enj@nursing.cu.edu.eg
- Editor In Chief:
- Prof. Warda youssef Mohamed
Dean of Faculty of nursing
Cairo University
- Secretary:
- Prof. Nefissa M. Abd El-Kader
Psychiatric Mental Health Nursing
Faculty of nursing
Cairo University
July 2015
enj@nursing.cu.edu.eg
A peer reviewed journal from
national and international
reviewers.
July 2015
enj@nursing.cu.edu.eg
Egyptian Journal of Nursing (EJN)
Egyptian Journal of Nursing (EJN) is dedicated to Faculty of NursingCairo University, Egypt. EJN is a peer-reviewed journal which is an
essential resource for all nurses, as well as providing the best outcomes for
the patients in their care. The Journal focuses on research papers and
professional discussion papers that have a sound scientific, theoretical or
philosophical base. Preference is given to high-quality papers written in a
way that renders them accessible to a wide audience without compromising
at least two researchers expert in the field of the submitted paper. The
editorial purpose of Egyptian Journal of Nursing (EJN) is to disseminate
empirical findings from the highest quality basic and clinical research
studies focused on (a) understanding health and illness experiences of
individuals, families, and communities; (b) estimating the impact of
therapeutic actions on health promotion, disease prevention, comfort during
illness, and (c) nursing systems and nursing resource management.
Review process. Manuscripts are evaluated on the basis that they present
new insights to the investigated topic, are likely to contribute to a research
progress or change in clinical practice. It is understood that all authors listed
on a manuscript have agreed to its submission. The signature of the
corresponding author on the letter of submission signifies that these
conditions
have
been
fulfilled.
Received manuscripts will be first examined by the EJN editors.
Manuscripts with insufficient priority for publication will be rejected
without external evaluation. Incomplete packages or manuscripts not
prepared in the advised style will be sent back to authors for correction. The
manuscripts will be sent to independent experts for scientific evaluation.
Submitted papers will be accepted for publication after a positive opinion of
the independent reviewers.
Types of articles accepted
1- Original articles: Articles which represent in-depth research in
various scientific disciplines.
2- Case reports
July 2015
enj@nursing.cu.edu.eg
3- Review articles: Should normally comprise less than 10,000
words contain an unstructured abstract of 200 words or less, and
includes up-to-date references.
4- Mini Reviews: These are reviews of important and recent topics
that are presented in a concise and well-focused structure. The
number of words is limited to 5,000 .
5- Short Communications: Should be complete and original
manuscripts of significant importance. However, their length
and/or depth do not justify a full-length paper. The total number of
Figures and Tables should not exceed 3. The number of words
should be = 2,500 .
6- Letter to the Editor for comments on recently published articles.
7- Special reports: Papers may be accepted on the basis that they
provide a systematic, critical and up-to-date overview of literature
pertaining to research or clinical topics. Meta-analyses are
considered as reviews. A special attention will be paid to a
teaching value of a review paper.
8- Announcements of forthcoming events (meetings, awards.. etc.).
Preparation of Manuscripts
 Type or print out the manuscript on white A4 paper, with margins of
at least 25mm (1 inch). Use Arial or Times New Roman 12 with
single spacing throughout the MS.
 Type or print on only one side of the paper.
 Please number the lines consecutively, beginning with the title page
 Please do not include more than 6 tables and/or illustrations in the
manuscript of a full length research paper and not more than 2 tables
and/or illustrations in a short communication.
 Please number the pages consecutively, beginning with the title page.
 The article is to be divided into sections with the following headings,
each started on a separate sheet:
Title page
It should contain the following; 1) The title of the article, which should be
concise (not more than 90 characters or 15 words), but specific and
informative, 2) Names of author and coauthors, academic degree, 3)
Affiliation for each author (department, hospital, or academic institution) to
which the work should be attributed, 4) Name and full address and e-mail
address of the author with whom correspondence will be made regarding the
July 2015
enj@nursing.cu.edu.eg
processing of the manuscripts and mailing of reprints, 5) A short running
title of no more than 40 characters to used in the header of the article. Title
should be written in the form of an inverse pyramid.
Abstract & keywords
All manuscript must have a brief abstract of maximum 200-300 words. The
abstract should concisely give the main aspects and features under the
following clearly labeled sections: Objective (or background and purpose),
material and methods, results, and conclusions. 3-6 key words for indexing
should be given on the same page of the abstract. Use time New Roman 10
with single spacing.
Text
Authors should use subheadings to divide the sections of their manuscript:
Introduction, Methods, Results, Discussion, conclusion, recommendation,
and References.
Introduction: State the purpose of the article and summarize the rational for
the study. Give only strictly pertinent reference and do not include data or
conclusions from the work being reported. Significance of the study, aim of
the study and research questions / hypotheses should be written at the end of
the introduction.
Material and Methods: Describe your selection of the design chosen in the
study, subjects (patients or laboratory animals, including controls). Identify
the age, sex, and other important characteristics of the subjects. Inclusion &
exclusion criteria. Describe the setting of the study, identify the methods,
tools, programs, procedures, pilot study and ethical considerations in
sufficient detail to allow other workers to reproduce the results. Describe
statistical methods or analysis with enough detail to enable a knowledgeable
reader to access to the original data to verify the reported results. Specify
any computer programs used.
Results: Present your results in logical sequence in the text, tables, and
illustrations. Do not repeat in the text all the data in the tables or
illustrations. Emphasize or summarize only important observations.
Tables: Each table should be typed signal-spaced on a separate sheet. Use
internal horizontal or vertical lines. Tables should be numbered
consecutively according to the order of their appearance in the text. The
table number is to be followed by a brief informative descriptive title.
July 2015
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Footnotes and explanations are to be typed underneath the table. In addition
explanation for each table should be typed before each one.
Illustrations: Limit the illustrations to those which clarify and reinforce the
text while avoiding illustrations that demonstrate the same features.
Photographs, line drawings, graphs and figures should be of a high artistic
and technical quality. A manuscript can be rejected on the basis of the poor
quality of illustrations. If photographs of people are used, the subjects must
not be identifiable. Illustrations should be submitted unmounted and
untrimmed. Color photographs are accepted with extra charge. Each
illustration should be identified by its number on the back along with the sur
name of the first author and an arrow indicating its upper border.
Discussion: Emphasize the new and important aspects of the study and the
conclusions that follow from them. Relate the observations to other relevant
studies.
Conclusion: It includes the main final conclusion of the study results.
Recommendation: State the most applicable suggestions, recommendation
which related to the study results (3-5 recomm).
Acknowledgements
The source of financial grants and other funding should be acknowledged,
including a frank declaration of the authors' industrial links and affiliations.
The contribution of colleagues or institutions should also be acknowledged.
Thanks to anonymous reviewers are not allowed
Correspondence author name:
- Name of main or first author.
- Department, faculty, university.
- E- mail address.
July 2015
enj@nursing.cu.edu.eg
References
We recommend the use of a tool such as Endnote or Reference Manager for
reference
management
and
formatting.
Endnote
reference
styles
can
be
searched
for
here:
http://www.endnote.com/support/enstyles.asp
Reference Manager Reference styles can be searched for here:
http://www.refman.com/support/rmstyles.asp
The Vancouver system of referencing should be used. In the text, references
should be cited using superscript Arabic numerals e.g. (2-5, 15). In the order
in which they appear. If cited only in tables or figure legends, number them
according to the first identification of the table or figure in the text. In the
reference list, the references should be numbered and listed in order of
appearance in the text.
Cite the names of all authors when there are five or fewer; when more than
six list the first three followed by et al.
Reference to unpublished data and personal communications should not
appear in the list but should be cited in the text only (e.g. Smith A, 2000,
unpublished data; in press).
References should be listed in the following form:
Journal articles
1. Lupton D. Discourse and analysis: a new methodology for understanding
the ideologies of health and illness. Australian Journal of Public Health
1992; 16 : 145-150 .
Online
articles
not
yet
published
in
an
issue
an online article that has not yet been published in an issue (therefore has no
volume, issue or page numbers) can be cited by its Digital Object Identifier
(DOI). The DOI will remain valid and allow an article to be tracked even
after its allocation to an issue.
July 2015
enj@nursing.cu.edu.eg
2. Birks M, Francis K, Chapman Y. Seeking knowledge, discovering
learning: Uncovering the impetus for baccalaureate nursing studies in
Malaysian Borneo. International Journal of Nursing Practice; doi:
10.1111 /j.1440-172 X.2009.01741 .x
Books
3. Dunning T. Care of People with Diabetes: A Manual of Nursing Practice.
Oxford: Blackwell Science, 1994.
Chapters in Books
4. Reid F. Mobility and safer handling. In: McMahon CA, Harding J (eds).
Knowledge to Care: A Handbook for Care Assistants. Oxford: Blackwell
Science, 1994; 53-69.
Electronic Material
5. Center of Disease Control, Taiwanese Ministry of H
July 2015
enj@nursing.cu.edu.eg
Table of Content
N.
1
P.
N.
Peer reviewer
Prof. Nagah Abdou
Prof. of
nursing
Community
health
2
Prof. Dr. Labiba Abd El Kader
Prof. Dr. of medical surgical
nursing & Head of Medical
Surgical Nursing dep.
3
Prof. Nefissa M. Abd El-Kader
Psychiatric
Mental
Health
Nursing
4
Prof. Dr. Labiba Abd El Kader
Prof. Dr. of medical surgical
nursing & Head of Medical
Surgical Nursing dep.
Assist. Prof. Shadia Reyad
Assist. Prof. of Pediatric Health
Nursing
5
6
- Prof. Nagat Saaid Habib
Prof. of Community Health Nirsing
- Assist. Prof. Abeer S. Eswi
Assistant Professor of Maternity
Nursing &Vice Dean of Graduate
Studies and Research
7
Prof. Gehan El samman
Prof. Dr. of Pediatric Health
Nursing &Head of Pediatric
Health Nursing dep.
8
Prof. Afkar Ragab
Prof. of Pediatric Health
Nursing
July 2015
Work-Related Risk Factors and Preventive Measures among Nurses and
Dentists at Faculty of Oral and Dental Medicine
Marwa Mamdouh Shaban*, Nagat Habib **, Shireen Taha ***, Eman M. Seif
El Naser****
* B.SC. Nursing - Faculty of Nursing- Cairo University, Cairo, Egypt, Cairo,
Egypt
** Professor of community health Nursing- Faculty of Nursing- Cairo University,
Cairo, Egypt
*** Professor of dental public health - Faculty of Oral and dental medicine- Cairo
University, Cairo, Egypt
****Lecturer of community health Nursing- Faculty of Nursing- Cairo University,
Cairo, Egypt
Patients Newly Starting Hemodialysis Sessions: Effect of Nursing Guidelines
on Safety Outcomes
Hanan Sobeih Sobeih, Manal Hussein Nasr *Waleed Abd-AL Mohsen
Medical Surgical Nursing-Faculty of Nursing, Ain Shams University* Nephrology
Department-Faculty of Medicine- Ain Shams university.
Stress and Coping Strategies among Nursing Students at Faculty of Nursing,
Cairo University By
Enas Mahrous AbdElAziz, D.N.Sc. and Sayeda Mohamed Mohamed, D.N.Sc.
Psychiatric Mental Health Nursing Department, Faculty of Nursing, Cairo
University
Effect of Nursing Guideline Instructions on the Incidence of Post Cardiac
Catheterization Complications
Sahra Zaki Azer1 ; Nagwa Mohamed Ahmed2 ; Sahar Ali Abd-El mohsen3
1, 2, & 3 Lecturer Adult Nursing Dept., Faculty of Nursing, Assiut University, Egypt.
Nurses ' Knowledge and Practice about Oxygen Therapy to High Risk
Neonates
Mona Khalf Allah 1
Sohier Dabash2,
Hanan Rashad 3
1- Clinical Instructor of Pediatric Nursing, Technical Nursing Institute, Cairo
University.
2- Assist. Prof. of Pediatric Nursing Faculty of Nursing, Cairo University.
3- Assist. Prof. of Pediatric Nursing Faculty of Nursing, Cairo University.
