Automation of Patient Trajectory Management: A deep-learning system for critical care outreach

The application of machine learning models to big data has become ubiquitous, however their successful translation into clinical practice is currently mostly limited to the field of imaging. Despite much interest and promise, there are many complex and interrelated barriers that exist in clinical settings, which must be addressed systematically in advance of wide-spread adoption of these technologies. There is limited evidence of comprehensive efforts to consider not only their raw performance metrics, but also their effective deployment, particularly in terms of the ways in which they are perceived, used and accepted by clinicians. The critical care outreach team at St Vincent’s Public Hospital want to automatically prioritise their workload by predicting in-patient deterioration risk, presented as a watch-list application. This work proposes that the proactive management of in-patients at risk of serious deterioration provides a comprehensive case-study in which to understand clinician readiness to adopt deep-learning technology due to the significant known limitations of existing manual processes. Herein is described the development of a proof of concept application uses as its input the subset of real-time clinical data available in the EMR. This data set has the noteworthy challenge of not including any electronically recorded vital signs data. Despite this, the system meets or exceeds similar benchmark models for predicting in-patient death and unplanned ICU admission, using a recurrent neural network architecture, extended with a novel data-augmentation strategy. This augmentation method has been re-implemented in the public MIMIC-III data set to confirm its generalisability. The method is notable for its applicability to discrete time-series data. Furthermore, it is rooted in knowledge of how data entry is performed within the clinical record and is therefore not restricted in applicability to a single clinical domain, instead having the potential for wide-ranging impact. The system was presented to likely end-users to understand their readiness to adopt it into their workflow, using the Technology Adoption Model. In addition to confirming feasibility of predicting risk from this limited data set, this study investigates clinician readiness to adopt artificial intelligence in the critical care setting. This is done with a two-pronged strategy, addressing technical and clinically-focused research questions in parallel

Registered nurses' experiences in nursing of children post cardiac surgery in an academic hospital in Gauteng

Abstract: Paediatric cardiac surgery is performed on children diagnosed with congenital, acquired heart defects. Post cardiac surgery, these children are admitted to the cardio-thoracic intensive care unit where they are nursed by trained registered nurses and experienced registered nurses. Most of the registered nurses are bridging courses nurses who completed training and education under Regulation (R683). The South African Nursing Council’s (SANC) R683 regulation leads to qualification as registered nurse and is known as bridging course in the South African nursing context. Based on the shortage of registered intensive care nurses in South Africa, the registered bridging course nurses are allowed to work in ICU even though they lack the requisite knowledge and skill. The researcher has observed that these registered nurses manage certain situations inappropriately, and they appear to be dissatisfied and unhappy, and that the atmosphere in the CTICU is often tense. The purpose of the study was to understand the registered nurses’ lived experiences in nursing children post cardiac surgery, and to describe recommendations to support them. A qualitative, exploratory, descriptive, and contextual research design was used. Purposive sampling was utilised. The target population comprised registered nurses who have undergone training in terms of the South African Nursing Council/s Regulation R683. Data collection was conducted by means of in-depth individual phenomenological interviews until data saturation...M.Cur. (Medical and Surgical Nursing Sciences

HIGH PERFORMANCE WORK PRACTICES: INVESTIGATING FOUR PERSPECTIVES ON THEIR EMPLOYEE-LEVEL IMPACTS SIMULTANEOUSLY

ABSTRACT This thesis has examined simultaneously two key debates of the High Performance Work Practices (HPWP) literature. The first debate, entitled ‘the integrationist and isolationist perspectives of HPWP’, looks at two methods of operationalizing HPWP. In the integrationist perspective, innovative Human Resource Management (HRM) practices are presumed to have mutually supportive properties such that when used together in a coherent manner, they may accrue far-reaching benefits for the organization and employees. By contrast, the isolationist perspective argues that individual HRM practices have unique independent properties and produce varying degrees of effects on outcomes. The second debate, entitled ‘the mutual gains versus the critical perspectives of HPWP’, looks at the employee-level implications of adopting HPWP. In the mutual gains perspective, HPWP are thought to promote desirable employee attitudes and well-being together with their beneficial effects on organizational growth and effectiveness. The critical perspective, on the other hand, assumes that the benefits associated with HPWP may be offset by increases in work intensification and the transfer of more work responsibilities to employees. These two debates have been investigated via two empirical studies. The first study was undertaken to examine the tenets of the two HPWP debates without consideration of sector-specific characteristics, whereas the second study was undertaken to highlight the role of sector-specific characteristics in explaining the employee-level implications of HPWP. Together, both studies provide a framework for determining the extent to which HPWP outcomes are generalizable across organizational settings. The results of both studies show that HPWP produce varying independent effects on employee-level outcomes, and work intensification may explain the intermediary processes underlying some of these effects. The results also indicate that HPWP have mutually supportive properties, and produce beneficial integrated influences on employee attitudes and well-being. However, when the independent iv and integrated effects of HPWP were examined simultaneously, the independent effects of HPWP accounted for variance in employee attitudes and well-being over and above the integrated effects of HPWP

