. Development of the typical motor vehicle case narrative from which its physics principles could be identified was imperative. Most motor vehicle rescue related training occur with the vehicle in the upright orientation on all four wheels. This manner of frequent training may restrict rescue practitioners from moving beyond their 'typical' training knowledge when the situation presents a typical. The thematic document analysis of the BEMC Physics and Extrication subject guides lacked the necessary coherence which is required for a professional degree. It was deemed void of certain threshold concepts and structure which would allow the student to move between the theoretical and contextual knowledge. Motor vehicle rescue subject guides and most textbooks on the topic leaned towards a procedural and very technically detailed pedagogy, to the extent that it could contribute to segmented learning. Conclusion: Developing curricula that is underpinned by a theoretically sound evidence base would promote credibility of a qualification. Curricula by design inform the teaching, learning and the competencies which would ultimately be assessed. Professional degrees are intended to develop practitioners who would graduate with the knowledge and competencies to adapt to situations. In addition, graduate attributes of lifelong learning, reflective practice and the ability to contribute to the development of new knowledge is secondary to the goal of qualification attainment.

As third-year medical students transition from the classroom to the high-stakes, high-stress environment of the emergency department (ED), they confront a unique set of challenges that result in significant personal trauma. The literature offers limited insight into the trauma experienced specifically during the shift to emergency medicine (EM) as medical students’ first clinical rotation. The purpose of this study was to bridge this gap by examining the interplay between students’ perceived psychological safety of their ED teams and their own self-efficacy on the trauma they experienced as learners when working in this unique learning environment. This mixed-methods study included interviews with 17 third-year medical students who immediately completed the EM clerkship at an urban, academic ED. The study addressed four main questions: 1) What types of trauma do students experience in the EM clerkship as they transition from the classroom into the clinical learning environment for the first time in their training? What are the factors of the learning environment that trigger trauma? 2) In what ways, if any, do students’ intersectional demographics affect their experiences of trauma during the EM clerkship? 3) To what extent does general self-efficacy predict medical students’ perceptions of the psychological safety afforded by their clinical team during the EM clerkship? 4) How are students’ experiences of trauma associated, if at all, with perceived psychological safety? What factors in the clinical learning environment contribute to psychological safety or its lack? This study utilized several data collection methods: (a) a pre-interview questionnaire soliciting information on student demographics and responses to items on the General Self-Efficacy Scale, (b) in-depth interviews using the critical incident technique, and (c) responses to items from the Team Psychological Safety Questionnaire. Several key findings emerged. A substantial amount of trauma that students experienced was rooted in a lack of peer support and student empowerment. Various triggers for trauma were identified that transcended different types of trauma. Demographic factors, such as race/ethnicity and gender, influenced the prevalence and nature of these traumatic experiences, with students from underrepresented backgrounds reporting deeper emotional connections with patients. While student self-efficacy was generally high, it did not correlate with the perceived psychological safety provided by their clinical teams. Furthermore, the perception of psychological safety within ED teams correlated with the nature of trauma experienced; those with lower safety scores reported trauma connected to peer support or issues related to cultural, historical, and gender considerations. Lastly, the opportunity for students to safely take risks or learn from mistakes, coupled with their own medical knowledge limitations, emerged as central to their perception of psychological safety within the team dynamic. Deeper insights into the data were revealed through a cross-interview analysis, and several analytical categories were used to further synthesize and interpret the data. Six conclusions were drawn from the study’s findings and analysis: 1) Medical students experience different types of primary trauma when immersed in the ED. 2) Several forces that are intrinsic to the ED workplace influence the trauma students experience. 3) Clerkship leadership must be aware of the unique experiences underrepresented students have in the EM clerkship. 4) The psychological safety provided to students by their teams impacts their experiences of trauma in the ED. 5) Self-efficacy offers a lens to understand students’ experiences of trauma in the ED, but it is insufficient. 6) Clerkship-specific interventions exist to amplify the team psychological safety afforded to medical students.

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Critical Incident Stress has the potential to affect emergency services personnel to the degree that it can change the way the responder acts and reacts in all facets of his or her life, including the job and his or her family. Research into these potential effects has produced a greater understanding of the responders experiences within a short period of time after the perceived critical incident. This study investigates the long-term effects of critical incident stress among emergency responders from two cities in the three emergency services professions were interviewed to determine what their experiences were at least six months post critical incident. A structured incident had in three areas of teh emergency responders lives: impact on job, impact on the individual responder, and perceived impact on emergency responders families. For particpants, symptoms of Critical Incident Stress lasted between 6 months and 2 years after the perceived critical incident. Analysis of the data indicatees that single responder critical incidents have the potential to negatively affect emergency responders resulting in the loss of enthusiasm and passion for their work, debilitating psychological distress, and isolation from valued support systems. Long-term effects of Critical Incident Stress change the perceptions that responders have about the job, about themselves, and the relationships with their families. The culture of emergency services, changing identities, and the lack of support from both within the system and outside of the system were seen as variables that contribute to the long-term effects of Critical Incident Stress. / xi, 181 leaves ; 29 cm.

