MSc (Med), Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand / Resuscitation of patients, be it medical or surgical, occurs on a daily basis in the Emergency Department. The resuscitation is usually pressurised and frantic, as a result family members are escorted out of the resuscitation room to a waiting room where they are isolated from the resuscitation. Since the late 1980’s the practice of Family Witnessed Resuscitation (FWR) has been explored1. FWR means that family members are invited into the resuscitation area whilst the medical team is attempting to resuscitate the patient. This practice has often been suggested but the opinions of medical staff remain varied 2,3,4. Resuscitation as discussed in this report is the medical proceedings that occur at a time when a patient presents with a life threatening emergency, be it medical or surgical, to an emergency department and the medical staff are unsuccessful in re-establishing respiratory efforts and cardiac output to maintain life. A review of the literature indicates that FWR is a means of the family gaining closure when the resuscitation is unsuccessful by observing the process of resuscitation and having their family member’s last moments clearer and more defined in their memory. The decision of FWR is one that needs to be taken by the family after the invitation has been extended by the medical team leader. There needs to be nursing staff available to be in attendance with the family at all times to answer their questions and explain procedures. The views of practitioners surveyed on FWR tend to vary, but irrespective there is a recurrent theme regarding the concerns expressed by emergency room doctors towards FWR. These concerns include traumatisation of the family, increased stress being placed on the medical team to perform while being watched, possible family interference with the resuscitation and the possibility of medico-legal consequences. These concerns are not simply regional but seem to be universal. This study sampled two groups of doctors:  Doctors actively working in emergency departments in the Gauteng area in Medi-Clinic and Life Healthcare facilities. These are private healthcare facilities.  Doctor participants in the University of the Witwatersrand, Faculty of Health Sciences Master in Science in Emergency Medicine programme. These doctors work in emergency departments in both the private and provincial sectors. This study found that there is not complete acceptance of FWR; 48 out of the 101 doctors in the sample had never considered allowing family to witness resuscitation. Doctor’s opinions vary regarding which family members, if any, they would allow to witness resuscitation, at which point in the resuscitation process they would allow family into the resuscitation area and how many family members would be permitted into the resuscitation at any one time. The opinion in this study was that due to space constraints no more than two family members would be allowed in the resuscitation area at any one time. Training and continued professional development seem to impact positively on the practice of FWR. The attendance at American Heart Association (AHA) courses such as Paediatric Advance Life Support (PALS) and AHA Acute Cardiac Life Support (ACLS) positively influences the doctors’ acceptance of FWR. Should death occur due to the acute life threatening emergency and resuscitation attempts are unsuccessful then FWR assists family in coming to terms with the death of a relative and is seen by the public to make the resuscitation a more humane process. The literature review and findings of this study concur that FWR is a practice that should be occurring in emergency departments. Some nursing councils have drawn up guidelines and mission statements that will ensure FWR is common place in the Emergency Departments (Appendix 1). If FWR is to become common practice then emergency departments need to be encouraged to draw up protocols and have processes in place that ensure that this process is performed in a way that allows staff to operate efficiently and the family to gain the most they can from a grave situation. The emergency medicine doctor that is in charge of the patient needs to be aware of the protocols and procedures that are in place in order to be able to facilitate FWR. In studies from KwaZulu Natal5, Western Cape6 and this study from Gauteng show that no unit in South Africa has policies yet. This study found that although FWR is currently not common practice in emergency departments in the Gauteng area, it is a practice that emergency doctors are willing to encourage in the future. The doctor’s attitude toward FWR is influenced positively by attendance at AHA PALS and AHA ACLS courses and the experience of the doctor of working in the emergency department. Doctors do have some concerns about the practice including psychological traumatisation of family members, extended length of resuscitation and medico-legal complications. It was found that parents would be the family members that are most likely to be invited by the medical team to witness the resuscitation of a family member and that the doctor would restrict witnesses to two family members only. It would seem that FWR will start occurring in emergency departments.

