Student Number : 0400522J - MSc research report - School of Civil and Environmental Engineering - Faculty of Engineering and the Built Environment / The Government of Botswana has, since 1972, implemented several programmes of labour intensive work as a complementary effort to alleviate high levels of unemployment, poverty and rural under-development. This research project describes and evaluates six of the programmes: the Botswana Labour Intensive District Roads Programme (LG 34), the Rural Roads Programme (RRP), the Labour Intensive Public Works Schemes (LG 38), the Labour Intensive Drought Relief Programme (LG 117), the current National Public Works Programme (LG 1107) and the current Labour Intensive Routine Road Maintenance Programme. The programmes have been described and evaluated in relation to their internal objectives as well as against international literature on labour intensive work in order to determine whether or not they were successful. The study reveals that the LG 34 was a highly successful programme as it achieved most of its key objectives and was in conformity with international literature. The programme created jobs for a significant number of poor Batswana through the construction of good quality low cost roads. It developed and established road construction and maintenance units within the District Councils. The success of the LG 34 was, however, later undermined by a depreciated wage rate contributing to the eventual demise of the programme. The Labour Intensive Road Maintenance Programme, although currently in its early stages of expansion, has been impressive. It has successfully developed and demonstrated through a Pilot Project a model for the use of labour based small contractors, managed by a private sector consultant, for routine road maintenance. This had not been done before in Botswana. The rest of the programmes were plagued by inefficiencies resulting from poor initial planning, lack of training and technical supervisory personnel, lack of proper organisational systems for the programmes and incorporation into drought relief activities. Most of these programmes were wound up, and the on-going National Public Works Programme is struggling to survive. In sum, the Botswana experience has shown that labour intensive methods could be successful if attention were paid to initial design and planning, training of technical supervisory staff and the establishment of proper organisational systems. In addition, to differentiate proper labour intensive work from drought relief, wages must be paid at or close to the Industrial Class minimum wage. DPDoFcuments Complete Click Here & Upgrade Expanded Features Unlimited Pages

MSc (Nursing), Faculty of Health Sciences, University of the Witwatersrand, 2009 / Anxiety, depressive and post-traumatic stress (PTS) symptoms have been identified in many patients following ICU treatment (Rattray, Johnston & Wildsmith 2005). The Intensive Care Unit (ICU) is a stressful environment and patients may be left with long standing psychological symptoms that impair their quality of life (Scragg, Jones & Fauvel 2001). There is a dearth of research on early assessment of the psychological sequelae following treatment in ICU in South Africa and interventions required to aid in the recovery process. Post-traumatic stress symptoms do not appear to decrease over time after ICU discharge (Jones et al 2001, Rattray et al 2005), indeed they may endure for a number of years (Kapfhammer et al 2004) causing the patients significant suffering. The purpose of this study was to investigate the prevalence of symptoms of anxiety, depression and post-traumatic stress in patients, at their first follow up visit in the outpatient department at a level one academic hospital in Johannesburg, South Africa. A prospective, quantitative, cross-sectional, descriptive format was used to investigate these variables. The total sample number was 98 and the instruments used in the structured interview were the Hospital Anxiety and Depression Scale (HADS) and the Experience After Treatment in ICU –7 (ETIC-7). The prevalence of symptoms of anxiety in this sample population was 48%, depression 28% and post-traumatic stress 32%. Fifty-eight percent of the sample had combined anxiety and depression scores severe enough to have a ‘possible clinical disorder’.

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.