Dissertation submitted in fulfilment of the requirements for the Degree of Master in Technology: Emergency Medical Care, Durban University of Technology, 2010. / South Africa currently has 1631 registered Advanced Life Support (ALS) paramedics to tend to the pre-hospital advanced life support needs of just under 50 million people. Compared to the globally accepted ratio of 1:10 000, the number of ALS paramedics in South Africa is grossly inadequate. The current shortage of South African ALS paramedics may be ascribed to migration. However, although literature on health worker migration in general abounds, there is a marked lack of national or international statistics and information on migration of ALS paramedics and their migration. Current measures to manage migration appear to be ineffective. The success of future strategies is dependent on an understanding of the migration of South African ALS paramedics - an understanding that presently does not exist. Purpose The purpose of this study was to describe the migration of South African undergraduate Advanced Life Support paramedics who qualified between 2001 and 2006, and to then develop a framework of retention strategies. In particular, it determined the extent and nature of their migration, identified the factors that have contributed to their decision to work outside South Africa and identified strategies to retain or encourage the return of ALS paramedics to practice exclusively in South Africa. Methods The study consisted of a two-phase mixed method descriptive survey. Paramedics with ALS undergraduate diplomas who qualified in South Africa between 2001 and 2006 made up the study population. Quantitative data (Phase One) was obtained from a web-based survey distributed to the accessible population (N=97). Thereafter, qualitative data (Phase Two) was gathered through in-depth interviews with selected information rich participants (n=10) also from within the accessible population. Through methodological triangulation, data from Phase One and Phase Two were Page vi integrated to obtain an in-depth understanding of South African ALS paramedic migration. Results Significant differences existed in the distribution of age (p=0.035), and years of experience post-graduation (p=0.007) and the ALS paramedic deemed most likely to migrate were individuals between the ages of 21 – 30. 15 (55%) of the participants working outside the country were engaged in short term contracts while all 24 (100%) of participants working inside South Africa were permanently employed. 18 (75%) of respondents working inside South Africa intended migrating, 12 (67%) of which intended to do so within 0 to 2 years. Nine major factors or reasons for migration were identified by participants. Working conditions, physical security and economic considerations were ranked as the top three major factors most likely to contribute to the decision or intended decision to migrate. This study also found five primary decisions that likely emerge during the life of a South African ALS Paramedic. The outcome of each decision is a result of facilitators weighted against barriers. Facilitators are factors that supported each of the primary decisions while barriers weakened or rejected them. Findings indicated that many barriers existed which rejected or weakened the decision of ALS paramedics to work inside South Africa, return to South Africa or remain in South Africa. On the converse, a vast number of facilitators existed which spurred continued migration. Conclusions As the decision to migrate may be conceptualised as early on as when individuals decide to become ALS paramedics, the constructs of return and retention strategies have to extend as far as revising recruitment policies. Preference or places into training programmes should be given to individuals who are less inclined to migrate, these include: military personnel; those already employed in the EMS, older mature candidates; candidates with families that have already settled in SA; and recognition of prior learning (RPL) candidates who are predominately obligated by contract to remain in South African EMSs.

M.A. / This study looks into the types of stressors specific to the Emergency Medical Services. The study was undertaken over a period of two years with the following objectives: • A literature survey regarding stress, organisational stress in general and stress in the context of Emergency Medical Services in particular. • An investigation of the personnel of the Emergency Medical Services to ascertain the stressors perceived as stressful by them. • Recommendations on how to prevent or lower stress in the Emergency Medical Services. The first part of this study is devoted to a theoretical investigation which gives an overview of stress in its broadest sense as well as stress in organisations which includes cumulative stress/burnout. Critical Incident Stress and Post Traumatic Stress are also closely examined, as well as the personality characteristics of members of the Emergency Medical Services. The point of departure for the researcher is an ecosystemic perspective where objectivity itself is questionable. Therefore, qualitative research was called for and the transactional/interactional model of Richard Lazarus was used to categorise stressors. The research results suggest that what the Emergency Medical Service personnel perceive as stressful are mainly organisational stressors but they acknowledge that in the long term the continual dealing with death and trauma starts to take its toll. Criticisms that could be levelled against the study are that the results are only generalisable to the personnel of the Johannesburg Emergency Services, whose demographic characteristics and backgrounds differ, for instance, from those who work at Bryanston, or Pretoria. As the study relied solely on personal disclosure and observation the results can be seen as somewhat subjective in nature. What was communicated as stress-related events was what was perceived as stressful by the personnel as well as the researcher's subjective perception of whether certain events were perceived as stressful for the personnel. After working on the ambulance with these personnel for over three years, the researcher is an accepted part of their system, and became subject to the same blunting of affect and depersonalisation of victims as the Emergency workers. Over an extended period in time, it became harder to divorce the researcher from the "worker" while on duty, to maintain a scientific perspective and to write objectively. However, the findings of this study concur with those done by previous researchers on this subject such as Sparrius (1992) and Du Toit & Botes (1996).