Submitted by Filipe dos Santos (fsantos@pucsp.br) on 2017-01-10T11:27:52Z No. of bitstreams: 1 Gabriel Henrique Santoro.pdf: 666203 bytes, checksum: 16211ec03dfb7742e92bcda64807a121 (MD5) / Made available in DSpace on 2017-01-10T11:27:52Z (GMT). No. of bitstreams: 1 Gabriel Henrique Santoro.pdf: 666203 bytes, checksum: 16211ec03dfb7742e92bcda64807a121 (MD5) Previous issue date: 2016-12-08 / This essay’s object is to examine one of the current problems of the Labor Courts, which is the overrated value provided to witnessing evidence over documented evidence. Within this reality, we will study the essential principles related to evidence definition and the truth as part of a regular procedural environment. Nevertheless, we shall consider crucial evidence-related elements such as hierarchy levels and the over-exaggeration of witnesses' testimonies within labor proceedings. The essay’s key scope is to point out that the recurrent devaluation of documented evidence over witnesses shall create enormous disadvantages. In addition, such measure shall undermine the search for the actual truth within labor proceedings and deliver a sensation of insecurity to all the involved in a specific dispute, especially given that witnesses can be extremely fragile and cast shadow over reality. After all the necessary reflections, this essay shall suggest eventual mechanisms to analyze evidences produced before courts, targeting the preservation of the actual truth and the continuity of the confidence in the Courts of Law / O presente estudo se propõe a examinar um dos problemas atuais da Justiça do Trabalho, qual seja, a valoração desmedida da prova testemunhal em detrimento da documental. Na esteira desta realidade abordar-se-á princípios próprios do campo probatório, bem ainda far-se-á uma análise da verdade dentro do campo processual. Não se perderá de vista, ainda, questões cruciais no campo probatório, como, por exemplo, a hierarquia da prova e a utilização desenfreada da prova testemunhal dentro do processo juslaboral. O escopo primordial do trabalho será demonstrar que a desvalorização recorrente da prova documental frente a testemunhal pode trazer grandes prejuízos ao jurisdicionado. Tal atitude também pode impor obstáculos na busca pela verdade dentro do processo e criar uma sensação de insegurança jurídica aos envolvidos na lide trabalhista, mormente porque a prova testemunhal, por sua própria essência, é extremamente frágil e, por vezes, maquiar a realidade dos fatos. Após todas as ponderações necessárias, o objetivo deste trabalho é sugerir mecanismos de análise das provas produzidas em juízo, no intuito de se preservar a verdade real e a continuidade da confiança no Poder Judiciário Laboral

Barnmisshandel är ett globalt folkhälsoproblem som resulterar i stora hälsokonsekvenser.Flera studier har visat att barnmisshandel kan leda till psykisk ohälsa hos de som utsatts,såsom depression och ångest. Det är dock få studier som har undersökt sambandet mellanbarnmisshandel och psykosomatiska symtom hos skolelever. Syftet med studien var attundersöka förekomsten av utsatthet (fysisk barnmisshandel och/eller barn som bevittnat våld)och psykosomatiska symtom bland elever i årskurs nio. Syftet var också att undersökasambandet mellan utsatthet och psykosomatiska symtom. Studien var en tvärsnittsstudie och gjordes utifrån redan insamlad data från den nationellakartläggningen om barnmisshandel 2011. Studiepopulationen bestod av 3207 elever i niondeklass och svarsfrekvensen var 84 procent. Specifikt utvalda frågor ur datamaterialetbearbetades utifrån deskriptiva frekvenstabeller, chi²- test och oddskvoter (OR) med 95procent konfidensintervall. Resultatet beskriver förekomsten av barnmisshandel och/eller bevittnat våld, psykosomatiskasymtom en gång i veckan eller oftare och sambandet dem emellan samt bakgrundsfaktorersom har samband med psykosomatiska symtom. Det var 18 procent av skoleleverna somangav att de någon gång blivit fysisk bestraffade och 7 procent angav att de bevittnat våldmellan föräldrarna. Det var 34 procent av eleverna som rapporterade 1-2 symtom en gång iveckan eller oftare och 26 procent rapporterade 3 eller fler symtom en gång i veckan elleroftare. Det statistsikt signifikanta sambandet mellan fysisk misshandel och psykosomatiskasymtom framkom vara starkare om eleven hade multipla symtom (OR=4,254). Det fannsinget statistiskt signifikant samband mellan att bevittnat våld och 1-2 psykosomatiskasymtom. Däremot fanns ett signifikant samband mellan att ha bevittnat våld hemma och 3eller fler symtom (OR=3,903). / Child abuse is a global public health problem with major health consequences. Several studieshave shown that child abuse can result in mental health problem, such as depression andanxiety. However, there have been few studies about the association between child abuse andpsychosomatic symptoms in schoolchildren. The aim of the study has been to investigate theprevalence of physical child abuse and/or children who have witnessed partner violence andpsychosomatic symptoms. The aim was also to examine physical child abuse associated withpsychosomatic symptoms.The study was a cross- sectional study and was based on already collected data from aNational Survey about Child Abuse 2011. The study constituted of 3207 students in 9th gradeand the response rate was 84 percent. In this study were questions selected from the NationalSurvey about Child Abuse 2011 