Modelling of expert nurses' pressure sore risk assessment skills as an expert system for in-service training

In the nursing literature to date there have been no reported applications of `cognitive simulation' nor of intelligent Computer Assisted Learning. In Chapter 1 of this thesis a critical review of existing nurse education by computer is used to establish a framework within which to explore the possibility of simulation of thinking processes of nurses on computer. One conclusion from this review which is offered concerns the importance of firstly undertaking reliable study of nursing cognition. The crucial issue is that an understanding must be gained of how expert nurses mentally represent their patients in order that a valid model might be constructed on computer. The construction of a valid computer based cognitive model proves to be an undertaking which occupies the remainder of this thesis. The approach has been to gradually raise the specificity of analysis of the knowledge base of expert and proficient nurses while seeking concurrently to evaluate validity of the findings. Reported in Chapter 2, therefore, are the several experimental stages of a knowledge acquisition project which begins the process of constructing this knowledge base. Discussed firstly is the choice of the skill domain to be studied - pressure sore risk assessment. Subsequently, the method of eliciting from nurses top-level and micro-level descriptors of patients is set out. This account of knowledge acquisition ends with scrutiny of the performance of nurse subjects who performed a comprehensive simulated patient assessment task in order that two groups might be established - one Expert and one Proficient with respect to the nursing task. In Chapter 3, an extensive analysis of the data provided by the simulated assessment experiment is undertaken. This analysis, as the most central phase of the project, proceeds by degrees. Hence, the aim is to `explain' progressively more of the measured cognitive behaviour of the Expert nurses while incorporating the most powerful explanations into a developing cognitive model. More specifically, explanations are sought of the role of `higher' cognition, of whether attribute importance is a feature of cognition, of the point at which a decision can be made, and of the process of deciding between competing patient judgements. Interesting findings included several reliable differences which were found to exist between the cognition of subjects deemed to be proficient and those taken as expert. In the final part of this thesis, Chapter 4, a more formal evaluation of the computer based cognitive model which was constructed and predictions made by it was undertaken. The first phase involved analysis in terms of process and product of decision making of the cognitive model in comparison to two alternative models; one derived from Discriminant Function Analysis and the other from Automated Rule Induction. The cognitive model was found to most closely approximate to the process of decision making of the human subjects and also to perform most accurately with a test set of unseen patients. The second phase reports some experimental support for the prediction made by the model that nurses represent their patients around action-related `care concepts' rather than in terms of diagnostic categories based on superficial features. The thesis concludes by offering some general conclusions and recommendations for further research

Effects of maternal mental disorders on mother-infant emotional availability in the perinatal period

