M.Cur. / Advances in medical technology have led to major technological developments in the field of neonatal care. Over the past three decades there has been increasing concern about noise levels in neonatal intensive care units. The experience of working in a neonatal intensive care unit and exposure to high noise levels of such a unit prompted the researcher to investigate the sources of noise further and to explore ways of reducing or preventing the occurrence of noise. After conducting an extensive literature review, a systematic measurement of noise levels in a neonatal intensive care unit was undertaken. The following findings emerged:- There is a considerable level of noise in the neonatal intensive care unit and this noise persists throughout day and night. The sources of noise are mainly environmental, equipment, personnel and patientrelated. It was significant to observe that neonatal personnel can contribute to the reduction or prevention of high noise levels in the unit. Guidelines for neonatal personnel have been developed to this end. It is hoped that this study will make a contribution to the creation of a more conducive neonatal environment.

It is essential that neonatal practitioners are able to use their theoretical knowledge in clinical practice in an appropriate manner, in order to render competent quality care to the critically ill neonate. However, theory and practice integration is also very difficult to achieve. Managers of neonatal units and neonatal students had voiced concerns regarding the integration of theory and practice in the neonatal programme offered by an Institution of Higher Education (IHE). Therefore the purpose of this research was to develop standards and criteria to facilitate the integration of theory and practice in the IHE Neonatal Programme A combined qualitative/quantitative exploratory, descriptive, contextual approach was followed, based on Muller's Model for the Development of Nursing Standards (1990:49-55). The design consisted of a development phase and a quantification phase. Standard development began with conceptualisation, that is, the definition of the research concepts and the integration of the study into existing theoretical frameworks. The legislative frameworks used for the study were those of the South African Qualifications Authority and the South African Nursing Council, that govern nursing education and nursing practice. The theoretical frameworks promote theory/practice integration. Standards and criteria were developed from the legislative and theoretical frameworks in order to facilitate the theory/practice integration of the IHE neonatal programme. Ten experts who met specific criteria for inclusion in the study were then asked to validate the standards. The quantification phase consisted of the statistical determination of the content validity of the standards, using a questionnaire. The original ten experts together with another forty participants who complied with specific inclusion criteria, were asked to evaluate the standards, using a four-point rating scale. A standard or criterion with a content validity index of 3.5 to 4. 0 was accepted as valid. The results of the data analysis for the fifty participants showed that all criteria had a mean score of over 3. 5 and thus could be considered valid and useful as a guideline for neonatal programmes. However it was evident from standard deviation scores that the expert group showed greater consensus than the additional participants regarding the validity of the standards. Further research may therefore be required in order to confirm the validity of the standards and criteria.

M.Cur. / The neonate has the right to quality nursing care and the Neonatal Intensive nursing care practitioner is personally and professionally-ethically liable for quality nursing care. The process of quality improvement is a structured, planned and purposeful action where standards are set and the nursing care is evaluated after which remedial steps are taken to improve quality nursing care. In this study the focus is on the first step in the quality improvement cycle; the setting of standards. The central theoretical statement is as follows: standards for Neonatal Intensive nursing care facilitate quality nursing care in the Neonatal Intensive Care unit. The purpose of the study is to describe and formulate standards for Neonatal Intensive nursing care which can be utilised as an accreditation instrument for institutional self evaluation to improve quality nursing care. The aim of the study is justified by means of a descriptive, explorative, contextual research design. Standards for Neonatal Intensive nursing care were developed and validated by utilising a threephase research method. In phase one subjects for standards were identified by a panel of six experts. They were chosen according to their academic qualifications and nursing experience. The identification was done by means of a critical debate, after which a preliminary conceptual framework was formulated. During the second phase a comprehensive literature control was undertaken to refine the preliminary conceptual framework. The final conceptual framework, that was formulated during phase two, served as a basis for the description and formulation of standards. The standards were divided as unit management standards and clinical nursing care standards. During the third phase a final validation of the standards occured by means of a consencus debate between the experts that were used in the first phase. An accreditation instrument was developed to be utilised for institusional self evaluation in order to facilitate quality nursing care. The standards comply with content validity within the context of a Neonatal Intensive Care unit in a private hospital in Gauteng. It is recommended that the standards are validated nationally in the Neonatal Intensive Care practice in order to be implemented after inservice training to the different role players. The following hypotheses is set for testing: standards for Neonatal Intensive nursing care improve quality nursing care in the Neonatal Intensive Care unit.