Effect of Health Education Program on the Knowledge Related To Hiv/Aids
among Secondary School Students at Khartoum State
Dr. Duria Abdelraheim Mohammed Ahmed Omer
MBBS. MD. Ain Shams University, Egypt
Associate prof. of pediatrics - Omdurman Islamic University
The Impact Of Massage On Reducing Post-Operative Pain Among Infants In
Zagazig University Hospitals
Amal El- Dakhakhny(1), Tarek Gobran(2), Shimmaa Mansour(1), Asmaa Ahmed
Salem(1).
1- Department of Pediatric Nursing, Faculty of Nursing, Zagazig University,
Egypt.
2- Department of Pediatrics, Faculty of Medicine, Zagazig University, Egypt.
Impact of interventional program on undergraduate nursing students'
perception of worry and comfort in pediatric clinical setting
Shimmaa Mansour Moustafa Mohamed
Lecturer of Pediatric Nursing, Faculty of Nursing, Zagazig University, Egypt.
1
15
30
49
62
84
89
104
enj@nursing.cu.edu.eg
9
10
Prof. Nagah Abdou
Prof. of Community
nursing
health
Prof. Effet El karmalawy
Prof. Dr. of Community health
nursing & Vice Dean of
community
service
environmental development
11
and
Prof. Effet El karmalawy
Prof. Dr. of Community health
nursing & Vice Dean of
community
service
environmental development
12
Assist. Prof.
ElGendy
Shadia
and
Reyad
Assist. Prof. of Pediatric Health
Nursing
13
Prof. Suzan Atya Abd El Sayed
Prof. of
Nursing
14
15
Medical
Prof. Afkar Ragab
Prof. of Pediatric
Nursing
Assist. Prof.
ElGendy
Shadia
Surgical
Health
Reyad
Assist. Prof. of Pediatric Health
Nursing
16
Assis. Prof. Magda Abdel
Hamid
Assist. Prof. of Administration
nursing
July 2015
Osteoporosis health guidelines to prevent its silent progression among male
and female Attending Cairo University Hospital
Gehan M. Ismail*; Enass H. El-Shair*; Heba M. Sharaa**
*Assistant Prof. of Community Health Nursing, ** lecturer of Community Health
Nursing
Faculty of Nursing, Cairo University,
Geriatric Homes Caregivers’ Knowledge and Practices Regarding Physical
and Social Needs of Elderly, Cairo Governorate
Mona Sadek Shenoda*, Gehan Mostafa Ismail ** Naglaa Mahmoud Abdel
Hamid ***
*Prof. Dr. / Community Health Nursing Department, Faculty of Nursing, Cairo
University, Cairo, Egypt
** Assist. Prof. Dr. /Community Health Nursing Department, Faculty of Nursing,
Cairo University, Cairo, Egypt
***B.Sc. Nursing, Cairo University
Community Based Early Detection and Prevention of Visual Problems among
School Children, Cairo Governorate
Dr. Gehan M. Ismail*; Dr. Eman M. Seif El-Nasr**
*Assistant Prof. of Community Health Nursing; **Lecturer of Community Health
Nursing, Faculty of Nursing, Cairo University,
115
Effect Of Postoperative Immobility On Children With Musculoskeletal
Disorders
*Samar Sobhi Abd Alkhair,** Afkar Ragab Mohammed,*** Sanaa Ahmed
Mahmoud*** Amr Said Arafa
* Clinical Instructor of Pediatric Nursing, Faculty of Nursing, Cairo University** Professor of Pediatric Nursing, Faculty of Nursing, Cairo University*** Lecturer of Pediatric Nursing, Faculty of Nursing, Cairo University****Lecturer of Orthopedics, Faculty of Medicine, Cairo
Burn patients’ Knowledge Regarding Rehabilitation
*Shimaa M. Farghaly, **Dr. Manal M. Mostafa, ***Dr. Yasmin A.El Fouly.
*Clinical Instructor, Medical Surgical Nursing, Faculty of Nursing Cairo
University, Egypt. **Professor of Medical Surgical Nursing, vice dean of
community affairs and environmental services, Faculty of Nursing Cairo
University, Egypt.*** Professor Medical Surgical Nursing, Faculty of Nursing
Cairo University, Egypt.
Effect of Phototherapy on Accuracy of Measuring Transcutaneous Bilirubin
(Tcb) Level in the Neonates with Hyperbilirubinemia
*Samar
Mahmoud
El-Hadary,
**
SoheirAbdelhamidDabash,
***
ShadiaRiadElGendy.
* Clinical Instructor of Pediatric Nursing, Faculty of Nursing, Cairo University.
** Assistant Professor of Pediatric Nursing, Faculty of Nursing, Cairo University.
*** Assistant Professor of Pediatric Nursing, Faculty of Nursing, Cairo University.
ASSESSMENT OF RISK FACTORS CONTRIBUTING TO ACCIDENTAL
POISONING AMONG CHILDREN LESS THAN SIX YEARS
Osama Mohamed Elsayed 1*, Gehan Ahmed Elsamman 2, Mahmoud Mohamed
Amr 3, Hewida Ahmed Hussein 4.
Demonstrator of Pediatric Nursing, Faculty of Nursing, Cairo University.
Professor of Pediatric Nursing, Faculty of Nursing, Cairo University.
Prof. of Occupational Medicine, Faculty of Medicine, Cairo University.
Assistant Professor of Pediatric Nursing, Faculty of Nursing, Cairo University.
Work Environment: the Quality and Risk Outcomes for Both Nurses and
Patients
Nadia Mohamed EL-Sayed, Lecturer of Nursing Administration, Faculty of
Nursing, Suez- Canal University
171
140
151
187
203
218
234
enj@nursing.cu.edu.eg
17
Prof. Yosria Ahmed El sayed
Prof. of Maternity Nursing
18
Assis. Prof. Hanaa El feky
Assis. Prof of Critical Care and
Emergency Nursing & Head of
Critical Care and Emergency
Nursing dep.
19
Prof. Mona Sadik
Prof. of
nursing
20
Community
health
Assist. Prof. Abeer S. Eswi
Assistant
Professor
of
Maternity Nursing &Vice Dean
of Graduate Studies and
Research
21
Prof. Manal Saied Ismail
Prof. of Critical Care and
Emergency Nursing & Vice
Dean of educational and
students Affairs
22
Assis. Prof. Hanaa El feky
Assis. Prof of Critical Care and
Emergency Nursing & Head of
Critical Care and Emergency
Nursing dep.
23
Prof. Suzan Atya Abd El Sayed
Prof. of
Nursing
Medical
July 2015
Surgical
Association between Menstrual Disorders, Body Mass Index and Physical
Activities among Female Adolescents
*Dr. Abeer Eswi BSN, MSN, PhD and **Dr. Hanan Fahmy BSN, MSN, PhD
Assistant Prof. of Maternity Nursing
Faculty of Nursing, Cairo University
Impact of a Nursing Educational Program about Early Detection and
Management of Cardiac Arrhythmias on Critical Care Nurses’ Knowledge
and Practices
Gehan A. Younis 1 and Safaa E. Sayed Ahmed 2
Lecturers of Critical Care Nursing,
Faculty of Nursing, Tanta University, Egypt
A Pilot study on infection control knowledge and practice in
selected
Governorates in Egypt
MahaMoussa
Mohamed
Moussa(1),
Naglaa
Ibrahim
Mohamed(2),EmanShokryAbdallh(3)
*Corresponding Address mahamoussa10@yahoo.com
(1,2 ) Lecturers Department of Community Health Nursing, Faculty Of Nursing ,
Port Said University ,Egypt (3) Professor of Community Health Nursing and
Geriatric Nursing ,Faculty of Nursing ,Zagazig University, Egyp
Effect of Uterotonic Drugs (Misoprostol versus Methyl-ergometrine and
Oxytocin) for The Prevention of Primary Atonic Postpartum Haemorrhage
Hala Abd El fttah Ali1, Sabah Ramadan Hussein Ahmed2 and Magdy H. A.
Kolaib3
1 Lecturer of Women's Health &Obstetric Nursing, Faculty of Nursing, Kafr El
Sheikh University
2 Lecturer of Maternal & Newborn Health Nursing, Faculty of Nursing, Helwan
University
3Professor of Obstetrics & Gynecology, Faculty of Medicine, Ain Shams
University
Nutritional Status Of Critically Ill Patients Receiving Enteral Nutrition At
Minia University Hospital: Nurses Knowledge And Practices.
Mohamed Mamdouh Yehia 1 *, Warda Youssef Mohammed Morsy2, Hanaa Ali
Ahmed Elfeky3,
1. Demonstrator of Critical care & emergency Nursing, Faculty of Nursing Minia
University.
2. Professor of Critical care and emergency Nursing, Faculty of Nursing Cairo
University.
3. Assistant Professor of Critical care & emergency Nursing, Faculty of Nursing
Cairo University.
Relationship between the development of Sepsis, Systemic Inflammatory
Response Syndrome and Body Mass Index among Adult Trauma Patients at
University Hospital in Cairo
Mohamed Hendawy Mousa1*, Warda Youssef Mohamed Morsy2,
YousriaAbd El-Salam Seloma3, Ibrahim Mohamed Attia4,
Clinical Instructor of Critical Care and Emergency Nursing, Faculty of Nursing,
Cairo University
Prof. of Critical care and Emergency Nursing, Dean of the Faculty of
Nursing,Cairo University
Lecturer of Critical Care and Emergency Nursing, Faculty of Nursing, Cairo
University
Lecturer of Critical Care Medicine Faculty of Medicine, Cairo University
Internet Versus Library Book as a Source of Academic Information among
Nursing Students
AmouraSolimanBehairy
Medical-Surgical Nursing Department, Faculty of Nursing,
252
267
295
308
324
339
355
enj@nursing.cu.edu.eg
24
Assistant Prof. Hanan Fahmy
Assistant Prof. of Maternity
Nursing
July 2015
Menofia University, Egypt;Unaizah Collage of Medicine and Medical Sciences,
Qassim University, KSA
Dalia Salah El-Deen El-Sedawy
Medical-Surgical Nursing Department, Faculty of Nursing
Cairo University, Egypt
Adolescent Girls: Assessment of Biological Factors
Tereza Khalifa1, Prof. Ragaa Ali Mohamed2, Assist. Prof. Gehan Ebrahim3
1 (Maternal& Newborn Health Nursing, Faculty of Applied Medical Science /
October 6 University, Egypt)
2 (Maternal& Newborn Health Nursing, Faculty of Nursing / Cairo University,
Egypt)
3(Maternal& Newborn Health Nursing, Faculty of Nursing / Cairo University,
Egypt)
369
Work-Related Risk Factors and Preventive.
enj@nursing.cu.edu.eg
Work-Related Risk Factors and Preventive Measures among Nurses and Dentists at
Faculty of Oral and Dental Medicine
Marwa Mamdouh Shaban*, Nagat Habib **, Shireen Taha ***, Eman M. Seif El
Naser****
* B.SC. Nursing - Faculty of Nursing- Cairo University, Cairo, Egypt, Cairo, Egypt
** Professor of community health Nursing- Faculty of Nursing- Cairo University, Cairo,
Egypt
*** Professor of dental public health - Faculty of Oral and dental medicine- Cairo
University, Cairo, Egypt
****Lecturer of community health Nursing- Faculty of Nursing- Cairo University, Cairo,
Egypt
Abstract
Background: Dental nurses and dentists are constantly exposed to a number of specific work-related health
risk factors which develop and intensify with years. Awareness regarding these work-related health risk factors
and implementation of preventive health care measures can provide a safe work environment for all dental
nurses and dentists. Study aim was to assess the work-related health risk factors among dental nurses and
dentists and preventive health care measures applied among dental nurses and dentists. A descriptive research
design was utilized in this study. Setting of the study was conducted at the dental clinics at faculty of oral and
dental medicine, Al-Kasr AlAiny Hospital. Subjects consisted of 50 dental nurses and 150 dentists who
fulfilled the inclusion criteria of the study. Tools: two tools were used for data collection and developed by the
investigator. A) First tool; Dentistry related health risk factors questionnaire and B) Second tool; structured
observational checklist. Results revealed that the most common work risk factors prevailing among dental
nurses were emotional exhaustion (82%), low back pain (76%) and latex allergy (62%) and the most common
work risk factors prevailing among dentists were percutaneous exposure incidents ‖PEI‖ (100%), emotional
exhaustion (100%) and low back pain (93.3%). Also, a highly statistically significant positive difference
(t=7.148, p=0.000) was found between incidence of low back pain among dental nurses and mechanical
preventive measures. A statistically significant negative difference (t=-2.550 , p=0.012) was found between
incidence of shoulder pain among dentists and mechanical preventive measures. Conclusion The studied
dental nurses and dentists exposed to many work-related health risk factors as latex allergy, percutaneous
exposure incidents, low back pain and emotional exhaustion related to inappropriate application of preventive
health care measures. Recommendation: 1- Raise awareness of dental nurses and dentists about work-related
health risk factors. 2- Design and implement health education program for preventive health care measures.
