Alison Lupton-Smith

Background. Mobilisation of critically ill patients in intensive care units (ICUs) is recognised for its potential to improve patient outcomes. There has been a paradigm shift toward incorporating mobilisation as standard practice in ICUs to mitigate complications associated with immobility. However, implementation remains inconsistent globally, and there is limited evidence regarding practice in South African (SA) ICUs. This study aimed to address this gap by examining mobilisation practices and barriers to mobilisation in a tertiary hospital setting in SA. Objectives. To describe mobilisation practices and examine staff knowledge of, and barriers to, mobilisation in ICUs at a tertiary hospital in SA. Methods. An observational cross-sectional study was conducted across four ICUs. Thirty patient folders were reviewed daily over five days to identify mobilisation opportunities. A self-designed review form incorporating safety criteria was used to assess the suitability of these opportunities. In addition, 26 nurses and 16 physiotherapists completed self-administered questionnaires assessing their knowledge of and perceived barriers to mobilisation. Results. The study included 30 patients, with a mean (standard deviation (SD)) length of stay of 15 (15.56) days. Of 107 identified potential mobility events, 77 (72%) were deemed safe for mobilisation. In-bed activities were more common than out-of-bed activities. Staff demonstrated good knowledge of the benefits of mobilisation but scored lower on safety criteria. Key barriers identified by nurses and physiotherapists included staffing shortages (n=19; 73% and n=15; 94%, respectively), excessive sedation (n=18; 69% and n=8; 50%, respectively) and the need for physician orders to mobilise patients (n=15; 58% and n=2; 13%, respectively). Conclusion. This study highlights conservative mobilisation practices and significant barriers to mobilisation in ICUs at a tertiary hospital. Targeted educational interventions and organisational changes are necessary to enhance mobilisation practices and improve patient outcomes.

Background: A large part of physiotherapy clinical training is situated in the workplace. Learning in an authentic environment is supported by facilitators. Objectives: This study focussed on the perceptions and understanding of physiotherapy students and facilitators while learning on the clinical platform. Method: A qualitative methodology within an interpretivist paradigm was followed using convenience sampling. Results: Physiotherapy students (n = 45) in their fourth and final year of study and clinical facilitators of this student group (n = 13) were invited to participate in a focus group discussion (FGD) for the students (n = 7) and semi-structured interviews for the facilitators (n = 7). An inductive data analysis approach was followed. Three themes were generated: Learning as a Shared, Active Process; Relationships, Role Modelling and Power Dynamics in Clinical Learning; and the Clinical Environment as Both Constraint and Catalyst. Conclusion: Across themes, learning was shaped by how students and facilitators understood and enacted their roles, the degree to which student agency was recognised and supported, and how relational safety and environmental constraints mediated engagement. Implicit and sometimes misaligned expectations between students and facilitators influenced whether learning opportunities were taken up or constrained. Clinical learning emerged as a co-constructed, relational process rather than a unidirectional transfer of knowledge. Clinical Implications: Supporting meaningful learning in the clinical environment requires greater attention to implicit expectations, relational dynamics and the conditions under which student agency can be enacted.

Background: Chronic respiratory diseases (CRDs) are a major global health burden, and pulmonary rehabilitation (PR) is a well-established, evidence-based intervention that improves functional capacity and quality of life for persons affected. Despite this, access to PR is limited globally and within South Africa. Insight into how PR programmes (PRP) are established and sustained in practice may help explain the persistence of this implementation gap. Aim: To explore physiotherapists’ experiences of establishing outpatient PRP in the Cape Metropole. Setting: The study included public and private physiotherapists in the Cape Metropole, Western Cape Province, South Africa. Methods: An exploratory qualitative descriptive design was employed using semi-structured interviews with six physiotherapists who had attempted to establish outpatient PRP. Data were analysed using reflexive thematic analysis, with Social Cognitive Theory informing interpretation of interactions between environmental conditions, clinician agency and programme outcomes. Results: Three interrelated themes were identified. Firstly, practice contexts, including funding structures, referral systems, organisational support and physical resources, shaped the feasibility of PRP. Secondly, clinician agency, expressed through motivation, self-efficacy, advocacy and adaptive capacity, influenced how physiotherapists navigated these contextual conditions. Thirdly, PRP followed divergent trajectories over time, with outcomes more predominantly shaped by how individual physiotherapists interpreted early experiences and feedback rather than by context alone. Conclusion: PRP implementation was shaped by dynamic interactions between contextual conditions and clinician agency. Participants faced similar challenges, however differences in their agency influenced whether PRP were sustained, adapted or remained partial. Strengthening physiotherapists’ self-efficacy, behavioural capability and access to mentorship may support more sustainable PR provision in contexts where services remain limited. Contribution: This study highlights clinician agency as a critical mechanism in PR implementation and suggests that interventions to expand PR services should address both structural barriers and the development of physiotherapists’ adaptive capacity