M.Cur. / An explorative, descriptive, contextual qualitative design was employed in an endeavour to unravel experiences of mothers with infants in the NICU regarding emotional support that they received from the nurses while nursing their infants in the unit. The sample of the study comprised eight (8) mothers who were selected through purposive sampling. Data were collected through the use of semi- structured questions. All the interviews were audiotaped. Data were collected in the Neonatal Intensive Care Unit (NICU) of Princess Marina Hospital, Botswana. Data were analysed through the use of Tesch's method of data analysis, which is based on thematic content analysis. Themes which emerged were acceptance of the infant, encouragement to keep on visiting the infant every three hours, information provided on caring for the infant, encouragement on giving the infant motherly love e.g. cuddling, nurses having no time for the mothers, nurses' mistrust of mothers and finally neglect. The results of the study revealed that mothers did receive the emotional support that they needed, perceived as an important aspect to mothers nursing infants in the Neonatal Intensive Care Unit. It was found that some nurses did provide emotional support to mothers while other nurses had no time to support the mothers in need.

M.Cur. / Please refer to full text to view abstract

Antimicrobials are the most frequently used medications in the Neonatal Intensive Care Unit (NICU). Antimicrobial Stewardship (AMS) efforts may be used to mitigate the consequences of antimicrobial overuse while optimizing clinical outcomes through the safe, judicious use of antimicrobials. One target of AMS efforts is to reduce the incidence of necrotizing enterocolitis (NEC), a serious intestinal infection in neonates of which a necessary component is dysbiosis, the development of aberrant intestinal microbiota typically associated with prior antibiotic use. The goal of this ILE is to implement and enhance AMS efforts in the neonatal population with a focus on preventing NEC. The specific aims progress through three relevant, practical examples of AMS in a stepwise manner. Methods: In Aim 1, a systematic review of the literature evaluating the relationship between antimicrobial therapy and subsequent development of NEC and a meta-analysis including non-interventional studies was performed. Data were pooled on adjusted odds ratios (OR) and analyzed using the generic inverse variance method. All analyses were random effects models. A sensitivity analysis was performed based on a range (0-40%) of credibility ceilings. In Aim 2, institutional guidelines for early and late onset neonatal sepsis using the principles of AMS and the evidence for safe restriction of antimicrobials targeted for reduction in use in neonates by the National Healthcare Safety Network (NHSN) were created and implemented . In Aim 3, a reproducible 2-class latent variable model to extract a date-stamped diagnosis of NEC from the Pediatric Health Information System (PHIS) database was created as a tool to enhance research evaluating antibiotic use and NEC from large databases. This model was created using a subset of infants at two PHIS sites that were able to be validated. M plus software was used. Conclusions: For Aim 1, 36 studies met inclusion criteria for the systematic review, with 33 proceeding to quantitative analysis. There were 10 RCTs, the remaining being observational studies. Using the ROBINS-I or RoB 2.0 tools as appropriate, all studies including the RCTs had a least a moderate or high risk of bias respectively. The overall analysis failed to provide evidence of an association between prior antimicrobial use and NEC when all 33 studies were included, with a summary OR of 1.13, CI95 (0.88, 1.45) and significant heterogeneity, I2 = 77%. Multiple subgroup analyses were performed: “intent” of antibiotic use (prophylaxis versus not) drug delivery method (oral versus parenteral) and study type. Subgroup analysis of prophylactic enteral antibiotics showed a reduction in NEC: OR 0.2 CI95 (0.08, 0.54), I2 = 35% while prior use of parental antibiotics showed a positive association with NEC OR 1.48, CI95 (1.18, 1.86), I2 72%; for this subgroup, using a c% shows heterogeneity first reaching an estimate of 0% at a ceiling of 10% with nominal statistical significance is maintained starting at a ceiling of 10%. This shows that consideration of the biologic mechanism of the exposure-disease association, as indicated by the subgroup analyses in this study, must be considered when performing further dataset evaluations lest biased conclusions will be reached. For Aim 2, Four guidelines were created and implemented and are being validated: • The evaluation and management of infants ≥ 35 weeks gestational age at risk for early onset sepsis at Tufts Medical Center • The evaluation and management of infants ≥ 36 weeks gestational age at risk for early onset sepsis at BronxCare Hospital Center • The evaluation and management of infants < 36 weeks gestational age at risk for early onset sepsis at BronxCare Hospital Center • The evaluation and management of infants at risk for late onset sepsis at BronxCare Hospital Center For Aim 3 a model was successfully created that can be used to add an important layer of detail, time-of-event, to patient level variables in a large data set. This model can also be used to tabulate the sensitivity of a disease in the absence of a gold standard. The model is portable and could serve as a template for the PHIS or other large databases where certain important exposures may not be date stamped. The model may be adapted to not only allow for appropriate extraction of variables, but also allow the correct modelling of time-dependent co-variables.