Key words: Work-related risk factors, Preventive Measures, Nurses, and Dentists.
factors include eye injuries occurring
from projectiles, cuts from sharp
instruments, or puncture wounds from
needles or other sharps instruments.
Such injuries can result in the
transmission of serious infectious
diseases to the dental nurses and dentists.
Also harmful radiation like Non-ionizing
radiation (visible and UV light) and
ionizing radiation (X-rays) can cause
damage to various body cells. Noise and
vibration from the hand piece can lead to
hearing problems (Mehta, Gupta, &
Upadhyaya 2012 ).
INTRODUCTION
In carrying out their professional
work, dental nurses and dentists are
exposed to a number of work-related
health risk factors. These factors cause
the appearance of various ailments
specific to the profession, which develop
and intensify with years. In many cases
they result in diseases and disease
complexes, some of which are regarded
as work-related illnesses. Theses health
risk factors categorized as physical,
mechanical, chemical, biological and
psychological. Physical health risk
1
July 2015
Work-Related Risk Factors and Preventive.
enj@nursing.cu.edu.eg
Mechanical risk factors like wrist ache,
lower backache, and neck ache can occur
due to the need to work in specific
working positions using a continuous
repetitive motion. Chemical risk factors
can be Inorganic (mercury toxicity),
organic (solvents, resins, gases), caustic
(formaldehyde, hydrogen peroxide),
toxicity from anesthetic gases (Nitrous
oxide) and latex glove allergy (contact
dermatitis) (Kedjarune, Leggat, & Smith
2010). Dental nurses and dentists are
exposed to biological risk factors as a
result of direct or indirect contact with
traumatized tissues, saliva and blood on
a daily basis. So, dental nurses and
dentists are at risk of exposure to
Hepatitis B, C and HIV (human immune
deficiency virus) and other types of
communicable infections. As well,
psychological problems can arise due to
stress/excess work load, lack of job
satisfaction/insecurity,
depression,
depersonalization
and
emotional
exhaustion (Fasunloro & Owotade
2012).
The preventive health care
measures is important in the practice of
dentistry because dental nurses and
dentists are exposed to a wide variety of
health risk factors include physical,
mechanical, chemical, biological and
psychological.
The
international
literature focuses mostly on infection
control and proper handling of
potentially infected materials to prevent
the transmission of microorganisms that
may include hepatitis B virus (HBV),
hepatitis C virus (HCV), and human
immunodeficiency virus (HIV). Also
there is importance for the dental nurses
and dentists to apply preventive health
care measures to protect themselves
against the risk of radiation, occurrence
of eye injury, skin penetrating injury
with a sharp instrument, the risks of the
chemical disinfectants and how to
ergonomically use the instruments and
what are the measures used to reduce the
work related stress or tension such as
effective time management for the work
demands and the workloads (CDC
2010).
Significance of the Study
Many studies clarified that dental
nurses and dentists complained from
frequent health problems than other
professional medical personnel. Dental
nurses, as well as the dentists were
constantly exposed to a number of
specific work-related health risk factors
like stressful situations, latex allergy,
allergic reactions due to various dental
materials, exposure to radiation (ionizing
and
non-ionizing),
percutaneous
exposure incidents (PEI) as well as
factors leading to the musculoskeletal
system diseases and diseases of the
peripheral nervous system. Knowledge
regarding these work-related health risk
factors and implementation of preventive
measures can provide a safe working
environment for all the dental nurses and
dentists (Brar & Karar 2011 ).
Therefore, the aim of this study
was to assess work-related health
risk factors and the application of
preventive health care measures
among dental nurses and dentists.
Research Questions
To achieve the aim of the study
the following research questions
were formulated:
(1)
What is the work-related
health risk factors prevailing among
dental nurses and dentists?
(2)
What are the preventive
health care measures applied by dental
nurses and dentists?
2
July 2015
Work-Related Risk Factors and Preventive.
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work training and safe environment. (c)
Workplace health risk factors found
among dental nurses and dentists as latex
allergy, eye injury, and low back
pain…….etc.
II:
Structured
observational checklist. It was used to
assess the preventive health care
measures applied by dental nurses and
dentists in dental clinics regarding workrelated health hazards as biological,
chemical, physical, mechanical and
psychological preventive health care
measures. To score the checklist, a score
of 1 was given to each done correct
practice and a score of zero was given to
each incorrect or not done practice. The
total score of practice reached 44 scores
for dental nurses and 50 scores for
dentists. The differences in the total
scores aroused from exclusion of not
applicable items either for nurses or
dentists. The total score of observed
practice was classified into three levels
as: Good, when score 90% or more of
the total score. Satisfactory, when scores
was 75% to less than 90% of total score.
Unsatisfactory, as when score was less
than 75% of total score.
Procedure
The potential subjects were
approached and interviewed at that time,
the purposed nature of the study were
explained. The questionnaire was
completed by dental nurse and dentists
in the presence of the investigator in the
dental clinic. Practice of dental nurses
and dentists was observed by the
investigator regarding the application of
preventive health care measures. The
time spent to fill the questionnaire by
each dental nurse or dentist ranged
between 10 to 15 minutes. The time
spent to fill the observational checklist
after two times of visiting the clinic per
week during six months.
MATERIALS AND METHODS
Research Design
A descriptive research design
was adopted in this research.
Subject
A convenient sample of dental
nurses and dentists at faculty of oral and
dental medicine at Cairo University
constituted the subjects of the study. The
total sample reached 50 dental nurses
and 150 dentists who were willing to
participate in the study as well as
fulfilling the inclusion criterion. This
criterion was the age from 20 to 40 years
old to exclude the changes resulting
from aging process. The exclusion
criteria were being pregnant, or
complaining from chronic diseases.
Setting
The study was conducted in the
dental clinics at faculty of oral and
dental medicine Cairo University,
including the three buildings. The total
number of the clinics were twenty two,
distributed on three buildings, the first
building provide the care for free and
include eleven out-patient clinics with all
specialties for the adult dental patients,
the second building provide paid care
and include seven out-patient clinics
with different specialties for the adult
dental patients and the third building
include four out-patient clinics and
provide free care for the pediatric dental
patients.
Tools
Data were collected using the
following tools (structured by the
investigator).I: Dentistry related health
risk factors questionnaire. It included
three parts; (a) Socio-demographic
characteristics: as age, gender, marital
status, education and years of
experience. (b) Services rendered for
dental nurses and dentists to prevent
these risk factors as: medical check-up,
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measures applied by dental nurses and
dentists.4) Correlation between workrelated risk factors and applied
preventive measures.
Part
I:
Socio-demographic
characteristics of dental nurses and
dentists: Regarding socio-demographic
characteristics of studied dental nurses,
100% of dental nurses were females
with a mean age of 31 years ± 5.28,
90% of dental nurses had secondary
school nursing education and 62% of
them were married. The highest
percentage of dental nurses 60% had less
than six years experience with a mean of
2.4 years±0.95. Regarding sociodemographic characteristics of studied
dentists, 68.8% of dentists were females
with a mean age of 28.18 years ± 2.51.
Fifty six percent of dentists had master
degree and 54% of them were married.
Sixty two percent of dentists had less
than six years experience with a mean of
2.3 years±0.76.
Part II: Work-related health risk
factors prevailing among dental
nurses and dentists (Tables 1&2).
Regarding health risk factors among
studied dental nurses, 82% of dental
nurses complained from emotional
exhaustion while non of dental nurses or
dentists complained from hepatitis B, C
nor mercury toxicity as indicated in
table(1).
All of dentists 100%
complained from percutaneous exposure
incidents.
Part III: Preventive health care measures
applied by dental nurses and dentists
(Tables 3&4).
Regarding preventive
measures applied by studied dental nurses,
53.6% of dental nurses applied biological
preventive measures, and 66.6% of dental
nurses applied chemical preventive
measures and 50% of dental nurses applied
physical preventive measures while only
25% of them applied mechanical preventive
Pilot Study
It was carried out 10% of dental
nurses and dentists to test the
applicability and clarity of the tools and
to determine the needed time for
application of the study tool. The
necessary modifications were done on
the tools based on the pilot study. Dental
nurses and dentists participated in the
pilot study were excluded from the study
sample.
Ethical Consideration
A written ethical approval was
obtained from the research ethical
committee of scientific research at the
Faculty of Nursing, Cairo-University. In
addition, an official permission to
conduct the proposed study was obtained
from the Vice Dean of the post graduates
and research studies at Faculty of
Nursing and an official permission was
obtained from the college council of the
faculty of oral and dental medicine. A
written formal consent was obtained
from the dental nurses and dentists after
explaining to them the aim of the study,
its benefits and risks, duration of the
study and the data collection tools.
Statistical Analysis
On completion of data collection,
data were tabulated and analyzed using
statistical package for social sciences
(SPSS) program version 20. Descriptive
and inferential statistics were performed
such as mean and standard deviation;
frequency; percentage and correlation
coefficient. Probability (p-value) less
than 0.05 was considered significant and
less than 0.001 was considered as highly
significant.
Results: Findings is presented in four
parts:
1)
Socio-demographic
characteristics data of dental nurses and
dentists.2) Work-related health risk
factors prevailing among dental nurses
and dentists.3) Preventive health care
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measures. Also, 43.3% of dental nurses
applied psychological preventive measures.
Regarding preventive measures applied by
studied dentists, 76.6% of dentists applied
biological and chemical preventive
measures while 50% of dentists applied
physical preventive measures. Only 33.4%
of dentists applied mechanical preventive
measures and 40% of dentists applied
psychological preventive measures.
Part IV: The relations between workrelated health risk factors and preventive
health care measures among dental
nurses and dentists (Tables 5&6).
Table (5) indicates that, a highly
statistically significance positive correlation
(t=7.148 , p=0.000) was found between
incidence of low back pain among dental
nurses
and
mechanical
preventive
measures, and table (6) reveals that there is
a
statistically
significant
negative
correlation (t=-2.55, p=0.012) was found
between incidence of shoulder pain among
dentists and mechanical preventive
measures.
Table 1: Work-related health risk factors among studied dental nurses (n=50 ).
Work risk factors
Biological health risk factors:
Hepatitis ―B‖
Hepatitis ―C‖
Chemical health risk factors:
Latex allergy
Mercury toxicity
Physical health risk factors:
Eye Injury
Percutaneous Exposure Incidents ―PEI‖
Hearing difficulties
Mechanical health risk factors:
Low back pain
Neck pain
Wrist pain
Shoulder pain
Psychological health risk factors:
Emotional Exhaustion
Depersonalization
Depression
Responses are not mutually exclusive.
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July 2015
Number
%
0
0
0
0
31
0
62
0
20
50
6
40
33.3
12
38
25
15
20
76
50
30
40
41
14
14
82
28
28
Work-Related Risk Factors and Preventive.
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Table 2: Work-related health risk factors among studied dentists (n=150 ).
Work risk factors
Biological health risk factors:
Hepatitis ―B‖
Hepatitis ―C‖
Chemical health risk factors:
Latex allergy
Mercury toxicity
Physical health risk factors:
Eye Injury
Percutaneous Exposure Incidents ―PEI‖
Hearing difficulties
Mechanical health risk factors:
Low back pain
Neck pain
Wrist pain
Shoulder pain
Psychological health risk factors:
Emotional Exhaustion
Depersonalization
Depression
Responses are not mutually exclusive.
