Doctoral Degrees (Nursing and Midwifery)

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    Best practice guideline for nurses for the assessment and management of acute trauma-related pain in emergency centers
    (Stellenbosch : Stellenbosch University, 2023-03) Magerman, Yolande Nerissa; Jordan, P. J.; Van der Heever, M. M.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Nursing & Midwifery.
    ENGLISH SUMMARY: Background: Pain is a universal, common symptom experienced by patients admitted to the emergency center (EC). The global burden of pain includes trauma-related pain, which is a natural consequence of injury. Guidelines are necessary tools in evidence-based practice for the implementation of standardised nursing care with a common, efficient approach to patient care. The absence of a guideline for the assessment and management of acute trauma-related pain creates the opportunity for nurses to practice variantly and inconsistently leading to possible negative patient outcomes. Aim: The purpose of the study was to contextualise a best practice guideline for the assessment and management of acute trauma-related pain in emergency centers in the Western Cape, South Africa. Methods: The research was conducted in three phases. Phase one comprised of two quantitative studies: professional nurses in sub-study one, and the patients in sub-study two. Phase two consisted of a scoping review to identify, appraise, and summarise the content of the available best practice guidelines for the assessment and management of pain in adult patients within the emergency care settings. Phase three included the synthesis of the extracted recommendations and the drafting of the best practice guideline. Results: Data was collected from 118 professional nurses and 529 patients in the ECs of five hospitals in the Western Cape, South Africa. The findings indicated that approximately half of the nurses displayed adequate knowledge, while half have good knowledge and 4% have poor knowledge related to pain assessment and pain management. Attitudes and self-reported practices on pain assessment and management were congruent with the knowledge levels of nurses. Most of the nurses (n=63, 54%) did not consider their level of knowledge on the assessment and management of acute trauma-related pain to be up to date according to best practice nursing. Patient data findings indicated that the nurses did not consistently practise assessment and management of acute trauma-related pain in the ECs. The findings confirmed the need for base practices on the best available evidence. Six best practice guidelines on pain assessment and pain management were identified by means of the scoping review and 114 recommendations were extracted from them. The contextualised guideline was validated by nine external reviewers, who appraised the guideline using the AGREE II tool. An algorithm was developed as an evidence summary and supporting document for ease of reference for professional nurses in the EC. Conclusion: The need for a best practice guideline in the EC for professional nurses, as the end-users, was evident by the variation in practice, lack in knowledge, attitudes, and practices of nurses. A contextualised best practice guideline was developed as the end-product of this research study. Further research is recommended to implement and test the feasibility, appropriateness, meaningfulness, and effectiveness of the best practice guideline for professional nurses in the EC in a South African context.
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    Development and validation of healthcare standards and criteria that contribute to the care of residents in homes for the elderly in Tanzania
    (Stellenbosch : Stellenbosch University, 2022-04) Mathias, Victor; Stellenberg, Ethelwynn; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Nursing & Midwifery.
    ENGLISH SUMMARY: Introduction: The problems experienced in homes for the elderly in Tanzania highlighted the need to develop healthcare standards to guide the provision of quality care to residents thus influencing healthcare outcomes. Study goal: Developing and validating healthcare standards and the associated criteria to contribute to quality care for residents in homes for the elderly in Tanzania. Objectives: i.To determine whether any healthcare standards are applied to ensure safe, qualitycare for residents in homes for the elderly in Tanzania. ii.To develop and validate quality healthcare standards to provide safe, quality careto residents in homes for the elderly in Tanzania based on the results of objective(i). iii.To develop validated measuring criteria to measure the validated healthcarestandards for safe, quality care for residents in homes for the elderly in Tanzania. Conceptual framework: The Donabedian quality model was applied to develop healthcare structure standards and the associated criteria. Methodology: The study was conducted in three phases: Phase 1: A situational analysis was conducted by applying a quantitative research approach with an exploratory research design aligned with objective (i). Validity Efforts were made to strengthen construct, content and face validity of all data collections tools. Reliability The alpha coefficient for the audit instrument was .983 and the Likert questionnaire was .928 indicating a high internal consistency. Phase 2: Drafted standards and associated criteria were developed based on the findings of phase one and the relevant literature aligned with objective (ii). Phase 3: The developed drafted standards and criteria were validated applying the Delphi technique which was applied quantitatively aligned with objective (iii). Ethical considerations: Approval was sought from Stellenbosch University (S19/02/048) and from Tanzania (NIMR/HQ/R.8a/Vol. IX/3191). Informed consent was obtained from managers of homes and participants. Results: Phase 1: All the homes for the elderly in the country N=32 (100%) were audited using an audit instrument which included seven fields, 26 drafted standards, four sub-standards and 262 associated criteria. All staff, N=65 (100%), from homes for the elderly completed a Likert scale questionnaire which was based on the items of the audit instrument which showed that all homes were non-compliant with all the standards and the criteria. Phase 2: Development of the drafted standards and associated criteria followed the COHSASA model. All 26 drafted standards and 257 (98%) of associated criteria were agreed upon by the experts, only 5 (2%) of the criteria underwent modifications which were then also accepted. Phase 3: Two rounds of the Delphi technique were conducted to validate the drafted standards and associated criteria. All 26(100%) healthcare standards reached consensus among the experts, including 258 (98.5%) criteria at a cut-off point of ≥ 80%. Four criteria were modified according to experts’ comments and included in round two, achieving consensus of 96%. Recommendation Based on the researcher’s observation and study findings, revealing poor care to residents in the homes for the elderly, the Government should respond to the plight of the elderly and urgently introduce the validated standards and criteria.