Each year in Canada there are nearly 13,000 infants born to women under the age of 20 years (Statistics Canada, 2016). Infants born to adolescent mothers are at an increased risk for preterm birth, low birth weight, and congenital anomalies, making these infants more likely to require hospitalization in a neonatal intensive care unit (NICU) shortly after birth (DeMarco et al., 2021; Fleming et al., 2013; Shrim et al., 2011). Admission of their infant to the NICU creates an increasingly complex situation, as adolescent mothers and their children often already experience multiple social, psychological, and economic difficulties (Fleming et al., 2015). Additionally, adolescents are still developing important cognitive functions, such as advanced reasoning and decision-making, thus making their ability to navigate complex systems such as the NICU particularly challenging (Blakemore & Choudhury, 2006). However, the unique experience of the adolescent mother within the context of the NICU and their transition-home following discharge is poorly understood. Therefore, the overall purpose of this thesis was to explore the issue of transition-home from NICU for adolescent mothers with infants admitted to the NICU. Three overarching goals guided this thesis work, these goals were to: (a) understand the transition experiences of adolescent mothers with infants in the NICU from a theoretical perspective; (b) understand how to best collect rich qualitative data among study participants experiencing marginalization or stigma; and (c) conduct research to further understand the phenomena and how to begin to address transition-related issues. Findings related to each of these goals are presented in four manuscripts that make up this sandwich thesis, including a critical review of theory, an exploration of methods, and an interpretive description study exploring NICU-to-Home transitions. The work presented in this thesis emphasizes the complexity of the NICU-to-home transition for adolescent mothers. Findings highlight the need for strategies within the NICU to mitigate the negative influence of this experience and opportunities for more integrated models of care within the NICU and extending into the community. Implications for research, policy, and nursing education and practice are discussed. / Thesis / Doctor of Philosophy (PhD) / Pregnancy and parenting during adolescence and care transitions from neonatal intensive care unit (NICU) to home are relatively complex experiences. While each have been explored separately, very little is known about when these experiences intersect. This thesis examines theory and methods related to this complex intersection and describes findings of research exploring NICU-to-home care transitions for adolescent parents.