Background: Maternal depressive symptoms are recognised as a significant risk factor for disturbances to the mother-infant relationship and child developmental outcomes. Less is known about the effects of specific maternal mental disorders, particularly comorbid or severe mental illness, on the mother-infant relationship. Aims: This dissertation aimed to gather new insights regarding mother-infant interaction quality in the context of maternal mental disorders (Study One and Two) and the assessment of mother-infant interaction quality in research (Study Three) and its application to clinical practice (Study Four). Methods: Empirical (Study One and Two), psychometric (Study Three), and translational (Study Four) research methods were used. Study One (N = 115) and Study Two (N = 127) involved a longitudinal pregnancy cohort of mother-infant dyads with repeated measurement of maternal disorders (major depression, generalised anxiety, bipolar disorder), symptoms (depressive, anxiety), and antidepressant use over the perinatal period, and assessment of mother-infant interaction quality at six months postpartum using the Emotional Availability Scales (EAS). Study Three (N =342) involved a higher-order factor analysis of EAS data followed by multigroup measurement invariance testing comparing a depressive disorder group to a comparison group not meeting diagnostic criteria. Lastly, Study Four (N =329) employed a translational approach using an online, cross-sectional survey and distributed globally to explore the parent-infant assessment practices and preferences of perinatal and infant mental health (PIMH) clinicians. Results: Compared to a comparison group, the risk of emotional unavailability was higher among dyads with lifetime major depression and even higher among dyads with a comorbid perinatal generalised anxiety disorder. Compared to no disorder or major depressive disorder, the risk of emotional unavailability was also higher among dyads with bipolar disorders. Psychometric evaluation of the EAS showed comparison group EAS data best fit a unidimensional factor solution and the EAS to be only partially invariant between a depressed and nondepressed group. The translational study indicated a strong endorsement of parent-infant relationship assessments independent of demographic or service characteristics among PIMH clinicians globally. Regardless of service context and framework, most clinicians endorsed a dyadic focus to assessment as their individual preference. Conclusions. Findings extend existing knowledge regarding parent-infant relationship quality in a mental health context, including assessment practices in research and practice settings and the potential effects of a range of maternal mental disorders on mother-infant emotional availability. Specifically, findings may support the identification of at-risk dyads who may require additional supports or specialised psychological interventions to assist them to improve emotional availability. Ongoing empirical, psychometric, and translational research involving mental health samples are needed to facilitate agreement among researchers and clinicians on optimal measures of parent-infant interaction quality

The Moderating Role of Culture in the Job Demands-Resources Model

During the past few decades, occupational health researchers have examined the effects of work characteristics on job stress and employee wellbeing (Beehr & Franz, 1987; Caulfield, Chang, Dollard, & Elshaug, 2004; Jex, 1998; Jex & Britt, 2014; Schaufeli & Greenglass, 2001; Sparks, Faragher, & Cooper, 2001). With the help of the Job Demands-Resources model (JD-R model; Bakker & Demerouti, 2007; Bakker, Demerouti, & Schaufeli, 2003; Demerouti, Bakker, de Jonge, Janssen, & Schaufeli, 2001; Schaufeli & Bakker, 2004), researchers have been able to examine the impact of jobspecific work characteristics (demands and resources) on employee wellbeing. The work processes outlined in the JD-R model have demonstrated utility in predicting a variety of health-related outcomes in various occupations and settings, and as a result, the model has received considerable support in the literature (e.g., Bakker & Demerouti, 2007; Schaufeli & Taris, 2014; Xanthopoulou, Bakker, Demerouti, & Schaufeli, 2007). However, it is possible that national culture influences occupational-health theories such as the JD-R model. Research exploring the tenets of the model under the lens of national culture has been limited to a few studies and has relied on generic demands and resources (e.g., Brough et al., 2003; Farndale & Murrer, 2015; Liu, Spector, & Shi, 2007). As such, the present research effort proposed to test the basic tenets of the JD-R model under the lens of national culture. Using the framework of Hofstede’s (1980, 2001; Hofstede, Hofstede, & Minkov, 2010) dimensions to define and assess national culture, in this study, I tested whether the demands/burnout (exhaustion and disengagement) and the resources/work engagement relationships differed depending on employees’ national iv culture. To do this, I collected data from nurses in two countries representing different national cultures: Spain and the United States