6
July 2015
Number
%
0
0
0
0
80
0
53
0
103
150
28
68.7
100
18.7
140
130
104
123
93.3
86.7
69.3
82
50
150
81
33.3
100
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Work-Related Risk Factors and Preventive.
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Table (3): Observed practice of dental nurses in application of preventive measures
(n=50 ).
Preventive health care measures
Biological preventive measures:
Hand washing
Using of personal protective
equipment as:
Wearing powdered gloves
Wearing mask
Wearing eye protector
Wearing protective clothes
Total
Chemical preventive measures:
Working in good ventilated spaces
Wearing of hypoallergenic gloves
Stored mercury in tightly and sealed
containers
Total
Physical preventive measures:
Use of sharp containers
No recapping of needles
Proper disposal of waste materials
Wearing of aprons for ionizing
radiation
Total
Mechanical preventive measures:
Changing position frequently
Reaching instrument easily
Total
Psychological preventive measures:
Modification of environment
Plan ahead for emergency
Appreciated work from supervisors
Total
Done
Number
14
7
July 2015
%
28
Not Done
Number
%
36
72
50
20
0
50
26.8
100
40
0
100
53.6
0
30
50
0
23.2
0
60
100
0
46.4
50
0
100
0
0
50
0
100
50
33.4
100
66.6
0
16.6
0
33.4
50
0
50
100
0
100
0
50
0
0
100
0
0
25
0
50
50
25
100
50
25
0
12.5
50
0
25
25
50
37.5
50
100
75
15
25
25
21.6
30
50
50
43.4
35
25
25
28.4
70
50
50
56.6
Work-Related Risk Factors and Preventive.
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Table (4): Observed practice of dentists in application of preventive measures
(n=150 ).
Preventive health care measures
Biological preventive measures:
Hand washing
Using of personal protective
equipment as:
Wearing powdered gloves
Wearing mask
Wearing eye protector
Wearing protective clothes
Total
Chemical preventive measures:
Working in good ventilated spaces
Wearing of hypoallergenic gloves
Stored mercury in tightly and sealed
containers
Total
Physical preventive measures:
Use of sharp containers
No recapping of needles
Proper disposal of waste materials
Wearing of aprons for ionizing
radiation
Total
Mechanical preventive measures:
Use ergonomically designed chairs
Use magnification devices
Use automatic and ultrasonic
instrument
Total
Psychological preventive measures:
Modification of environment
Plan ahead for emergency
Appreciated work from supervisors
Total
Done
Number
%
130
86.6
8
July 2015
Not Done
Number
%
20
13.3
150
130
15
150
115
100
86.6
10
100
76.6
0
20
135
0
35
0
13.3
90
0
23.4
150
45
100
30
0
105
0
70
150
115
100
76.6
0
35
0
23.4
150
0
150
100
0
100
0
150
0
0
100
0
0
75
0
50
50
75
100
50
0
0
0
0
150
150
100
100
150
50
100
33.4
0
100
0
66.6
15
150
15
60
10
100
10
40
135
0
135
90
90
0
90
60
Work-Related Risk Factors and Preventive.
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Table (5): Correlation between mechanical work related health risk factors and
applied mechanical preventive measures among dental nurses (n=50 ).
Mechanical health risk factors Mechanical preventive measures
low back pain
t= 7.148
p=0.000 **
Neck pain
t= 0.579
p= 0.565
Wrist pain
t= 0.620
p=0.538
Shoulder pain
t= 0.652
p=0.518
** Correlation is highly significant at the level of ˂ 0.01
Table (6): Correlation between mechanical work related health risk factors and
applied mechanical preventive measures among dentists (n=150 ).
Mechanical health risk factors Mechanical preventive measures
low back pain
t= -0.543
p=0.588
Neck pain
t= - 1.262
p= 0.209
Wrist pain
t= -0.981
p=0.328
Shoulder pain
t= -2.550
p=0.012 *
* Correlation is significant at the level of ˂ 0.05
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complained from any of blood borne
diseases as hepatitis B, or hepatitis C and
HIV and this may be related to proper
application of biological preventive
measures by studied dentists as they
were wearing latex gloves, wore of
protective clothes and using sharp
containers and proper disposal of waste
materials. Also the most of dentists were
immunized against hepatitis B. The
results of this study agreed with
(Ammon et al 2010 ) who studied 215
dentists and 108 dental nurses in Berlin
and found that the minority of dentists
had serological evidence of previous
HBV and HCV infection, also more than
two thirds of dentists immunized against
hepatitis B.
Regarding to chemical workrelated health risk factors prevailing
among dental nurses, results of this
study revealed that slightly less than two
thirds of dental nurses complained from
latex allergy and that all dental nurses
wore powdered latex gloves, and
depending on extensive number of
literature reviews that powdered latex
gloves is considered the major cause for
latex allergy. Also results of this study
revealed that, no one of dental nurses
complained from mercury toxicity and
that may be related to proper application
of chemical preventive measures by
studied dental nurses as appropriate use
and storage of mercury in tightly closed
and sealed containers, use of high power
suction and work in good ventilated
clinic.
Regarding to chemical workrelated health risk factors prevailing
among dentists, results of this study
revealed that, more than half of dentists
complained from latex allergy and that
all of them wore powdered latex gloves,
and depending on extensive number of
literature reviews that powdered latex
Discussion:
Dental nurses and dentists are
constantly exposed to specific number of
work-related health risk factors such as:
stressful
situation,
latex
allergy,
percutaneous exposure incidents (PEI) as
well as factors that leading to
musculoskeletal disorders. Awareness
regarding these work-related health risk
factors and implementation of preventive
health care measures can provide a safe
work environment for all dental nurses
and dentists (Brar & Karar 2011). So
this study aims at assessing the workrelated health risk factors among dental
nurses and dentists and to assess the
preventive health care measures applied
among dental nurses and dentists.
Regarding to biological workrelated health risk factors prevailing
among dental nurses, results of this
study revealed that no one of the studied
dental nurses complained from any of
blood borne diseases as hepatitis B, or
hepatitis C and HIV (human immune
deficiency) and related to proper
application of biological preventive
measures by studied dental nurses as
they were wearing of latex gloves,
protective clothes and using of sharp
containers and proper disposal of waste
materials. Also majority of dental nurses
immunized against hepatitis B. The
results of this study agreed with
(Ammon et al 2010 ) who studied 215
dentists and 108 dental nurses in Berlin
and found that only one of studied dental
nurse had serological evidence of
previous HBV and no one of dental
nurses had serological evidence of HCV
infection, also two thirds of dental nurses
were immunized against hepatitis B.
Regarding to biological workrelated health risk factors prevailing
among dentists, results of this study
revealed that, no one of studied dentists
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gloves are considered the major cause
for latex allergy. The results agreed with
a study done by (Al-Ali, Khalid &
Raghad 2012) in Emirates among 844
dentists and found that one fifth of
dentists complained from latex allergy.
Concerning to physical workrelated health risk factors that prevailing
among dental nurses, results of this
study revealed that, more than one third
of dental nurses complained from eye
injury that may be related to improper
application of physical preventive
measures by studied dental nurses as no
one of dental nurses wore eye goggle
and according to extensive number of
literature reviews the use of eye goggle
was an appropriate method for protection
from eye injury. This result contradicted
the study done by (Albdour & Othman
2010) in Jordan which is indicated that
minority of dental nurses complained
from eye injury. The result of the study
reveals that one third of dental nurses
complained from percutaneous exposure
incident and that included complain from
needle stick injury as a result of
recapping of anesthesia needles after
injection to patients and unavailability of
needle stick protector in dental clinics
and injury from contaminated sharp
instrument when dental nurses cleaning
it. This result was in agreement with a
study done by (British Association of
Dental Nurses (BADN), 2014 ) which
reported that more than half of dental
nurses complained from percutaneous
exposure incident.
Concerning to physical workrelated health risk factors that prevailing
among dentists, results of this study
showed that more than two third of
dentists complained from eye injury
which may be due to the most of studied
dentists didn‘t wear eye goggle during
their contact with patients. This result
supported by the study done by (Albdour
& Othman 2010) in Jordan which is
indicated that two thirds of dentists
complained from eye injury while the
result of this study is contradicted the
study done by (Mehta, Gupta &
Upadhyaya 2012) who found that the
minority of dentists complained from
eye injury.
Also results of this study
revealed that all of dentists complained
from percutaneous exposure incident
from needle stick injury as a result of
recapping of anesthesia needles after
injection to patients and unavailability of
needle stick protector in dental clinics
and injury from contaminated sharp
instrument. The results was supported by
(Mehta, Gupta & Upadhyaya 2012) who
found that majority of dentists
complained from percutaneous exposure
incident. Also, this result is in the same
line with a study done by (Shimoji et al
2010) on a single educational center in
Japan they reported that more than half
of dentists complained from injury from
sharps. Regarding to hearing difficulties
prevailing among studied dentists,
results of this study indicated that a
minority of dentists complained from
hearing difficulties. In agreement with
the results of this study, a study done by
(Al-Ali, Khalid & Raghad 2012 ) in
Emirates among 844 dentists and found
that the minority of dentists complained
from hearing problems.
Regarding mechanical workrelated health risk factors, results of this
study revealed that most of dentists
complained from low back pain. Also
the majority of dentists complained from
neck pain and shoulder pain while more
than two third of dentists complained
from wrist pain. This high prevalence of
these mechanical work-related risk
factors among dentists may be related to
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the following causes, awkward posture
followed by improper workplace
ergonomics, prolonged static posture,
prolonged sitting in poorly designed
chairs and repetitive movements. The
results was supported by (Al-Ali, Khalid
& Raghad 2012 ) in Emirates among 844
dentists and found that, more than two
thirds of dentists complained from
musculoskeletal problems and it was the
most common occupational problem
among studied dentists. Also, (Mehta,
Gupta & Upadhyaya 2012 ) found that
more than one third of dentists
complained
from
musculoskeletal
problems.
Related to psychological workrelated health risk factors, results of this
study revealed that, all of dentists
complained from emotional exhaustion
and more than half of dentists
complained from depression while one
third of dentists complained from
depersonalization. From investigator
observation the high prevalence of
psychological work-related health risk
factors as a result from, low autonomy,
work overload, and inappropriate
relation
between
power
and
responsibility and their teaching role in
addition to their clinical role. The result
was supported by (Mehta, Gupta &
Upadhyaya 2012) found that more than
one third of dentists complained from
job-related stress.
results in the same direction with a study
done by (Saleh 2010 ) who found that,
less than one quarter of dental nurses
done hand washing, the majority of
dental nurses wore latex gloves and
protective coat, also no one of dental
nurses wore eye protector. Related to eye
protection, the result of this study
revealed no one of dental nurses wore
eye
protector,
these
results
contraindicated with a study done by
(Albdour & Othman 2010 ) in Jordan and
found that one third of dental nurses
wore eye protection routinely.
Regarding preventive measures
applied by studied dentists, the results of
this study revealed that, majority of
dentists do hand washing. Regarding to
wearing
of
personal
protective
equipment (PPE), the results of this
study showed that all of dentists wore
powdered latex gloves and protective
clothes while less than one third of
dentists wore eye protector. The results
supported by a study done by (Saleh
2010) and found that, all of dentists
wore powdered latex gloves and
protective clothes. Regarding chemical
preventive measures, results of this study
indicated that all of dentists used tightly
closed capsule of mercury and stored in
sealed containers while slightly less than
one third of dentists worn hypoallergenic
non-latex gloves. In agreement with the
study results, a study done by (Mehta,
Gupta & Upadhyaya 2012 ) found that
more than half of dentists used tightly
closed capsule of mercury and stored in
sealed containers.