and data were processed by descriptive tables, chi²- tests andodds ratio (OR) with 95 percent confidence intervals. The results describe the incidence of child abuse and/or children who have witnessed partnerviolence, psychosomatic symptoms once a week or more and the association between themand background factors associated with psychosomatic symptoms. It was 18 percent of thestudents who reported they had been physical punished and 7 percent reported they havewitnessed violence between parents. It was 34 percent of the students who indicated that theyhad 1-2 symptoms once a week or more and 26 percent of the students who indicated that theyhad 3 or more symptoms once a week or more. There were a statistic significant associationbetween physical abuse and psychosomatic symptoms and it was even stronger if the studenthad multiple symptoms (OR=4,254). There were no statistic significant association betweenwitnessing violence and 1-2 psychosomatic symptoms. However, there were a statisticsignificant association between witnessing violence and 3 or more symptoms (OR=3,903).

Background: According to the ethical guidelines, family members of the patient should be allowed to be present during cardiopulmonary resuscitation (CPR). Nurses should be able to, besides performing CPR, decide if family presence is appropriate, support and explain the course of events to the family. Aim: The aim of this study was to illuminate nurses' experiences of family presence during resuscitation. Method: A literature study has been made of 11 qualitative studies, where differences and similarities were analysed. The studies were published between the years 2000 – 2015. Result: Two main themes were identified and five subthemes. The main themes were: "The nurse's experience of their work situation" and "The nurse's experience of the circumstances that affects the nursing". The findings showed that the nurses experienced a dilemma when they needed to decide if family presence was appropriate. The nurses experienced that a bond could be created with the families through the role of support person. They experienced that the family members could participate in the care but they could also be a distraction and a source of stress. Conclusion: Clear local guidelines would facilitate the decision if family presence is appropriate. A support person for the family would also facilitate the family's presence. More education and experience in this subject helps nurses overcome fears of difficulties often associated with family presence.

Det råder delade meningar angående närståendes närvaro under hjärt-lungräddning på sjukhus. Trots internationella riktlinjer från Emergency Nursing Association som säger att närstående bör erbjudas möjlighet att närvara under hjärt- lungräddning så följs ej dessa generellt på sjukhusen. Syftet: Var att beskriva närståendes upplevelser att närvara under hjärt-lungräddning på sjukhus. Metod: En litteraturstudie har gjorts där 13 vetenskapliga artiklar har granskats. Resultat: Närstående ville ha en valmöjlighet om de skulle närvara eller ej. De flesta närstående var nöjda med sitt beslut att närvara och skulle göra det igen trots att situationen upplevdes som svår. Närstående kände samhörighet med patienten och upplevde att de hanterade situationen bättre om de fick kontinuerlig information om händelseförloppet samt hade en stödperson vid sin sida. Sorgen underlättades då de delat den sista stunden med sin närstående. Slutsats: Närståendes närvaro under hjärt-lungräddning är fortfarande ett relativt outforskat område. Valmöjligheten att närvara är viktig, likaså kontinuerlig information och att ha en stödperson hos sig under hjärt-lungräddningen anses väsentligt. Närstående som varit närvarande under hjärt- lungräddning uppvisar lägre tendens till negativa psykologiska effekter och upplever även att sorgeprocessen underlättas. / A difference of opinion exists regarding the issue of relatives being present during cardiopulmonary resuscitation in hospital. Despite international guidelines from the Emergency Nursing Association stating that relatives should be offered the opportunity to be present during cardiopulmonary resuscitation, this is generally not the case. The aim: of this study was to describe relatives' experiences of being present during cardiopulmonary resuscitation in hospital. Method: A literature review in which 13 scientific papers have been reviewed. Results: Relatives preferred to be given the option to attend the cardiopulmonary resuscitation or not. Most relatives were satisfied with their decision to attend and would do it again even though the situation was perceived as difficult. Relatives experienced an emotional connection with the patient and felt that they handled the situation better if they were given continuous information on the events and had a support person at their side. Relatives also felt it easier to cope with the grieving process when they had shared their loved ones last moment. Conclusion: The attendance of relatives during cardiopulmonary resuscitation is still a relatively unexplored area. To be given the option to attend or not is important, as is continuous information during the resuscitation as well as a support person throughout the process. Relatives who were present during resuscitation showed lower tendency to experience negative psychological effects, and that the grieving process felt easier to go through.