Electronic health records (EHRs) led to improvements in patient safety, care delivery, and efficiency; however, they have also resulted in significant increases in documentation time. EHR documentation burden, defined as “added work (e.g., documentation) or extraneous actions (e.g., clicks) performed in the EHR beyond that which is required for good clinical care”, has been linked to increased medical errors, poorer patient outcomes, reduced care quality, cognitive overload, and ultimately, burnout among clinicians. Relative to other clinical practice settings where patient flows are more predictable and of lower intensity, emergency department (ED) clinicians report markedly higher workload. Furthermore, EHR implementation research in the ED indicates that incongruities between EHR design and usability and the clinical workflow may intensify clinician workflow fragmentation. In our prior work, we identified workflow fragmentation, which we define as task switching, as one potential approach for evaluating documentation burden in ED practice settings. Yet, no standardized, scalable measures of documentation burden have been developed. Despite shortcomings, there have been increasing efforts to leverage information from EHR event logs as an alternative to direct clinical observation methods in evaluating user-centric behaviors and interactions with health information technology systems. Using EHR event logs, this dissertation aims to advance the study of evaluating burden by investigating EHR-mediated workflow fragmentation as a measure of EHR documentation burden among physicians and registered nurses (hereinafter interchangeably referred to as “clinicians”) in the ED. First, I review the literature on the existing quantitative approaches employed for measuring clinician documentation burden in clinical practice settings. Next, I explore EHR factors perceived to contribute to clinician documentation burden as well as the perceived role of workflow fragmentation on clinician documentation burden in the ED. Lastly, I investigate data-driven approaches to abstract clinically relevant concepts from EHR event logs for studying EHR documentation burden—culminating into a computational framework to evaluate ED clinician documentation burden in the context of cognitive burden. Collectively, the work conducted in this dissertation contributes computational methods that are foundational for investigating clinician documentation burden measurement at scale using EHR event logs, informed by current evidence and clinician perspectives, and grounded in theory.

Dissertation submitted in fulfilment of the requirements for the Degree of Master of Technology: Emergency Medical Care, Durban University of Technology, 2011. / South African Advanced Life Support (ALS) providers follow an autonomous practice model of care. This advanced role profile is characterized by clinical skill competence and autonomous decision making whilst demonstrating a high level of awareness of their own ethical attitudes, values and beliefs. It is through a professional commitment that ALS providers deliver an advanced evidence based practice that should be maintained constantly within a dynamic environment. Continuous Professional Development (CPD) is seen as an instrument for this. CPD should also serve as a means to acquire professional excellence and going beyond the boundaries of meeting the base level standard with the aim of providing the finest quality of care in the interest of patient safety. Purpose of the research The purpose of this research is to identify gaps in the professional development of out-of-hospital ALS providers trained in South Africa by assessing frequency of performance of ALS clinical skills, by determining perceived level of competence and predictors of confidence, and by sourcing information on attendance of CPD activities and training needs. vi Methodology This study used a quantitative non-experimental design. Data was attained from an e-mail based descriptive survey that was limited to a precise and concise questionnaire. The data from 140 (N) ALS providers was subjected to a descriptive statistical analysis using the PASW statistics version 18.0 to systematically show patterns and trends. Frequency distributions were generated to describe data categories. Bivariate analysis was conducted using Chi-square and Pearson correlation tests. Results Results indicated that ALS providers performed clinical skills infrequently. Of the total number of respondents 140 (N), the average ALS clinical skills performance was 6 (4.8%) daily. In the 2-6 times a week category 8 (6.4%) ALS clinical skills were performed. ALS clinical skills performance in the once a week category showed an average of 7 (5.6%) and the once a month category, an average of 17 (13.7%) ALS skills were performed. An average of 31 (25%) ALS skills were performed in the once in six months category whilst an average of 54 (43.5%) were performed in the greater than six months category. CPD activities that are appropriate to ensuring the maintenance of competence for these clinical skills were not adequately undertaken. Medical updates were mostly attended by ALS providers, 52 (42.9%) whilst CPD events that addressed clinical skills, was mostly limited vii to the ACLS course 42 (34.7%). The needs assessment for CPD showed that 56 (53%) of respondents expressed a need for paediatric and obstetric simulated skill sessions, whilst 43 (40.9%) requested clinical skills workshops and 39 (37.1%) expressed a need for clinical practice in theatre and coronary care units. Conclusions and recommendations This study shows that ALS clinical skill competence is maintained by frequent practice and appropriateness of CPD activities. The infrequent performance of ALS skills coupled with the lack of appropriate and diverse CPD activity attendance results in poor maintenance of competence. The loss of competence can be related to poor reported levels of confidence which consequently places patient safety at risk. To safeguard against medical error and ensure patient safety, it is strongly recommended that CPD audits be undertaken on all ALS providers for appropriate CPD compliance related to clinical skills performance. In addition to a clinical skills audit, it is recommended that a national clinical skills registry be established with the intention of facilitating clinical skill surveillance, to determine a notifiable, high risk skill set. To safeguard against knowledge and clinical skill attrition and loss of competence, the delivery of CPD activities should be assessed for effectiveness and appropriateness.

published_or_final_version / Public Administration / Master / Master of Public Administration