Regarding physical preventive
measures, the results of this study
revealed that, all of studied dental nurses
used sharp containers and recapped
needle after injection. The results of this
study contraindicated, the study done by
(Saleh 2010 ) and found that all of
Regarding preventive measures
applied by studied dental nurses, results
of this study revealed that, more than
one quarter of dental nurses done hand
washing. Regarding to wearing of
personal protective equipment (PPE), the
results showed that all of dental nurses
wearing powdered latex gloves and
protective clothes while no one of dental
nurses wearing eye protector. These
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studied dental nurses didn‘t use sharp
containers for disposal of sharps and
needles after injection. Recapping of
needles increase incidence of needle
stick injury and it considered a major
cause for transmission of blood borne
pathogens.
Regarding physical preventive
measures, results of this study indicated
that all of dentists used sharp containers
and recapped needles after injection. The
results supported by a study done by
(Saleh 2010) and found that, all of
dentists used sharp containers. All of
dentists‘ recapped needle after patient
injection and this explain high
prevalence of percutaneous exposure
incident among studied dentists and it
considered
a
major
cause
for
transmission of blood borne pathogens.
In relation to, application of mechanical
preventive measures, results of this study
revealed that no one of dentists used
ergonomically designed chairs nor
maginification devices during their
dealing with patients and that explained
the higher incidence of mechanical
health risk factors among studied
dentists.
Conclusion:
The results of the present study
demonstrates that many of dental nurses
and dentists complained from chemical,
physical, mechanical and psychological
work-related health risk factors related to
inappropriate application of preventive
health care measures of different workrelated health risk factors in dentistry.
Also, more than two third of dental
nurses‘ practices of preventive measures
were unsatisfactory and less than two
third of dentists‘ practices of preventive
measures were unsatisfactory. There was
a highly statistically significant positive
correlation between the incidence of low
back pain and application of mechanical
preventive measures. Also, there was a
statistically
significant
negative
correlation between the incidences of
shoulder pain and application of
mechanical preventive measures among
dentists.
Recommendations:
Based on the findings of this research,
the following are recommended:
1- Raise awareness of dental nurses
and dentists regarding the workrelated health risk factors.
2- Design and implement preemployment and continuous
health education program about
work-related health risk factors
and preventive health care
measures.
3- Follow instructions about new
equipment usage to avoid
exposure to any work-related risk
factors.
References:
1- Al-Ali.,
Khalid.H.,&
Raghad.(2012 ).
Occupational
health problems of dentists in the
United
Arab
Emirates.
International Dental Journal; pp
52-56 . Available at : (http//
onlinelibrary.wiley.com/journal).
2- Albadour M., & Othman E.
(2010 ) Eye Safety in Dentistry.
Pakistan Oral and Dental Journal.
Volume 30, pp 8-13.
3- Ammon A., Reichart P., Pauli G
& Petersen L. (2010 ). Hepatitis
B and C among Berlin dental
personnel: incidence, risk factors,
and effectiveness of barrier
prevention
measures.
Epidemiological
infection
journal. Volume 125. Pp 407413.
4- Brar R.,& Karar H.(2011 ).
Occupational hazards in current
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Work-Related Risk Factors and Preventive.
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dental profession. The Open
Occupational of Health and
Safety
Journal;
pp57-64 .
Available
at:
(http://creativecommons.org/lice
nses/by-nc/3.0/).
5- British Dental Journal (BDA).
(2014 ) Over half of dental nurses
have had a needle stick injury
article. Volume 217.
health care worker thesis. pp 79104.
6- CDC (2010 ): Recommended
infection-control practices for
dentistry. MMWR; 42(8): 1-13.
7- Fasunloro A., & Owotade F.(
2012 ). Occupational hazards
among clinical dental staff. The
Journal of Contemporary dental
staff; pp 1-10. Available
at:(http://www.thejcdp.com).
8- Kedjarune U., Leggat P., &
Smith D. (2010).Occupational
Health Problems in Modern
Dentistry.
The
Industrial
Health Journal, Volume 45 ,
pp1-11 .
9- Mehta A., Gupta M., &
Upadhyaya N. (2012 ).Status of
occupational hazards and its
preventive
among
dental
professionals.
The
Dental
Research Journal; pp 446-451 .
Available
at:
( http://www.mui.ac.ir).
10- Shmoji S., Ishihama K., Yamada
H.,
&
Okayama
M.
(2010 ).Occupational
safety
among dental health care worker.
Journal of Advances in Medical
Education and Practice. Volume
1,pp 41-47.
11- Saleh R. (2010 ). Knowledge,
attitude and practice toward
blood borne diseases (HBV,
HCV& HIV) among dental
14
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Patients Newly Starting Hemodialysis.
enj@nursing.cu.edu.eg
Patients Newly Starting Hemodialysis Sessions: Effect of Nursing Guidelines on
Safety Outcomes
Hanan Sobeih Sobeih, Manal Hussein Nasr *Waleed Abd-AL Mohsen
Medical Surgical Nursing-Faculty of Nursing, Ain Shams University* Nephrology
Department-Faculty of Medicine- Ain Shams university
Abstract:
Back ground: Nursing guidelines must provide with the maximize efficiency and safety of each
patient‘s hemodialysis treatment session. Aim: To evaluate theeffect of nursing guidelines on safety
session outcome for patients newly starting hemodialysis treatment design: A quasi experimental.
Setting: At dialysis units affiliated to Ain Shams university Hospitals. Subject: Included 30 adults
patients from both sexes under certain criteria: All patients were early referral to hemodialysis treatment
surrogated by level of creatinine clearance not less than 5-2ml/min and without signs and symptoms of
uremia and17nurses'working in hemodialysis units .Tools: Two tools were used for nurses and three for
patients:1-Self-administered questionnaire: a- Nurses' characteristics, b-Nurses' knowledge :To assess
the level of nurses' knowledge2-Hemodialysis observation's checklist: to evaluate the level of nurses'
practice1-Patient's data sheet.2- Safety session observation checklist: to assess patient's safety
outcome/session. 3- Rating anxiety scale: to assess the anxiety (pre/posttests).Results: there was
statistically significant differences as regards the levels of nurses' knowledge and practice (pre/posttests)
at p<0.001 except post- session washout p>0.05. There were a positive predictors as regards stability of
body weight and maintain of BP as well free from bleeding at the end of follow-up period. The levels
of anxiety there were highly statistically significant differences (pre/posttests) .No significant differences
as regards hemoglobin level were detected, while there was a positive predictor as regards BP measuring
pre-and at the end of follow-up period. Conclusion: The level of nurses' knowledge and practice about
hemodialysis treatment were increasing significantly after nursing guidelines and was decreasing
significantly the side effect of hemodialysis session more than before it. The level of patient anxiety was
decreasing significantly after guidelines application. Recommendation: Hemodialysis patients in need
to decrease side effects during hemodialysis session through improving care .While the dialysis nurse in
need for training program pre-contact with hemodialysis patients.
Key words:Nursing guidelines- Newly hemodialysis - Safety outcome
Introduction:
Dialysis is a treatment for severe kidney
failure also, called renal failure, or endstage renal disease. When the kidneys
are no longer working effectively, waste
products and fluidsbuilt-up in the blood.
Dialysis takes over a portion of the
function of the failing kidneys to remove
the fluids and wastes. Dialysis is
typically needed when approximately 90
percent or more of kidney function is
lost. Kidney function can be lost rapidly
(acute renal failure or acute kidney
injury) or over months or years (chronic
kidney disease). Early in the course of
kidney disease, other treatments are used
to help preserve kidney function and
delay the need for replacement therapy.
(Bems, 2014)
The Patients survival and quality of
their life depend on each hemodialysis
session being performed without fault.
Severe decrease of renal function, either
acute or chronic, is a threat for life and
for its treatment wastes and excess water
should be eliminated and volume of the
body liquids should return to its normal
state. For this aim, dialysis can be used.
If the function decrease is irreversible it
is necessary to do maintenance dialysis
for life preservation (Blegen, Vaughn
and Goode, .2012).
The number of patients receiving
renal replacement therapy in the world is
rapidly rising. Active intervention to
reduce the high morbidity and mortality
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in the first year of patient's life on
dialysis can successfully impact on their
outcomes and there is also increased
recognition that the type of access with
which the patient initiations dialysis has
strong influence on subsequent outcomes
In the United States, nearly 25000
patients
receive
regular
dialysis
treatment to manage ESRS (National
Kidney Foundation 2001 ) and (Walter
2010).
Justification of the problem:
End-stage renal disease (ESRD) is one
of the main health problems in Egypt.
Currently, hemodialysis represents the
main mode for treatment of chronic
kidney disease stage 5 (CKD5),
previously called ESRD or chronic renal
failure. In Egypt, the estimated annual
incidence of ESRD is around 74 per
million and the total prevalence of
patients on dialysis is 264 per million.
Hemodialysis centers in Egypt exist in
governmental, military, and university
hospitals as well in the private sector.
The average cost of the hemodialysis
session ranges from US $16 in
governmental hospitals to around US
$32 in some private centers. The main
hemodialysis regimen adopted in Egypt
is three times per week (Ahmed et al.,
2010).
Providing guidelines for all staff
working
within
the
nephrology
department especially for nursing staff
lead
to
improve
the
patient‘s
hemodialysis
treatment
sessions'
outcomes. Thus reducing complications,
achieving the prescribed adequacy and
increasing the patient‘s wellbeing. The
nurse caring for the hemodialysis patient
must maximize patient comfort and
safety, review patient's blood levels,
adequacy and arrange timely vascular
access suited for each patient. As well as
taking the preventative measures to
eliminate hemodialysis complications
and identifying the patients at risk of
hypertension or hypotension also must
do appropriate selection of the dialysis
concentration when preparing for the
dialysis treatment (Tordoir, et. al.2012 ).
The number of end stage renal
disease in Egypt in 2009 was 375
thousand according to Egypt Association
of Renal Failure Patients, the vast
majority of them are treated at dialysis
center. The number of death among end
stage renal disease (ESRD) patient in
2011 was 190/1000 dialysis patient (El
Minshawy, 2011 ).
Based on other research studies
concerning end-stage renal disease,
nurses are lacking knowledge and skills
required for caring of patients subjected
to hemodialysis treatment.Best practices
guidelines are not available for nurses
working in dialysis units. So, the current
guidelines was developed for nurses to
update and upgrade their knowledge and
skills and to be reference guide
whenever needed, also, it should be
utilized
and
integrated
through
educational modalities, in order to assist
nurses to be competent in delivering care
Safety outcomes of hemodialysis
sessions are considered as indicators of
improved patient's condition, decreased
session's
complications
and
consequently improving morbidity &
mortality rates. So, it is a must to use
every teaching and training modality for
nurses working in hemodialysis units to
provide best practices for such patients.
(Marcille, et. al. 2014 ).
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for such patients and a consequent
improvement in post session's outcomes
is achieved, this best practices'
guidelines.
Aim of study:
This study aimed to evaluate the
effect of nursing guidelines on safety
sessions' outcomes for patient newly
starting hemodialysis treatment: This
aim was achieved through the
followings:
Post-session washout: mean the patient,
feels weak, extreme fatigue, stiffness in
joints, headaches, nausea and loss of
appetite. This syndrome may begin
toward the end of treatment or minutes
following the hemodialysis treatment.
Subjects and Methods:
Research design:
A quasi- experimental design was
used to conduct this study.
Setting:
The study was conducted in the three
hemodialysis units affiliated to Ain
Shams University Hospital.
Subjects:
Number of patients who were on
hemodialysis treatment in the dialysis
units affiliated to Ain Shams University,
in the last two years (2012-2013 and
2013-2014 ), were approximately 1350
and 1412 respectively. Around 600 of
them were newly starting this treatment
(Ain Shams University Statistical
Center2014). Five percent (30 adult
patients from both sexes) were recruited
as a purposive sample. The inclusion
criteria include all patients who were
early starting hemodialysis treatment,
their level of creatinine clearance not
less taken5 to 2 ml/min and without
signs and symptoms of uremia. As well,
all available nurses (17) working in
hemodialysis units were included in the
study.
Tools of data collection:
Five tools were used by the researchers
to collect the data for the purpose of this
study.
Two tools were used for the studied
nurses:
1 - Self-administered
questionnaire:It was divided into
two parts as the followings:
a- Characteristics of the
studied nurses: it includes;
1- Assess nurses' knowledge and
practice regarding hemodialysis
treatment.