Objectives: The objectives of this exploratory study were to describe the safety, comfort, and effects of applying a weighted blanket to restrict anterior chest movement on oxygenation, and regional ventilation in clinically stable, nonventilated infants, and children hospitalized with lower respiratory tract infections (LRTIs). Our hypothesis is that the application of a weighted blanket would not adversely affect comfort levels or oxygenation in nonventilated infants and children with LRTIs. Method: A prospective, exploratory interventional pilot study of nonventilated children and infants aged 2 months to 9 years of age admitted to hospital for the management of a LRTI. Comfort and pain scores, vital signs (heart rate [HR], respiratory rate [RR], oxygen saturation, and blood pressure), and electrical impedance tomography (EIT) measurements were captured at baseline, immediately and at 5 min, 10 min, and 30 min after application of the blanket. Results: Thirty children (median interquartile range [IQR] 8.31 months old [2.46–22.27]; 16 [53.30%] males), received the intervention, and were included in the analysis. Just over half of the children recruited were admitted with a clinical diagnosis of pneumonia ( n = 17; 56.70%). No adverse events were recorded during the study intervention. Overall, oxygen saturation increased from median (IQR) 97% (91–100) to 100% (93–100) ( p < 0.001); COMFORT‐B score improved from median (IQR) 13 (6–14) to 11 (6–16) ( p = 0.02) from baseline to 30 min postintervention and there was no significant change in the faces, legs, activity, cry, and consolability (FLACC) pain scale. Conclusion: The application of a weighted blanket in nonventilated infants and children with mild LRTI was well tolerated, with no adverse effects and was associated with improvements in comfort levels and SpO _2.

Background. Traditionally, it was understood that children universally show greater ventilation of the non-dependent lung. Recent studies have questioned the understanding of ventilation distribution patterns in the paediatric population. There are no studies examining the effect of body position in mechanically ventilated infants/children. Objectives. To determine the effect of body position on regional ventilation distribution in mechanically ventilated children. Methods. Thoracic electrical impedance tomography (EIT) measurements were taken in left- and right-side lying, supine and prone positions in mechanically ventilated infants/children. Functional EIT images were produced, and regional relative tidal impedance (ΔZ) in the left, right, ventral and dorsal lung regions was calculated. The proportion of ventilation occurring in large lung regions and regional filling were also calculated. Results. Seventeen children (n=8; 47% male) aged 6 months - 6 years are presented. Many of the children (n=8; 47%) consistently showed greater ventilation in the right lung in both side-lying positions, and in the dorsal lung region (n=6; 35%) in both the supine and prone positions. Regional filling was similar between lung regions in the different body positions. Conclusion. Ventilation distribution in mechanically ventilated infants/children with mild lung disease is variable and similar to that of healthy spontaneously breathing infants/children.

IMPORTANCE AND OBJECTIVES: The aim of this study was to explore peripheral and respiratory muscle structure and strength from unit admission to hospital discharge among ICU patients in a resource-constrained setting. DESIGN: Prospective, observational study. SETTING: Tertiary academic hospital. PARTICIPANTS: Newly intubated critically ill adults admitted to the medical and surgical ICUs and expected to be mechanically ventilated for more than 48 hours were included in the study. MAIN OUTCOMES AND MEASURES: Ultrasonography of the right hemi-diaphragm and quadriceps muscles were taken at admission for 3 consecutive days. Respiratory and peripheral muscle strength were evaluated using the Medical Research Council-Sum Score, dynamometry and maximal inspiratory pressure (MIP) at awakening, ICU discharge and hospital discharge. RESULTS: Forty-five participants were included, with a median (interquartile range) age of 34.5 (24.3–47.4) years and 73% were male. Most of the change in diaphragm thickness was observed on day 3, with 5 (22%) participants showing a decrease of more than 10% from baseline. Minimal changes in rectus femoris cross-sectional area were noted during the first 3 days. Eleven participants (44%) presented with ICU-acquired weakness at awakening, which decreased to 7 (29%) participants at ICU discharge and 5 (24%) participants at hospital discharge. The mean ± sd percentage of predicted quadriceps force was 22.2 ± 5.1 N at hospital discharge. The mean ± sd percentage of predicted MIP scores was 29.6% ± 10.5% at ICU discharge and 29.1% ± 8.6% at hospital discharge. CONCLUSIONS AND RELEVANCE: Patients discharged from the ICU in a resource-constrained setting presented with peripheral and respiratory muscle weakness, with minimal change in muscle structure shown by ultrasonography, despite short ICU stays, low Acute Physiology and Chronic Health Evaluation II scores, and a relatively young age. Future research should explore whether these findings indicate a distinct phenotype of critical illness in such environments.