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    The development of validated guidelines that contribute to the prevention of malpractice litigation in nursing practice in South Africa
    (Stellenbosch : Stellenbosch University, 2020-03) Gcawu, Luleka Patricia; Stellenberg, Ethelwynn L. (Ethelwynn Linda); Whittaker, Stuart; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Nursing & Midwifery.
    ENGLISH SUMMARY : Introduction: Substandard care resulting in billions of rand pay-outs due to malpractice litigation remains a challenge in nursing practice. Purpose: To develop validated guidelines that contribute to the prevention of malpractice litigation in nursing practice in South Africa. Research questions: What are the contributing factors that lead to adverse events in nursing care? What are the validated guidelines that can be developed to contribute to the prevention of malpractice litigation in nursing practice in South Africa? Methodology: The study was conducted in three phases: Phase 1: A retrospective audit of adverse events using a descriptive quantitative design with Pearson Chi-Square test, CI 95%, p ≤ 0.05 was conducted on 203 malpractice litigation cases from the Eastern Cape and Gauteng public healthcare sectors. Phase 2: A comparative statistical analysis was carried out to compare and contrast adverse events - 122 malpractice litigation cases audited by two master’s students in the Western Cape and Gauteng private sector with the phase 1 litigated cases. Phase 3: Nursing practice guidelines were developed using the identified adverse events that contributed to adverse events by applying the WHO guidelines and expert validation using the Delphi method. Results: Phase 1: A key finding - Out of 143 cases admitted to labour wards 135 babies had cerebral palsy in this study. Adverse events contributing factors: • Nursing clinical management (87% of adverse events): Assessment; diagnosis; planning; implementation and evaluation including observations; tests; interpretation and documentation; as well as clinical management. • Behavioural problems (12.3% of adverse events): Not following guidelines (91.6%), non-response to clinical manifestations (79.4%), accumulation of omissions (49.8 %), an accumulation of errors (41.8 %), administering and incorrect treatment (16.0 %). • Organisational and administrative factors Lack of knowledge (28.9 %), organisational (23.7%), system failure (21.5, lack of training (19.4 %) %), lack of supervision (17.5 %) and administrative (6.5%). Phase 2: • A total of 325 trial bundles were audited - 122 by two master’s students in private and 203 in public healthcare by a PhD student. Statistical differences showed that 76.0% of patients’ quality of life were affected (p=0.01). • Statistically, it was shown that patients were more likely to die in the private sector (p=0.01) and more likely to be disabled in the public sector (p=0.01). • No statistical difference was identified in clinical management between private and public healthcare sectors (p= 0.27). • The private healthcare sector was more likely to have adverse events, due to organisational and administrative problems. • The public healthcare sector was more likely to have poor resources with a critical shortage of doctors and nurses. Phase 3: • Guidelines were developed by applying the WHO guideline development process and validated, applying the Delphi method. • One hundred and forty-four guidelines were developed, validated and grouped into Clinical Management, Human Behaviour, and Organisational factors. • National and international experts participated in the validation process. Ethical considerations: Approval was obtained from Stellenbosch University (N16/02/027A). Recommendation: The validated guidelines developed in the study should be further tested and implemented in South Africa to contribute to the prevention of the escalating malpractice litigation in nursing practice.
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    A framework to facilitate the appointment of women nurses of colour to leadership positions in hospitals
    (Stellenbosch : Stellenbosch University, 2018-12) Van der Heever, Mariana; Van der Merwe, A. S.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Nursing & Midwifery.