2- Design and implement nursing
guidelinesthen evaluate itseffect
on nurses' knowledge, practice
and patients' safety sessions
outcomes.
Research hypotheses:
- The level of nurses' knowledge
and their practice regarding
hemodialysis treatment will
significantly,
increase
after
implementing
the
nursing
guidelines.
- The
nursing
guidelines'
application will significantly
decrease
the
undesirable
outcomes
of
hemodialysis
sessions.
- The level of patient anxiety will
decrease
significantly
post
implementing
the
nursing
guidelines.
Operational definition:
Safety sessions outcomes: It means
prevention of errors or adverse effects,
according the criteria of this study,
(vomiting, bleeding, leg cramps,
unstable body weight and decreased
blood pressure) that may occur to those
patients during hemodialysis sessions.
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Patients Newly Starting Hemodialysis.
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age, qualifications and years
of experience.
b- Nurses'
knowledge
assessment
form
(pre/posttests): It was
designed by the researchers
based on recent literatures
(Nascimento&
Marques,
2005 and Step by step
description
of
hemodialysis,2015). Five
experts in the field of
dialysis
and
medical
surgical nursing tested it for
content validity. It was used
to assess the level of nurses'
knowledge pre/post nursing
guidelines.
This form involved 75 multiplechoice questions (MCQ) about
general knowledge related to
normal range of kidney function
and electrolytes, signs and
symptoms of uremia, indications
of safety dialysis sessions, side
effects of hemodialysis treatment
and complications,the total score
75 marks.
- It involved also,(25) true &
falsequestions
and
rational,
regarding
healthteaching
ofhemodialysis
patient
about
nutrition, medication and hygiene.
Thetotal scores 50 marks. Scoring
system: The correct response was
scored "1", while the incorrect
scored zero. The total satisfactory
level of their knowledge was
≥70%; while the unsatisfactory
level of knowledge was <70%.
2- Hemodialysis
observational
checklist for nurses: This tool was
adopted fromDeniel, et al.(2015),
Samuel et al. (2015 ), and Step-bystep description of hemodialysis
(2015 ), and modified by the
researchers,
guided
by
nephrologists to suite the study's
aim to evaluate the level of nurses'
practice
pre/ post
nursing
guidelines as regards the procedure
of hemodialysis
session which
included:
a- Explainingthe procedure
(=10 items): especially in
the first session.
b- Preparation of patient
pre-session (=7items): it
includes
patient's
assessment
regarding
hemodynamic stability and
recent blood results.
c- Care during sessions (=13
items): included, vascular
access and monitor patient
adverse reactions.
d- Care post sessions (=15
items): included assessment
of patient disconnection of
machine, and assessment of
patient condition.
e- Post-session washout (= 9
items): included assessment
of patient as regards
disequilibrium syndrome.
Scoring: The items observed to be
done correctly were scored "1" and
the not done or incorrectly done
were scored "0". For each
procedure, the scores of the items
were summed-up & the total is
divided by the number of the
items, giving a mean score. Then it
was converted into a percent score.
The practice were considered
competent if the percent score was
(≥80%), and incompetent if it was
(< 80%).
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- Mild level of anxiety from 45 to 59
- Moderate level of anxiety from
60 to 74
Three tools were used for the studied
patients
1- Patient's questionnaire sheet:It
was developed by the researchers to
collect bio-socio-demographic and
medical related data, which
included age, sex, educational
level, the starting time of treatment,
number of dialysis session/week,
and level of hemoglobin and blood
pressure.
- Sever level of anxiety from 75 to 80.
Content validity and reliability:
Validity test was done by 5 experts from
Medical Surgical Nursing specialty and
others from nephrology consultants .The
questionnaire and checklists reliability
were confirmed by Cronbach‘s alpha
coefficient (alpha = 0.88 for nurses'
knowledge questionnaire& alpha = 0.85
for hemodialysis observation checklist
and alpha = 0.92 for safety session
observation checklist.
2- Safety
session
observation
checklist: This tool was adopted
from Pamela, et al, (2005) it was
used to assess patient's session
safety
outcomes
(pre/post
hemodialysis sessions and at the
end of follow-up period). It was
modified by the researchers to suite
the study' aim. It represented that,
each session free from bleeding,
vomiting and leg cramps .As well
maintaining stable weight and
blood pressure.
Scoring:For
each
item
achieved(scored =1), while not
achieved item (scored =zero). The
competent level was considered at
≥80% while the incompetent was
at<80%.
Ethical considerations and human
rights:
Agreements from patients to
participate in this study were taken after
the aim of the study was explained to
them. They were given the opportunity
to refuse to participate, and they were
assured that the information will be
treated confidentially and used for
research purposes only .The application
of nursing guidelines was done during
morning and afternoon shifts. Approval
with taken by staff nurses to participate
in the current study.
Pilot study:
A pilot study was carried out on
10% of the total study sample to test the
clarity, feasibility and practicability of
the tools in addition to the subjects and
settings. Pilot subjects were later
included in the study as there was no
radical modifications in the study tools.
3-Anxiety rating scale: It was
adopted from Zung (2014) and it
was used to assess the anxiety
levels of the studied patients
pre/post nursing guidelines and it
was involved 20 felt or behaved
items andtotal score was 80 marks.
The scale scored as: a little of time
(1) some of the time (2) part of the
time (3) and most of the time (4).
The level of anxiety was scored as
follows:
- No anxiety from 20 to 44
Field work:
 The study was implemented
during the period from the
beginning of July 2014 to the
end of December 2014 .
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Patients Newly Starting Hemodialysis.



enj@nursing.cu.edu.eg

The study tools were designed by
the researchers after reviewing
the relevant literaturesbased on
patients' needs.
Content validity and reliability
tests were done before starting
data collection process.
The data collection, pre/post,
nursing guidelines was done by
the researchers who were
available 3 days / week at the
morning and the afternoon shifts.
Theoretical Part:it contains the
following items:
- Normal range of kidney function and
electrolytes
- Signs and symptoms of uremia and
disequilibrium syndrome
- Indications of safety dialysis session
- Side effects of hemodialysis and
complication
- Health teaching about nutrition,
medication and hygiene.
 Practical Part: it contains the
following items:
- Explain patient' procedure
- Preparation
of
patient
prehemodialysis session
- Dialysis care during , after and postsession washout
Method of teaching
- Presentation.
- Discussion.
Media of teaching:
- Illustrated guidelines.
- Computer and board.
Nursing intervention guidelines:
Assessment phase:
Before
starting
hemodialysis
session, the researchers interviewed each
patient individually, from 10-15 minutes
and explained the aim of this study, then
asked each one to answer anxiety sheet
through checking the column which best
describes how often he/she felt or
behaved to evaluate the levels of
patients'
anxiety
before
nursing
guidelines application as a pre/test.As
well, the researchersinterviewed each
nurse individually from 20-25 minutes
according to their readiness and ask
each one of them to answer and fill the
questionnaire
sheet
about
their
knowledge regarding
hemodialysis
treatment after orienting them about the
content and purpose of the study , also
evaluated their practice through the
observation checklist.
Implementation and evaluation phase:
Through two weeks in the morning and
afternoon shits and according the studied
nurses readiness, the individualized or
small group sessions were done (theory
&practice). The researchers explained
the content of the nursing guidelines and
clarified each item. The number of
theoretical sessions wasthree and each
session'sdurationlasting from 30 – 40
minutes. The contents of each lecture
werehandled for the studied nurses at the
end of each session. Evaluation of
nurse's knowledge was done at the end
of teaching time through final
examination and took 45 minutes for
each small group according to their
proper time. While regardingthe
practical part, evaluation was done after
2weeks and at the end of follow-up
period (after 4 weeks) through the same
Planning phases:
Nursing guidelines was designed
according to predetermined actual
patients' needs regarding hemodialysis'
safety session (before, during& after).
As well, it was also built on the studied
nurses levels of knowledge and practice
as regards hemodialysis treatment. The
nursing guidelines consisted of two parts
(theoretical &practical) as follows:
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observation checklist. Anxiety level of
the patients was measured post the
guidelines implementation.
respectively).While there was no
statistically significant differences as
regards thecompetent level regarding,
post-session washout (t=0.07 at p>0.05).
Statistical analysis:
The Statistical Package for Social
Science (SPSS) version 12 was used for
data analysis. Data were presented using
numbers, percentage and t-test. Level of
significant was thresholds at p <0.05.
Table (3): Showed the demographic
characteristics of the studied patients.
The mean age of the studied patients,
was 40±1.0 and 70% of them were
males, as well (50%) of them having
university level of education and
(86.6%) of the studied patients were in
the third session of hemodialysis
treatment. (56.7%) of the patients
represented normal level of HB and
(83.3%) were hypertensive.
Results:
Regarding
the
demographic
characteristics of the studied nurses,
(64.7%) of them were more than 25
years old and (76%) have diploma level
of education as well 88.2% have more
than five years of experience.
Table (4): Shows the percentage change
as regards safety sessions outcomes in
the studied patients' pre, post nursing
guideline and at the end of follow-up
period. Significant differences were
detected as regards stability of body
weight from 23.3% to 83.3% and 100%
respectively.
While,
there
were
percentage changes from 0.00 % prenursing guidelines to 56.7% post nursing
guidelines and 66.7 % at the end of
follow-up period as regards stability of
blood pressure. As well there were
percentage changes as regards post
session washout, free from bleeding,
vomiting and leg cramps. Pre-nursing
guidelines, from 83.3%, 30% and 10%,
to 1oo%, 43.3 and 16.7 post-nursing
guidelines and then at the end of the
follow up period the percentages were
66.7%, 43.3% and 23.3%, respectively.
Table (1): displays the level of studied
nurses'
knowledge.
There
was
statistically significant differences as
regards the satisfactory level of nurses'
knowledge pre/post nursing guidelines
about normal range of kidney function
and electrolytes, signs ,symptoms of
uremia and disequilibrium syndrome,
indications of safety dialysis session as
well, side effects of hemodialysis session
and complications, (t = 13.6 & at p
<0.001 ). Also,there was a statistically
significant difference of their knowledge
about health teaching as regards
nutrition, medication and hygiene (t =
2.2 & at p <0.05).
Table (2): It displays the level of the
studied nurses' practice. there were
statistically significant differences as
regards thecompetent level of nurses'
practice pre and post nursing guidelines
about hemodialysis procedure regarding,
explaining the procedure, patients
preparation
(pre-session)andPatients'
dialysis care during session and postsession.(t= 11.5, 6.2,9.0 &7.1 at p<0.001
As regards the levels of anxiety
among
hemodialysis
studied
patients(mild, moderate and sever), table
(5)revealed that there were highly
statistically significant differences pre
and
post
nursing
guidelines
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(t=4.6.12.5 &21.5 at p<0.05, &0.001
respectively).
hemoglobin level was recorded (56.7%
and 43.3%). While at the end of followup period there was a positive predictor
as regards blood pressure represented
with
decreased
percentage
of
hypertension from 83.3% to33.3% as
well hypotension from 16.7% to 10.0%.
Table (6): shows the predictors of
nursing guideline as regard hemoglobin
and blood pressure levels among the
studied patient at the end of follow-up
period. The same percentage of




Table (1): Level of nurses' knowledge pre and post nursing guidelines as regards
hemodialysis treatment (n=17 )
Satisfactory level of knowledge
tPre- guidelines
Post- guidelines
P-value
Variables
test
Mean ±SD
Mean ±SD
Normal range of kidney
function &electrolytes
Signs &symptoms of uremia
&disequilibrium syndrome
Indications of safety dialysis
40.8±9.5
55.8±7.9
13.6 <0.001 **
session
Side effects of hemodialysis
&complication
 Health teaching about
nutrition,
medication&
28.7 ±16.6
39.5±23.0
2.2
<0.05*
hygiene
*P value: significant
**P value: Highly significant
Table (2): Number & percentage distribution of nurses' practice pre and post
hemodialysis nursing guidelines (n=17 )
Competent level of nursing practice
PItems
Pre-guidelines
Post guidelines t- test
value
Mean ±SD
Mean ±SD
Explain procedure
42.8±9.9
53.4±7.8
11.5
Patient preparation
(Pre session)
During session
30±14.8
27.2±18.0
Post session
29.2±14.7
Post-session washout
33.0 ±18.9
*P value: significant
**P value: highly significant
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July 2015
42.9±19.6
39.2±17.5
44.9±19.5
31.8±14.4
6.2
9.0
7.1
<0.001 **
0.07
>0.05*
Patients Newly Starting Hemodialysis.