Objectives: The quality of securement directly impacts the functionality, duration of patency and likelihood of a complication for a given peripheral intravenous catheter. The objective of the study was to determine which method of peripheral intravenous catheter securement, StatLock or Tegabear dressing was more effective by comparing duration of catheter patency and complication rates. Study Design & Method: A quasi-experimental study using the Model for Improvement was conducted in a neonatal intensive care unit of a tertiary care hospital. Infants requiring insertion of a peripheral intravenous catheter for parenteral nutrition or administration of medications were eligible to participate. The study was conducted over a 4-month period and was divided into two phases, with each phase lasting two months. Results: A total of 363 peripheral intravenous catheters were inserted in 175 infants. There were 211 catheters secured with StatLock and 108 secured with Tegabear dressing. There were 42 catheters which were unable to use StatLock or Tegabear dressing and were secured with a combination of transparent dressing/ tape. There were two peripheral intravenous catheters inserted where the method of securement was not indicated. The groups were similar with regards to all demographic variables except postmenstrual age, where the Tegabear group consisted of a larger proportion of older infants (p=<0.001). There was no significant difference in the mean duration of catheter patency between the StatLock and Tegabear group (46.04 hours versus 45.33 hours respectively), p=0.84. Complication rates and reasons for catheter removal did not significantly differ between the two groups (p=0.78 and p=0.93 respectively). The proportion of catheters that used an arm board was significantly greater with the Tegabear dressing (23.8%) compared to 10.5% with StatLock (p=0.002). Twenty one percent (n=23/108) of the catheters secured with the Tegabear dressing required reinforcement with tape or transparent dressing whereas no catheters in the StatLock group needed to be reinforced (p<0.001). Conclusion: Catheter dwell time and complication rates did not differ significantly between StatLock and Tegabear dressing. However, when evaluating a new product, it is important to consider that there is often a learning curve that must be overcome. A larger study with a more rigorous design such as a randomized controlled trial is needed to validate or dispute the study findings. In the meantime, nurses must exercise individual and independent judgment when selecting a securement method most appropriate for their patient. / Thesis / Master of Science in Nursing (MSN)

No description available.