Role of Adaptive Team Coordination during Cardiopulmonary Resuscitation

Plus de 200 000 patients en Amérique du Nord subissent un arrêt cardiaque à l’hôpital chaque année, mais moins de 25 % des patients survivent jusqu’à leur congé de l’hôpital. Lorsque le coeur aux battements arythmiques d’un patient ne parvient pas à faire circuler efficacement le sang, une équipe de secouristes procèdent à des interventions vitales définies en fonction d’algorithmes de réanimation cardiorespiratoire (RCR). Depuis l’adoption des lignes directrices de l’American Heart Association (AHA) il y a plus de 30 ans, les travaux de recherche ont principalement porté sur l’amélioration des taux de survie grâce à l’efficacité des tâches techniques de RCR. Au cours de la dernière décennie, une plus grande importance a été accordée aux facteurs associés à la performance d’équipe. Outre les facteurs propres au patient, les chances de survie dépendent du délai de traitement et de la qualité de la RCR que vient compliquer l’interaction de multiples intervenants qui tentent d’orchestrer des mesures de secours concurrentes. Ainsi, la coordination et le travail d’équipe inefficaces font partir des plus grands obstacles à une réanimation réussie en équipe. Dans le cadre de la présente thèse, la relation entre les différents mécanismes de coordination et le résultat technique de la RCR, mesurée en temps passif dans deux contextes de recherche empirique de réanimation simulée, a été mise à l’essai. Les résultats laissent croire que si l’action explicite constitue la caractéristique déterminante des mécanismes de coordination utilisés en réanimation cardiaque en équipe, les équipes qui performent le mieux coordonnent leurs activités de manière différente de celles qui performent le moins bien, et qu’il existe un lien important entre les tendances en matière de mécanismes de coordination et la réussite de la RCR, qui change en fonction des exigences de la tâche. Ces résultats combinés permettent d’établir un cadre de coordination proposé pour les soins de réanimation actifs et de proposer des aspects pratiques pour la formation en RCR et une contribution méthodologique aux futurs travaux de recherche.In-hospital cardiac arrest affects over 200,000 patients in North America each year, but less than 25% of patients survive to hospital discharge. When a patient’s arrhythmic heart is unable to effectively circulate blood, a team of rescuers provide lifesaving interventions according to Cardiopulmonary Resuscitation (CPR) rescue algorithms. Since the inception of the American Heart Association (AHA) CPR guidelines over 30 years ago, research pursuits to improve survival rates have primarily focused on the technical tasks such as CPR technique. Over the past decade, there has been increased focus on team performance related to treatment delays and CPR quality, touting ineffective coordination and teamwork as some of the largest obstacles to successful team resuscitation. The objective of this work was to validate a proposed framework outlining the relationship among explicit and implicit coordination mechanisms required for successful CPR performance: minimal interruptions (hands-off ratio), rapid initiation of chest compressions and defibrillation. The framework was tested in two independent studies of simulated adult and pediatric resuscitation of in-hospital cardiac arrest. The results showed that while team performance improved over time, the main Explicit and Implicit coordination type patterns were stable. Instead, small shifts occurred within the Information and Action coordination sub-types. Explicit coordination was dominant throughout all resuscitation scenarios, but only Implicit coordination was associated with better hands-off ratio performance. In both studies, higher performing teams coordinated differently than lower performing teams and there was a significant relationship between the patterns of coordination mechanisms and CPR performance. The combined results are used to refine a proposed coordination framework for acute resuscitation care and propose practical implications for CPR training and methodological contribution for future research

An exploration of the strengths and weaknesses of using text messaging as a tool for self-report data collection in psychological research

Short Message Service (SMS) has immense potential for self-report data collection because it makes use of mobile phones that people already own, and allows researchers to communicate with participants regardless of physical location. Though interest in the possibilities of SMS as a tool for psychological research is slowly growing, to date, there has been no structured investigation of how this potential may be applied in psychological research. The research within this thesis examined the feasibility of using SMS as a tool for self-report psychological research, focussing on its strengths and weaknesses as a research mode. Across fifteen studies, this was investigated using a mixture of literature review, meta-analysis, surveys, and interviews. Participant samples varied from the broad (general population, university students) to specific (the elderly, the deaf). Strengths of SMS as a tool for self-report psychological research included growing interest in research community; positive perceptions of SMS as a research tool amongst potential sample; prompt responses and high response rate; suitability for frequent repeated sampling; and usefulness as a reminder prompt to support other modes of data collection. Weaknesses included a disconnect between stated willingness to participate and actual participation; response incompleteness; unsuitability for infrequent sampling; and some problems with psychometric equivalence in relation to other research modes like online or paper surveys. This was the first structured evaluation of SMS as a tool for self-report data collection in psychological research. Conclusions are limited by somewhat arbitrary design choices (such as the psychological topic within surveys) made in the absence of guiding background literature. Future research can refine these choices and use the logic presented here to guide further investigation into how SMS performs with more varied samples, different psychological topics, and as part of different research designs. This research has shown that while SMS has great potential as a tool for psychological self-report research, it has a number of weaknesses. Identifying these strengths and weaknesses, and some design choices which may mitigate the weaknesses, will open up possibilities for a wide range of future psychological research