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Table (3): Bio- Socio demographic characteristics of the hemodialysis studied
patients (n=30 )
Items
No
%
Age:
17
56.7
 25-<40
13
43.3
 40-65
X±SD
40±1.0
Sex:
21
70.0
 Male
9
30.0
 Female
Education level:
15
50.0
 University level
10
33.3
 Secondary level
5
16.7
 Read &write
Starting of dialysis:
2
6.7
 1 st session
nd
2
6.7
 2 session
rd
26
86.6
 3 session
Number of sessions/week
30
100
 Three/week
 Two/week
HB level:


Within normal
Abnormal
Blood pressure:
 Hypertension
 Hypotension
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July 2015
17
13
56.7
43.3
25
5
83.3
16.7
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Table (4): Number and percentage distribution of hemodialysis safety sessions'
outcomes among studied patients pre/post nursing guidelines and at the end of
follow-up period (n=30
Variables of safety
sessions' outcomes
1-Maintian:
-Stable weight
-Blood pressure
2-Free from
-Bleeding
-Vomiting
-Leg cramps
Pre-nursing
guidelines
post-nursing
guidelines
(after2weeks)
No
%
No
%
7
0
23.3
0.0
25
17
25
9
3
83.3
30.0
10.0
30
13
5
Follow-up
(after 4weeks)
No
%
83.3
56.7
30
20
100
66.7
100
43.3
16.7
30
13
7
100
43.3
23.3
Table (5): The total level of anxiety in the studied patients pre/post nursing
guidelines (n=30 )
Variables
Pre-nursing
guidelines
X±SD
Post-nursing
guidelines
X±SD
t-test
P-value
3.0±1.0
2.2±1.1
1.7±0.5
4.3±0.5
4.7±0.5
4.5±0.5
4.6
12.5
21.5
<0.05*
<0.001 **
<0.001 **
1-Mild
2-Moderate
3-Sever
*P value: significant
**P value: highly significant
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Table (6): Number and percentage distribution of nursing guidelines' predictors among
the studied patients regarding hemoglobin and blood pressure
Variables
HB level:

Normal
Abnormal
Blood pressure:
 Hypertension
 Hypotension
Pre-nursing
guidelines
No
%
17
13
56.7
43.3
17
13
56.7
43.3
25
5
83.3
16.7
10
3
33.3
10.0
Discussion:
Many of risks and side effects
associated with hemodialysis technique
are a combined result of both the dialysis
treatment and patient's condition of end
stage renal disease. The nurses are the
ones on the health team that have most
contact with the dialysis patients, thus
the nurse's knowledge about renal
failure, mechanics and technical dialyzer
and expected patient's outcomes more
efficient during hemodialysis session
(Rebeca,2010).
may be in need for support by nursing
guidelines.
As regards the studied nurses level
of knowledge pre-nursing guidelines
they couldn't gain a pass level, about
normal range of kidney function and
electrolytes, signs and symptoms of
uremia, indication of safety dialysis
session, side effects of hemodialysis
treatment and complications, while post
guidelines , all of them were having a
satisfactory level of knowledge. This
result fulfilled the first part of the study
hypothesis regarding nurses' knowledge.
Other studies congruent this result by
Brimble, et al. (2003 ), who reported
that, the main role of dialysis nurse is to
provide hemodialysis patients with
complete health teaching during dialysis
session.Providing the studied nurses
with
recent
guidelines
about
hemodialysis treatment may help them to
deal with dialysis patient without
complication especially in the first
sessions.
The
socio-demographic
characteristics of the studied nurses
revealed that their age was between 20
to 25 years old and also more than three
quarter of them have diploma level of
education as well,more than three
quarter of them have more than five
years of experience. In this context,
Blegen, Vaughn and Goode, (.2012),
reported that it is generally believed that
more experienced nurses provide higherquality of patient's care. The current
study results incongruent that years of
experience in this study only were not
enough to provide quality of patient care
during hemodialysis session so nurses
In the same issues the studied nurses
pre-nursing guidelines they couldn't gain
a competent level of their practice as
regards explained procedure, patient
25
July 2015
At the end of
follow-up period
No
%
Patients Newly Starting Hemodialysis.
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preparation pre- hemodialysis session,
during, post-session and post-session
washout. While post guidelines, all of
them were having a competent level of
practice except post-session washout.
This result achieved the first part of the
study hypothesis regarding nurses'
practice.In a similar study byFrancesco,
et al., (2014 ) emphasized that the most
appropriate composition of the dialyzed
fluid has been one of the central cause
of post-hemodialysis syndrome which
is called "washout" the patient feels
weak, tremulous, extremely fatigue as
well, the patients suffered from stiffness
in joints and other flu-like symptoms
including headaches, nausea and loss of
appetite. The syndrome may begin at the
end of treatment or minutes following
the treatment.
result ofRosner and Thomposom,
(2010 ), whorevealed that the optimum
timing of hemodialysis treatment for
patient with chronic renal failure prevent
serious and uremic complication. These
data revealed that the researchers could
follow the effect of nursing guidelines
during dialysis sessions on patient
condition.
In this study, the number of
hemodialysis sessions were thrice /week
for
studied
patients,which
was
recommended
by consultants
of
nephrologists, this results congruent by
Janice, (2004 ) who emphasized that all
adultpatients
receive
outpatient
hemodialysis three time/week.
On the other hands percentages changes
were noticed at the end of follow-up
period as regards patient safety
outcomes/session, positive changes were
observed as regards maintain a stable
weight and blood pressure. Patient's
improvement was also observed as free
from bleeding at the end of follow-up
period, while there were slightly
significant differences were noticed
asregards frequency of vomiting and leg
cramps. This result has fulfilled the
second part of the research hypothesis.In
agreement with this result, Francesco, et
al. (2014 ) mentioned that, the most
complications
that
occur
during
hemodialysis can be prevented or easily
managed if the nurse is monitored
carefully during each session. Possible
complications may include, low blood
pressure and this is most common
complications of hemodialysis, muscles
cramps that usually happen in the half of
a dialysis session, nausea, vomiting, or
confusion. These results revealed that
there may besome problems led to
incomplete safety dialysis session such
Regarding patients' demographic data,
findings of the present study related that,
their mean age were 40.0±10 years.
Nearly three quarter of the study sample
was males and half of them havehigher
level of education. This finding was
congruent with Adel, et al. (2000 )
whoreported that the distribution of
dialysis in Egypt was 61.37% in males
and 38.7% in females and mean of their
age 46.3.
In the same point the majority of studied
patient were starting hemodialysis
treatment since three weeks and they
were early referred to betreated by
maintenance hemodialysis surrogated by
level of creatinine clearance and patients'
without signs and symptoms of uremia.
These results were in congruent with
Paula, et al. (2009 ), who stated that
delaying the initiation of dialysis until
frank uremia develops is a clear
deterioration of the patient condition.
This finding was also consistent with the
26
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Patients Newly Starting Hemodialysis.
enj@nursing.cu.edu.eg
as lack of nursing practice or side effect
of dialysate fluid during hemodialysis
treatment.
of patient condition after one month of
follow –up period. While as regards
number of patients suffered of
hypotension was noticed to beslightly
decreased at the end of follow-up period.
This result revealed that hypotension
may be due to dialysis procedure,
Lhynnee, (2011) congruent the previous
results who reported that hypotension is
a
common
problems
during
hemodialysis treatment due to excessive
multifiltration or excessive antihypertensive medications.
The current study discovered that,, the
levels of anxiety were decreased after
nursing guidelines in the studied patients
especially, in the moderate and sever
levels. This result has ascertained the
third part of the study hypothesis.This is
congruent with Mollaoglu et al, (2012)
who emphasized that health teaching
about hemodialysis treatment decreased
anxiety
in
patients
undergoing
hemodialysis and it is important to
perform patient education and health
teaching regularly, because it increases
the level of orientation regarding illness
and interventions. The result in this point
may reflect the important of patients'
health teaching to improve their session
outcome.
Finally, the results of the study revealed
that stable numbers of patients suffered
of anemia at the end of follow-up period.
Similarly Edmund et al, (2010) stated
that anemia is a universal complication
of chronic renal failure due to decreased
production of erythropoietinhormone
and dialysis itself may contribute to the
anemia. These results might stressthe
good
nutritional
assessment
of
hemodialysis patient by dialysis nurse
through providing health teaching about
intake of iron between meals.
On the other hands Brimble, et al.(2003)
emphasized that hypertension results
from
volume
overload
causing
disequilibrium during dialysis session,
also indicated that the hemodialysis
patients exposure to complications for a
long run has confirmed the role of staff
nurse in providing patient's health
teaching that help to avoid deterioration
Conclusion:
According to the findings of the current
study and the researchers' hypotheses,
the levels of nurses' knowledge and their
practice about hemodialysis treatment
have increased significantly after the
nursing guidelines. Also, The nursing
guidelines application has decreased
significantly the side effect of
hemodialysis sessions more than before
it. While, regarding level of patients'
anxiety, it has been decreased
significantly post-nursing guidelines
application.
Recommendations:
This study recommended that:
- Training programs for nurses pre-dealing
with hemodialysis patients should be
done.
- The illustrated nursing guidelines for
nurses working at dialysis units should
be presented and provided to them.
- Further studies:
1. Continuous training courses for such
group of nurses should be held regarding
new technology in hemodialysis.
2. Awareness programs should be prepared
for hemodialysis patients to improve
post sessions' outcomes.
27
July 2015
Patients Newly Starting Hemodialysis.
enj@nursing.cu.edu.eg
7- Edmund G. Lowrie M. &Pollak
M. (2010 ): Anemia in patients
with chronic renal failure and in
patients undergoing chronic
hemodialysis, oxford Journals,
Medicine, Nephrology Dialysis
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Governorate,
Upper
Egypt: an epidemiological study.
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http://www.SaudiJKidneyDisTranspl.
2011 Sep;22(5):1048-54 .
9- Francesco L., Adrian C., Charles
H. andKarellE.(2014 ):Optimal
composition of the dialysate,
with emphasis on its influence on
blood pressure, Nephrology
Dialysis Transplantation ndt,
Oxford journals, org., Nephrol.
Dial.
Transplant, 19 (4): 785796.
10- Justin K. (2008 ): Clinical
pathway
development/Review
checklist. Clinical pathway: A
Guide for Clinicians. Available
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nursing/
dialysis.
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.Retrieved on 10-9- 2010 .
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Peralta R., Fezendeiro J., Porra
A., Moscardo V., Parisotto M. T.,
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(2014 ):
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Egyptian Renal Registry 5 th
Annual Report, Ain Shams
University,
Cairo,
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eived on17-1 2015.
2- AhmedM. N., AllamE. S.,
HabilA. M. and Metwally N. A.
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&Goode C. J. (2012): Nurse
experience and education: effect
on quality of care, School of
Nursing, University of Colorado,
Health Science Center, Denver,
Colorado, USA. J Nurs Adm.;
31(1):33-9.
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information:
Hemodialysis
(Beyond the Basics), available
at:http://www.uptodate.com/cont
ents/hemodialysis-beyond-thebasics.
5- Brimble K. S., Darin J., Joye S.
O. &Euan J.C. (2003): Risk
factors for increased variability
in
dialysis
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hemodialysis
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M., Tuncay
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O., Fertelli T. K. and Yurugen B.
(2012 ): Effect on anxiety of
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education programmer about care
of
patients
undergoing
hemodialysis;13(2):152-6 .
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ubmed/retrievedon 11/2/2015
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Louis G. R. (2009 ): Influence of
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(2010 ):
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21-1-2015 .
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Konner K., and Basic A.
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29
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Stress and Coping Strategies.