Bakgrund: Omkring 10.000 människor drabbas årligen av hjärtstopp i samhället. För den bästa chansen till överlevnad krävs snabb behandling med HLR och defibrillering. Att medverka som närstående vid en återupplivning beskrivs som den mest traumatiska händelsen en människa kan bevittna, samtidigt ökas förståelsen av situationen och ger ett avslut. Sjuksköterskan har ett stort ansvar över patientens omvårdnad och relaterat till behovet av resurser och otillräckliga riktlinjer så kan sjuksköterskan hamna i en utsatt position. Syfte: Syftet med litteraturstudien var att beskriva sjuksköterskors erfarenheter av närståendes närvaro vid återupplivning med HLR efter hjärtstopp. Metod: En beskrivande litteraturstudie innehållande 12 vetenskapliga artiklar med kvalitativ, kvantitativ och mixad ansats. Artiklarna söktes fram genom den vetenskapliga databasen Medline via PubMed. Huvudresultat: Resultatet visade ingen konsensus i sjuksköterskornas erfarenheter. De ville inte ha närstående närvarande på grund av negativ effekt på utförandet. Känslor av otrygghet hos sjuksköterskorna skapades av närstående. Sjuksköterskorna ansåg att närstående blev traumatiserade av händelsen. Resursbehovet blev tydligt då sjuksköterskorna upplevde bemanningen för låg för att avsätta personal till närstående. Sjuksköterskornas professionalism ökade med närvaron och närståendes sorgeprocess främjades. Det var viktigt att beakta patientens egen önskning inom ämnet. Slutsats: Trots positiva effekter ansåg sjuksköterskorna att de negativa aspekterna dominerade. Det är en komplicerad fråga med olika åsikter. Informationen som framkommit ger insikter i hur närståendes närvaro upplevs. Detta behövs för att chefer och HLR-utbildade ska ta ställning, öka kunskapen och starta en diskussion om fenomenet. / Background: Approximately 10.000 people experience cardiac arrest every year. The best opportunity for survival is effective treatment with CPR and defibrillation. To participate as a relative during a resuscitation is described as traumatic, but it increases the understanding and gives a closure. Nurses have a responsibility for the patient’s care and due to resources and vague guidelines, nurses can be in an exposed position. Aim: The purpose of this study was to describe nurses’ experiences of relatives’ presence during resuscitation with CPR after cardiac arrest. Method: A descriptive literature review containing 12 scientific articles with qualitative, quantitative and mixed methods. The articles were identified in the database Medline via PubMed. Result: There was no consensus in the nurses’ experiences. They did not want relatives present due to negative impact on their work. Feelings regarding insecurity arose with relatives’ presence. According to the nurses, relatives became traumatized by the event. The staff level was too low to assign personnel to relatives due to the lack of resources. However, nurses also reported increased professionalism and that the relatives’ grieving process benefited. It was important to consider the patient's wishes on the subject. Conclusion: Despite positive effects, the nurses felt that the negative aspects dominated. It is a complicated question with multiple views. The results provide knowledge on how the presence of relatives is experienced. This is needed for personnel to take a stand, be educated and start to discuss the phenomenon.