Background: Feedback is an important part of learning, however, it often does not have the desired effect. Much work has been done exploring students’ engagement with feedback and factors which may impact engagement. Mutual understanding of feedback and feedback practice on the part of the student and educator is essential. Methods: This study explored the perceptions of feedback of final-year physiotherapy students at Stellenbosch University (South Africa). Twelve semi-structured interviews were conducted to generate data. Cultural-historical activity theory was used as an analytic lens in the data analysis. Results: Students understood feedback to be a continuous, bidirectional conversation in which they were actively involved. Students recognised their agency in feedback practice. Despite their understanding, their agency was often undermined by factors such as the environment, context and most notably the perceived positioning and relationships between students and educators. Educators who were perceived as credible and created a safe psychosocial space had a positive influence on the students’ perception of feedback. Conclusions: Students’ perceptions of feedback and their engagement was the product of a complex and dynamic interplay of factors. While students recognise their agency, this may be hindered by relationships and the design of feedback in the curriculum. As educators, one must consider how we contribute to this and enable students to activate and use their agency in feedback practice.

Purpose: Trauma is known as a leading cause of mortality and injury related disability globally. In South Africa (SA) the socioeconomic burden of trauma is magnified as the working age is most affected. The aim of this study was to describe the proportion of major trauma survivors who returned to work (RTW) during a 6-month period post hospital discharge and to identify the factors associated with the RTW outcome. Methods: This was a prospective observational cohort study involving major trauma survivors from a private level 1 trauma centre intensive care unit in SA between January and September 2022. RTW status was assessed using the Employment Questionnaire. Univariate and multivariable Cox proportional hazards regression was used in analysis. Results: Sixty-four of the 86 participants (74.4%) RTW at six months post hospital discharge. RTW had a median time of 16 weeks. After adjusting and backwards analysis, Chelsea Critical Care Physical assessment tool scores (adjusted hazard ratio (AHR), 1.06, 95% CI 1.01–1.10, p = 0.007), and not having applied/received any form of grants (AHR 2.26, 95% CI 1.35–3.77, p = 0.002) were the only factors that were associated with the RTW outcome. Conclusion: The cumulative probability of no RTW was 25.6% among participants after 24 weeks. Higher physical function at ICU discharge and not seeking any form of compensation was associated with a higher probability of RTW. This study has highlighted the complexities of RTW and the socioeconomic burden following major trauma. There is therefore a need for further studies on RTW following major trauma in SA.

Background. Growing evidence is describing the long-term morbidity experienced by critical illness survivors, a major contributing factor being impaired physical function. Consensus is yet to be reached on which physical function measures should be included in this population. This review aimed to describe physical functioning measurement instruments used in longitudinal studies of critical illness survivors, based on the International Classification of Function (ICF). Methods. An electronic database search of EbscoHost, Web of Science and Scopus was conducted from inception to November 2023. Two reviewers independently applied the inclusion and exclusion criteria to titles, abstracts and full text-studies. Extracted data included year of publication; country; participant age; follow-up timeframes and physical measurement instruments used. Instruments were classified according to ICF domains. Results. Eighty studies published between 1995 and November 2023 were included. Forty-four different outcome measures were identified. Most studies (68) included multiple followed-up points and were completed within a year, and few studies (12) follow-up beyond a year. Based on the ICF, 11 (25%) instruments measured impairments and 33 (75%) activity limitations. Muscle power functions were the most frequently measured impairment (65%), utilising manual muscle testing (37.3%). The six-minute walk test (6MWT) was the most frequently used instrument in the activity/participation domain (31.6%). Only one instrument addressed all five the physical activity/participation domains, while the majority focused on mobility domain. Conclusions. Multiple tools are used to report on physical deficits experienced by ICU survivors, either measuring impairments or activity/ participation limitations. Most studies report on physical function within the first year of survival. The heterogeneity and inconsistency over time of instruments used prevents synthesis of data to determine intervention efficacy. The validity, predictive value and sensitivity of the reported measures within ICU survivors needs to be established, only then can intervention studies be designed to measure effectiveness.