Thesis (MPhil)--University of Stellenbosch, 2004. / ENGLISH ABSTRACT: This thesis discusses the value of medical futility as an action guide for neonatal endof- life decisions. The concept is contextualized within the narrative of medical progress, the uncertainty of medical prognostication and the difficulty of just resource allocation, within the unique African situation where children are worse off today than they were at the beginning of the last century. parties actively engage in an interactive deliberation for a plan of action. Both parties ought to accept moral responsibility. Such a model of deliberation has the added advantage of transcending the limitations of the participants to arrive at a higher-level solution, which is considered more than just a consensus. It has been argued that medical progress has obscured the basic need for human compassion for the dying and for their loved ones. The literature furthermore reports that the quality of end-of-life care is unsatisfactory for both patients and their families. It is within this context that the concept of medical futility is positioned as a useful action guide. As we do not have the luxury of withdrawing from the responsibility to engage in the deliberation of end-of-life decisions, such responsibility demands an increasing awareness of ethical dilemmas and a model of medical training where communication, conflict-resolution, inclusive history taking, with assessment of patient values and preferences, is focussed on. The capacity for empathetic care has to be emphasized as an integral part of such approach. Finally, in this thesis, the concept of medical futility is tested and applied to clinical case scenarios. It is argued that the traditional medical paradigm, with its justification of an 'all out war' against disease and death, in order to achieve utopia for all, is outdated. Death in the neonatal intensive care unit is increasingly attributed to end-of-life decisions. Futile treatment could be considered a waste of scarce resources, contradicting the principle of nonmaleficence and justice, particularly in an African context. The ongoing confidence in, and uncritical submission to the technological progress in medicine is understood as a defence and coping mechanism against the backdrop of the experience of life's fragility, suffering and the inevitability of death. Such uncritical acceptance of the technological imperative could lead to a harmful fallacy that cure is effected by prolonging life at all cost. What actually occurs, instead, is the prolongation of the dying process, increasing suffering for all parties involved. The historical development of the concept of medical futility is discussed, highlighting its applicability to the paradigmatic scenario of cardio-pulmonary resuscitation. Particular attention is given to ways in which the concept could endanger patient-autonomy by allowing physicians to make unilateral, paternalistic decisions. It is argued that the informative model of the patient-physician relationship, where the physician's role is to disclose information in order for the patient to indicate her preferences, ought to be replaced by a more adequate deliberative model, where both / AFRIKAANSE OPSOMMING: Hierdie tesis bespreek die waarde van mediese futiliteit as 'n maatstaf vir aksie in gevalle van neonatale 'einde-van-lewe' besluite. Die konsep word gekontekstualiseer binne die wêreldbeskouing van mediese vooruitgang, die onsekerheid van mediese prognostikering en die probleme wat geassosieer IS met regverdige hulpbrontoekenning; spesifiek binne die unieke Afrika-situasie. Dit word aangevoer dat die tradisionele mediese paradigma, met regverdiging vir voorkoming van siekte en dood ten alle koste, verouderd is. Sterftes in neonatale intensiewe sorgeenhede word toenemend toegeskryf aan 'einde-van-lewe' besluite Futiele behandeling sou dus beskou kon word as 'n vermorsing van skaars hulpbronne, wat teenstrydig sou wees met die beginsels nie-skadelikheid ('nonmaleficence') en regverdigheid. Die volgehoue vertroue in en onkritiese aanvaarding van aansprake op tegnologiese vooruitgang lil geneeskunde, kan beskou word as verdediging- en hanteringsmeganisme in die belewenis van lewenskwesbaarheid, lyding en die onafwendbaarheid van die dood. Sodanige onkritiese aanvaarding van die tegnologiese imperatief kan tot 'n onverantwoordbare denkfout, naamlik dat genesing plaasvind deur verlenging van lewe ten alle koste, lei. Wat hierteenoor eerder mag plaasvind, is 'n verlenging die sterwensproses en, gepaard daarmee, toenemende lyding van all betrokke partye. Die historiese ontwikkeling van die konsep van mediese futiliteit word bespreek met klem op die toepaslikheid daarvan op die paradigmatiese situasie van kardiopulmonêre resussitasie. Spesifieke aandag word gegee aan maniere waarop die konsep pasiënte se outonomie in gevaar stel, deur die betrokke medici die reg te gee tot eensydige, paternalistiese besluitneming. Die argument is dan dat die informatiewe model, waar die verhouding tussen die dokter en pasiënt gebasseer is op die beginsel dat die dokter inligting moet verskaf aan die pasiënt sodat die pasiënt 'n ingeligte besluit kan neem, vervang moet word met 'n meer toepaslike beraadslagende model, waar sowel die dokter as die pasiënt aktief deelneem aan interaktiewe beraadslaging oor 'n aksieplan. Albei partye word dan moreel verantwoordbaar. So 'n model van beraadslaging het die bykomende voordeel dat dit die beperkings van die deelnemers kan transendeer. Sodoende word 'n hoër-vlak oplossing - iets meer as 'n blote consensus - te weeg gebring. Die argument word ontwikkel dat mediese vooruitgang meelewing met die sterwendes en hul geliefdes mag verberg. Verder dui die literatuur daarop dat die kwaliteit van einde-van-lewe-sorg vir sowel die pasiënte as hul familie onaanvaarbaar is. Dit is binne hierdie konteks dat die konsep van mediese futiliteit kan dien as 'n maatstaf vir aksie. Medici kan nie verantwoordelikheid vir deelname aan beraadslaging rondom eindevan- lewe beluitneming vermy nie, en as sodanig vereis die situasie toenemende bewustheid van sowel die etiese dilemmas as 'n mediese opleidingsmodel waann kommunikasie, konflikhantering, omvattende geskiedenis-neming, met insluiting van die pasient se waardes en voorkeure, beklemtoon word. Die kapasiteit vir empatiese sorg moet weer eens beklemtoon word as 'n integrale deel van hierdie benadering. Ten slotte, hierdie tesis poog om die konsep van mediese futiliteit te toets en toe te pas op kliniese situasies.