Syftet med studien var att utifrån ett omsorgs- och delaktighetsperspektiv analysera bedömningen av barnets bästa i umgängesfrågor, i de fall där en förälder utövat våld mot den andra föräldern. För att besvara vårt syfte har vi använt oss av tre frågeställningar; Vad innebär barnets bästa för de yrkesverksamma som kommer i kontakt med barn som bevittnat våld? Vad innebär bevittnat våld för de yrkesverksamma och hur beaktas detta av de som arbetar med barnen? Hur mycket inflytande anser de yrkesverksamma att barnet ska ges vid processer som rör dem? För att samla in material utfördes sju intervjuer med yrkesverksamma som genom sitt arbete träffar barn som bevittnat våld, samt är mer eller mindre i direkt kontakt med beslut gällande umgänge mellan barn och en våldsutövande förälder. Materialet har sedan analyserats utifrån rådande lagstiftning, tidigare forskning, samt barndomssociologin och delaktighetsstegen. Vi kom i vår studie fram till att de yrkesverksamma fann att barnets bästa var att ha kontakt med båda sina föräldrar. De hade en vid uppfattning om vad begreppet bevittnat våld innefattade, dock togs detta inte till stor hänsyn i det praktiska arbetet. Från vårt resultat gick att urskilja att det är olika faktorer som spelar in i hur mycket ett barn delaktiggörs. / The purpose of the study was that from a caring and participation perspective to analyze the assessment of the best interests of the child regarding visitation matters, in cases where a parent used violence against the other parent. The purpose is broken down into three main questions; What does the best interests of the child mean to the professionals who gets in contact with children who have witnessed violence? What does witnessing violence mean to the professionals and how is this taken into account by those who work with children? How much influence considers the professionals that the child should be given in the processes that affect them? In order to answer our purpose we performed seven interviews with professionals who, through their work meet children who have witnessed violence, and are more or less in direct contact with the decision regarding visitation between children and a violent parent. The material was then analyzed based on current laws, earlier research, as well as childhood sociology and ladder of participation.Our result showed that the professionals found that the child’s best interest was to have contact with both parents. They had a broad idea of what the concept witnessed violence included, but this were not considered in the practical work. Our results also showed that there are different factors that play into how much the child was involved.

The aim of the study was to describe the perceptions of critical care nurses concerning family witnessed resuscitation, presenting arguments for or against the practice thereof. A quantitative, descriptive and exploratory approach was used. For the study, a non- probability convenience sample of 100 critical care nurses from five critical care units were used. A combined open-ended and closed-ended questionnaire was used. The majority of critical care nurses in the study disapproved of the idea of family witnessed resuscitation. They believed it to be traumatic for relatives, threatening to the resuscitation process and increasing litigation. Although the dominant feeling was one of disapproval, some critical care nurses felt that family witnessed resuscitation was beneficial to relatives. Recommendations for future practice included incorporation of educational programmes for critical care nurses concerning family witnessed resuscitation and providing training to deal with the stresses of family witnessed resuscitation. / Health Studies / M.A (Health Studies)

The aim of the study was to describe the perceptions of critical care nurses concerning family witnessed resuscitation, presenting arguments for or against the practice thereof. A quantitative, descriptive and exploratory approach was used. For the study, a non- probability convenience sample of 100 critical care nurses from five critical care units were used. A combined open-ended and closed-ended questionnaire was used. The majority of critical care nurses in the study disapproved of the idea of family witnessed resuscitation. They believed it to be traumatic for relatives, threatening to the resuscitation process and increasing litigation. Although the dominant feeling was one of disapproval, some critical care nurses felt that family witnessed resuscitation was beneficial to relatives. Recommendations for future practice included incorporation of educational programmes for critical care nurses concerning family witnessed resuscitation and providing training to deal with the stresses of family witnessed resuscitation. / Health Studies / M.A (Health Studies)