    ENGLISH SUMMARY : Background: Notwithstanding a 79% African majority and the implementation of the Employment Equity Act (EEA) in 1998, the employment equity reports of the Department of Health in the Western Cape and private health sector nationally in South Africa show under-representation of African and Coloured nurses in leadership positions. International and national literature indicate that the appointment of women to leadership positions tends to be influenced by issues related to race, class and gender. The purpose of the study was to develop a framework to facilitate the appointment of women nurses of colour to leadership positions in hospitals. The objectives were to:  Explore the influence of the EEA on the appointment of nurses in leadership positions  Explore the opinions of nurses regarding the influence of race, class and gender on the appointment of nurses in leadership positions  Explore the practices imbedded in the selection processes of nurses in leadership positions as experienced by those involved in the selection processes  Develop a race, class and gender sensitive framework to support nurses in their preparation for leadership positions Design: A concurrent mixed methods design was employed using a quantitative cross-sectional descriptive survey and qualitatively, interpretive phenomenology. The study was based on the philosophy of pragmatism. Population and setting: The study was conducted in the public and private health care sectors in the Western Cape and Gauteng provinces. Quantitative research: The survey was completed by n=573 professional nurses (return rate =83%). The researcher used a structured questionnaire with Likert scale and open-ended questions. Data was analysed with SPSS statistical software, version 24, and the assistance of a statistician. Inferences of the Likert scale questions showed that racial, gender and hierarchical relationships in the workplace had improved since the implementation of the EEA. However, inferences from the open-ended responses revealed the opposite. The findings demonstrated distrust in the promotion systems applied by the public and private health sector. Qualitative research: Interviews were conducted with 5 nurse leaders and another 40 interviews were conducted with people who had participated in the selection processes of nurses appointed to leadership positions: successful and unsuccessful candidates, human resource staff and the chairperson of selection committees e.g. nursing service managers. The researcher observed distinct efforts to accommodate the EEA during formal promotion processes. However, interview questions were sometimes revealed before the time and nepotism did occur. Other findings include stereotyping of the abilities of women of colour resulting in overt and covert racial discrimination. There were also distinct efforts to promote those similar to those who made the appointments e.g. males appointing other males. The influence of class on promotion varied from factors such as professional dress code and sound conduct to being able to converse in eloquent English and physical attractiveness. Findings confirmed the intersecting influence of race, class and gender to marginalize women of colour. Lastly, the framework was developed from the meta-inferences (the integrated inferences from the quantitative and qualitative findings) and focuses on improving the credibility of the promotion process, diversity training, succession-planning and the creation of healthy managerial structures.
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    The development of an instrument to measure adolescent HIV self-management in the context of the Western Cape, South Africa
    (Stellenbosch : Stellenbosch University, 2018-03) Crowley, Talitha; Skinner, Donald; Van der Merwe, Anita S.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Nursing & Midwifery.
    ENGLISH SUMMARY: Introduction and rationale: South Africa is home to 20% of the global human immunodeficiency virus (HIV)-infected adolescent population of 1.8 million. The clinical HIV management of adolescents may be challenging and are compounded by the physical and psychological changes that occur during adolescence. With the advent of antiretroviral treatment access, HIV is managed as a chronic disease and elements such as self-management become an important component of care. Research to date has not focused on adolescent HIV self-management or the measurement thereof. Aim: To develop an instrument to measure adolescent HIV self-management in the context of the Western Cape, South Africa. Methods: A mixed-method explorative sequential design was used. The study setting included selected healthcare facilities in the Cape Metropole of the Western Cape. Adolescents aged 13 to 18 who attended HIV services, their caregivers and healthcare workers/academics experienced in adolescent HIV care and research, were the target population groups. Individual interviews were conducted with six adolescents, six caregivers and six healthcare workers, followed by five focus groups with adolescents. Interpretive phenomenology was used to situate the experiences of participants in their social and cultural context. In the second study phase, items were inductively developed based on the participants’ experiences, the theoretical framework for the study and literature. Thirdly, adolescents and caregivers in focus groups had an opportunity to evaluate whether the developed items resonated with their experiences using cognitive questioning. Following this, a group of experts evaluated the content validity and clarity of each item thereby reducing the initial 65 items to 44 highly relevant items. Participants were purposefully selected for the more qualitative components. Finally, in the fourth phase of the study, in order to establish validity and reliability, a cross-sectional design was used and the self-administered questionnaire was completed by 385 adolescents who were sampled serially from 11 healthcare facilities in the Cape Metropole. Findings: Five components of adolescent HIV self-management were identified though exploratory factor analysis: Believing and knowing; Goals and facilitation; Participation; HIV biomedical management; and Coping and self-regulation. These components were meaningful and could be related to the theoretical framework for the study and the qualitative data. The final Adolescent HIV Self-Management (AdHIVSM) measure consisted of 35 items. The developed AdHIVSM-35 had acceptable reliability and stability. The sub-scales had acceptable reliability, but some of the sub-scales had undesirable stability and questionable convergent validity. Confirmatory factor analysis on the structure developed through exploratory factor analysis indicated a good model-fit that supported its structural validity. The study provides evidence that participants who have higher self-management had better HIV-related and general health outcomes, which supports the criterion- and convergent validity of the identified components. Conclusion: Targeting adolescent HIV self-management in the clinical HIV management setting has the potential to improve adolescents’ adherence to treatment, viral suppression rates and their health-related quality of life.