Hypothermia treatment with cooling to a body temperature of 32-34°C has been shown to be an effective way of improving neurological outcome and survival in unconscious patients successfully resuscitated after cardiac arrest (CA). The method is used clinically but there are still many questions on the biological mechanisms and on how the treatment is best performed. This thesis focuses on cerebral and haemodynamic effects of hypothermia and rewarming. A porcine model of CA was used. To shorten time to reach target temperature, induction of hypothermia, by means of infusion of 4°C cold fluid, was started already during ongoing cardiopulmonary resuscitation. The temperature was satisfactorily reduced without obvious haemodynamic disturbances. Cerebral effects of hypothermia and rewarming were studied. Microdialysis monitoring showed signs of cerebral energy failure (increased lactate/pyruvate-ratio) and excitotoxicity (increased glutamate) immediately after CA. There was a risk of secondary energy failure that was reduced by hypothermia. Intracranial pressure (ICP) increased gradually after CA irrespectively of if hypothermia was used or not. There were no indications of increasing cerebral disturbances during rewarming. Haemodynamic effects of hypothermia treatment and rewarming were examined in a study of patients successfully resuscitated after CA. Hypothermia was induced by means of cold intravenous infusion. No negative effects on the cardiovascular system were revealed. There were indications of decreased intravascular volume in spite of a positive fluid balance. Cerebral microdialysis and ICP recording were performed in four patients. All patients had signs of energy failure and excitotoxicity following CA. ICP was only exceptionally above 20 mmHg. In contrast to the experimental study indications of increasing ischemia were seen during rewarming. Glycerol had a biphasic pattern, perhaps due to an overspill of metabolites from the general circulation. As most patients become extensively anti-coagulated following CA, intracranial monitoring is not suitable to be used in routine care.

Thesis (M.S.N.)--Marshall University, 2002. / Title from document title page. Document formatted into pages; contains v, 60 p. Includes bibliographical references (p. 48-51).

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

Critically ill patients in an intensive care unit (ICU) often require mechanical ventilation (MV). Humidification systems are essential devices for MV which replace the natural heat and moisture exchange process of inspired gases. A heat and moisture exchanger (HME) is commonly used for the humidification of MV patients in ICU. In contrast, a heated humidifier (HH) that is a more complicated device is used only for prolonged MV patients because of its higher cost and nurse workload. However, HME may increase the breathing workload of patients, thereby inflicting damage to their respiratory function, especially among respiratory failure patients. However, there was no evidence-based guideline that instructs nurses on choosing humidification devices in ICU. This dissertation aimed to 1) evaluate the current evidence and formulate evidence-based guideline in selecting a humidification device for mechanically ventilated acute respiratory distress syndrome (ARDS) patients in reducing the risks of breathing workload; 2) assess its implementation potential, as well as its feasibility and transferability; and 3) develop implementation strategies and evaluation plans for the use of this device in an adult ICU. Three electronic databases, namely, Proquest, Ovid, and Google Scholar, were searched for randomized controlled trials (RCTs) of humidification systems for MV. Eight articles were retrieved. Their reference lists were read and found two additional RCT. Four high-quality RCT showed that HH increased the breathing workload more than HME. Several studies showed that HME has potential drawbacks of significantly increase airway resistance, minute ventilation, CO2 retention, and respiratory discomfort. However, studies showed that no significant difference of ventilator-associated pneumonia (VAP) rate between HME and HH. The initial application of HME is safer and less costlyl. However, prolonged use of HME in ARDS patients may induce further workload on the respiratory system and worsen treatment progress. An evidence-based clinical guideline in choosing the humidification system was formulated and assessed using the appraisal instruments of Scottish Intercollegiate Guideline Network. It is deemed to be transferable with patient characteristics, clinical situation, and organizational infrastructure similar to studies evaluated the suggested innovation. Feasibility was also assessed and is considered to be high. The setup and running cost per year were HKD17450 and HKD6600. Although the humidification system had no actual cost reduction, non-material benefits such as prevention of tube blockage, reduction in breathing workload, and respiratory discomfort were more important than the cost. An implementation plan including a one-month communication plan with stakeholders and one-month pilot testing were developed. The evaluation of the guideline will last for 10 months. The effectiveness of the innovation will be determined by the reduction in breathing workload, cost and benefit ratio, and staff satisfaction level. / 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