Contexte. L’étiologie des comportements antisociaux est complexe et varierait au cours de la vie. Tandis que les études antérieures suggèrent que de nombreux facteurs de risque soient impliqués, plusieurs incertitudes demeurent quant aux gènes spécifiques liés à ces phénotypes et en regard de la nature indépendante ou jointe de leurs contributions avec l’environnement. Objectif. L’objectif de cette thèse est d’étudier la contribution des gènes sérotoninergiques et de la violence parentale aux comportements antisociaux à trois périodes développementales : l’enfance, l’adolescence et le début de l’âge adulte. Méthodologie. Afin d’atteindre cet objectif, les données de 410 participants de l’Étude Longitudinale des Enfants de la Maternelle du Québec (ÉLEMQ), un échantillon populationnel à devis longitudinal et prospectif ayant débuté à l’enfance et s’étant poursuivi à l’âge adulte, ont été analysées. Plusieurs comportements antisociaux ont été mesurés à l’enfance (7 ans à 11 ans), à l’adolescence (15 ans) et au début de l’âge adulte (21 ans) par le biais de plusieurs méthodes et d’informateurs: 1) questionnaires complétés par les enseignants, 2) des entrevues semi-structurées, ou 3) des questionnaires auto-rapportés. Les données relatives à la violence parentale ont été obtenues via les questionnaires complétés de façon rétrospective par les participants à l’âge adulte. Des analyses de régressions négatives binominales ont été réalisées afin de vérifier l’association indépendante et conjointe des variants mesurés dans 11 gènes impliqués dans le système sérotoninergique (HTR1A, HTR2A, HTR2C, HTR5A, HTR6, HTR7, SLC6A4, MAOA, MAOB, TPH-1, TPH-2), deux formes de violence parentale – la violence subie et l’exposition à la violence conjugale – et les comportements antisociaux. Résultats. Les indices cumulatifs de risque génétique dérivés à partir de blocs d’haplotypes des gènes investigués permettaient d’expliquer entre 2% et 8% de la variance des comportements antisociaux, que ces derniers soient mesurés à l’enfance, l’adolescence ou à l’âge adulte. De plus, ces indices multigéniques modifient, dans certains cas, l’association entre la violence subie ou l’exposition à la violence conjugale et les comportements antisociaux. Conclusions. Les résultats de cette thèse soutiennent ceux issus des études antérieures soulignant le rôle des gènes impliqués dans le système sérotoninergique à la manifestation des comportements antisociaux. D’autre part, ces résultats suggèrent l’interaction entre les indices cumulatifs génétiques et la violence parentale à la manifestation de comportements antisociaux de l’enfance à l’âge adulte. Or, ces interactions ne sont pas observées de façon consistante et peuvent prendre diverses formes. L’investigation de l’étiologie génétique et environnementale des comportements antisociaux doit être poursuivie de façon à mieux circonscrire leurs effets synergiques, s’il y a lieu, et afin que ces connaissances puissent, éventuellement, éclairer l’examen des mécanismes impliqués et bonifier les modèles théoriques et conceptuels en découlant. / Background. The etiology of antisocial behaviors is complex, and likely vary across the life course. While the multifactorial nature of these phenotypes is clear, uncertainties remain as to which genes are involved whether or not these genes interact with putative pathogenic environments. Aim. The aim of this thesis is to investigate the unique and joint contributions of serotonergic genes and parental violence in three developmental periods: childhood, adolescence, and early adulthood. Methodology. Data were from 410 male members of the Quebec Longitudinal Study of Kindergarten Children, who were prospectively followed from kindergarten to early adulthood. Antisocial behaviors were assessed in childhood (7-12 years), adolescence (15 years) and early adulthood (21 years) using a multi-method and multi-informant strategy, including teacher ratings, clinical interviews and self-report questionnaires. Negative binominal regressions were used to investigate the main and interaction effects between the cumulative indexes encompassing 11 serotonergic candidate genes (HTR1A, HTR2A, HTR2C, HTR5A, HTR6, HTR7, SLC6A4, MAOA, MAOB, TPH-1, TPH-2), two forms of parental violence – child-directed and child-witnessed parental violence – and antisocial behaviors. Results. Haplotype-based cumulative genetic indexes explained between 2% and 8% of the variance in antisocial behaviors, measured in childhood, adolescence, and early adulthood. Moreover, these multigenic serotonergic risk indexes moderated, in some instances, the association between parental violence and antisocial outcomes. Conclusions. This thesis offers additional support suggesting that the serotonergic candidate genes may be involved in the etiology of antisocial behaviors. It also provides further evidence that these genes may interact with parental violence in antisocial social behaviors exhibited in childhood, adolescence, and early adulthood. However, these interactions did not arise uniformly and took multiple forms. Overall, our findings suggest that the investigation of the genetic and environmental etiology of antisocial behaviors should be pursued to better delineate their synergic effect, if any, and to eventually mobilize this knowledge to inform the search of the underlying mechanisms and to improve our theoretical and conceptual models.