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Stress and Coping Strategies among Nursing Students at Faculty of Nursing, Cairo
University
By
Enas Mahrous AbdElAziz, D.N.Sc. and Sayeda Mohamed Mohamed, D.N.Sc.
Psychiatric Mental Health Nursing Department, Faculty of Nursing, Cairo University
Abstract
This study aimed to investigate sources of stress and coping strategies among nursing students at the
faculty of nursing, Cairo University. A descriptive cross sectional research design was utilized in this study.
The present study was conducted at the faculty of nursing, Cairo University. A convenient sample consists
of (480) students, three tools were used to collect the data for the current study, Socio-demographic data
sheet, sources of stress questionnaire and Coping Orientation for Problem Experiences Questionnaire.
Results proved that there were statistically significant differences between source of stress and studied
variables. The major stressors of nursing students have been frequent exam followed by discrimination
among students, increase stress during exams and routine administrative procedures in the faculty. The
higher percentage of coping strategies among nursing students were, escape from situations as sleeping
55.2% and listen to music 43.5%, development of social support as say good for others 62.5%, try to reach
a decision by myself 60.5%, Help others to solve their problems, 64.4%, work useful things for the family
38.6%, resorting to prayer frequently 50.7%, get close to friends you love 46.4%, and resorting to jokes..
The present study recommended that another longitudinal study could be carried out with a cohort of
students to investigate the levels of stress among students in all the four years of undergraduate nursing
years and the associated factors.
Key words: nursing students, coping strategies, stress
settings, Some of the most common
stressors are time pressures, workload,
making decisions, continuous changes
and economic mistakes at work
(Spielberger & Reheiser. 2005).
Sources of stress among nursing
students can be viewed from four
domains,
namely;
academic,
intrapersonal,
interpersonal,
and
environmental. As regards academic
stressors which refer to stress associated
with studying, including study load,
performance,
and
conflict
with
instructors and staff. Excessive duties as:
Midterms, final examinations, research
papers and other assignments. In
addition, nursing students experience a
clinical component, which is highly
stressful (AL-Barrak, EL-Nady, &
Fayad. 2011 ).
Introduction
Stress has many definitions, but
most known ones highlights stress as
―any factor that threatens the health of an
individual or has an adverse effect on the
functioning of the body‖ (Pourrajab,
Rabbani,& Kasmalenzhadfard. 2014).
Students' stress is a normal phenomenon,
because of their adolescence, they study
in the high competitive faculty and they
must adjust to their academy life. The
harsh long lasting stress can negatively
affect their academic achievement, and
increase the potential use of drugs and
narcotics (Richlin-Klonsky & Hoe,
2003).
Nursing students face not only academic
stress, but other stresses like clinical
practice during their training period. One
focus of interest in research on stress at
work is the sources of stress, or
stressors, which interact and contribute
to the onset of stress in organizational
Interpersonal stress may be due
to move away from home for the first
time, which can necessitate leaving all
30
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Stress and Coping Strategies.
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previously learned support systems such
as parents, siblings and high school
friends. Students may need to develop
entirely new social contacts and are
expected to take responsibility for their
own needs. They may have difficulty
adjusting to more rigorous academic
expectations and the need to learn to deal
with individuals of differing cultures and
beliefs. Thus, stress may result from
being separated from home for the first
time, the transition from a personal to an
impersonal academic environment, and
the structure of the academic experience
at the faculty level (Seyedfatemi,
Tafreshi, & Hagani. 2004).
reduce academic performance and
interfere with a student's ability to
participate in and contribute to campus
life (Fatmi, Tafreshi, & Hagani, 2007 ,
AL-Barrak, EL-Nady, & Fayad. 2011 &
Pourrajab,
Rabbani,
&
Kasmalenzhadfard. 2014).
Coping strategies serve to reduce
psychological
and
psychosomatic
symptoms of distress. Individuals who
possess a strong sense of control over the
environment are more likely to cope
effectively. Most students, managing
stress during college can be extremely
challenging. However, learning how to
manage stress may help students cope
with everyday social and academic
pressures, and thus have a better college
experience (Poon, & Ong. 2012).
Students have a large amount of
preparatory work before their clinical
assignments. They often must travel long
distances to clinical sites and use highly
technical equipment. In addition, they
must perform procedures that can cause
serious harm to their patients, thus
enhancing their fear of making mistakes.
Studies indicate that nursing students
may be more prone to stress than other
students (Sayead, et al. 2014 ).
In addition, Nursing students
experience high levels of stress. Coping
mechanisms such as utilization of social
support are effective in managing the
effects of stress and promoting
individual well-being. The use of social
support from faculty members and peers
in nursing programs has not been studied
sufficiently (Reeve, et al. 2013).
The effects of stress on nursing
students have been well documented.
The nursing educational program strives
to produce competent and skillful
graduates. However, studies have shown
that undergraduate nursing students
experience varying degrees of stress,
even "more stress" than other colleagues
enrolled in other programs; which
impacts on their health, academic
performance and social functioning.
Stress results when an individual is
unable to cope with a perceived past,
present or future situation. Stress may
arouse feelings of fear, incompetence,
uselessness, anger, aggression and guilt,
and if unresolved, may even lead to
Some students used distancing
strategies such as joking around and
having a sense of humor, intellectual
discussion, and socializing. Hence,
avoidant coping may initially be
perceived as an appropriate reaction to
stress. But it is mostly utilized by
individuals who perceive stress as
uncontrollable and therefore, according
Poon, & Ong. (2012 ), this technique is
associated with poor adjustment of life,
while coping with the help of drugs,
analgesics, alcohol, smoking and eating
actually are counterproductive and may
worsen the stress.
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A student‘s life is subjected to
different kinds of stressors, such as the
pressure of academics with an obligation
of success, uncertain future and
difficulties envisaged for integration into
the system. These students face social,
emotional and physical and family
problems which may affect their learning
ability and academic performance. Some
of them find it hard to cope with the
stress and lag behind, while others see
the pressure as a challenge to work
harder. Medical students, particularly
perceive themselves more likely to
become ill than others (Saipanis, 2003 ).
In general , learning to cope with
a stress is a useful skill for nursing
career and a life ahead. By setting
priorities , planning ahead by organizing
self, one can minimize the impact of
stress. Lazarus and Folkman, ( 1984 )
used the term coping to describe the
"cognitive and behavioral efforts", a
person employ to manage stress,
generally categorized as emotionalfocused and problem focused coping.
Various coping strategies used by
students include ventilation, diversion,
relaxation, self – reliance, social peer
group support, avoidance, praying, day
dreaming listening to music, smoking
and joking (Fatmi,
Tafreshi,
&
Hagani, 2007). Thus , the current study
is taken up to assess "stress level" and
"coping strategies" used by nursing
students. Avoidant coping reflects the
individual's cognitive or behavioral
attempt to avoid stress, and demonstrates
the tendency to avoid thinking and
stressful situations by engaging in
substitute activities (Wrzesniewski, &
Chylinska, 2007 and Poon, & Ong.
2012)
Significance:
Faculty, students, especially
nursing students is particularly prone to
stress due to the transitional nature of
college life. For example, many college
students move away from home for the
first time, which can necessitate leaving
all previously learned support systems
such as parents, siblings and high school
friends. Students may need to develop
entirely new social contacts and are
expected to take responsibility for their
own needs. They may have difficulty
adjusting to more rigorous academic
expectations and the need to learn to deal
with individuals of differing cultures and
beliefs.
At Cairo University, Faculty of
Nursing, no research studies was
conducted in this respect, so an in depth
research is needed to clarify the
magnitude of the problem as to
emphasize whether these stressors are
mostly related and how the students cope
with these stressors. It is concluded that
stress in academic institutions can have
both positive and negative consequences
if not well managed. It is important to
investigate the stress that undergraduate
students experience because of being
nursing student can make it even more
difficult to handle stress as an
undergraduate. High levels of stress are
believed to affect students‘ health and
academic functions. If the stress is not
dealt with effectively, feelings of
loneliness, nervousness, sleeplessness
and worrying may result. It is important
to look at the different factors of stress to
help students cope effectively. Stress
reduction and adopting a healthier
lifestyle have been major concerns of the
students. Students revert to different
coping strategies, harmful as well as
constructive. There have been very few
32
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Stress and Coping Strategies.
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studies done so far to assess the
perceptions of stress among students,
and still fewer are those done on medical
student population.
briefed on the objective of the study and
encouraged to actively participate.
Tools:
Three tools were used for data
collectionby
structured
interviewscheduale and included:
1-Socio-demographic data sheet:
This sheet is developed by the
researchers, it included data about
the students 'age, gender, level of
education and residential status.
2-Sources of stressors Questionnaire:
It was developed by the researchers
after reviewing related literature to
investigate sources of stressors that
might face nursing students. It is
composed of 74 items categorized
under four domains. First domain
included statements to assess the
studying stressors. Second one,
refers to health- related stress
(physical and psychological impact
of stress). Third one, is relevant to
the lifestyle and the fourth domain,
relates to educational environmental
stresses. Answers were rated on a
5-point Likert scale ranging from 1
(Never) to five (Most of the time). It
takes 15-20 minutes to be
completed and 5 minutes to score.
Total score ranged from 74 to 370.
It was translated and back translated
into Arabic were done by the
researchers and by two bilingual
experts in psychiatric nursing. The
content validity of this questionnaire
was checked by three experts in the
field of mental health nursing and
statistics. Necessary modifications
were done. The reliability of the
scale was measured by alpha
coefficient and it is equal to 0.79.
3-Coping Orientation for Problem
Experiences (COPE) scale:
Cope scale was developed by
Patterson & Mc-Cubbin (1987 ),
Aim of the Study
The aim of the present study is to
investigate the sources of stress and
coping strategies among nursing students
at the faculty of nursing, Cairo
University.
Subjects and Methods
Research design:
A descriptive cross sectional research
design was used for this study to
investigate sources of stress and coping
strategies among nursing students at
Faculty of nursing, Cairo University.
Setting:
The present study was conducted at the
faculty of nursing, Cairo University.
Sample:
A convenient sample consists of (480)
students from different levels who were
willing to participate in the study.
Students who attend faculty of nursing.
Data collection was started at the
beginning of the semester (October,
2014). Subjects who willing to
participate were asked for informed
consent. All participants were informed
that the study hasn't any risk for them.
All graduate nursing students enrolled in
the academic year as of 2013-14 from
the first to fourth level of the faculty of
nursing – Cairo University, were eligible
to participate (N=480). The average age
of the study population was 22 years
(18-23 year) from different specialties
such as fundamental nursing, medical,
surgical nursing, critical care nursing,
pediatric nursing,
obstetrics and
midwifery nursing, community health
nursing and psychiatric mental health
nursing. After have been exposed to the
rules of ethics, the participants were
33
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Stress and Coping Strategies.
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used to assess the coping strategies
utilized by nursing students to
overcome their stress. This scale
was developed to evaluate the
student‘s efforts to encounter,
refrain from facing or gain control
over the stressful situation. The
responses
anticipated
from
participants were based on their kind
of reaction to different stressful
circumstances in the nursing
learning environment; it is a 5-point
Likert scale varying from 1 to 5. ―1"
has not been doing this at all‖ to 5:
―I‘ve been doing this a lot. It
contains total 54 items under
11domains. Total score
ranged
from 54 to 270. The reliability of
the scale was checked to be the
alpha coefficient equal (0.81).
Pilot Study
A Pilot study was carried out with
10% of nursing students who attended
the academic study to test the clarity,
feasibility and the applicability of the
study tools.
Some items required
specific clarifications and explanations
from the researchers, so needed changes
in specific items are done; those
participants whom involved in the pilot
study weren‘t included in the actual
study.
Ethical Consideration
First, primary approval from the
Ethical Research Committee of faculty
of nursing - Cairo University obtained to
conduct the current study. Then, an
official permission was obtained from
the concerned authorities (vice dean of
education and student affairs at the
faculty of nursing, Cairo university) and
also from the head of each department to
conduct the study. The ethical rules of
research are guaranteed for each
participant not to refrain. The student
was assured that the data are confidential
and used only for research purposes. The
researcher arranged time with each head
of the department and nursing course
coordinators of each level to
meet
students on planned time for each level.
Researchers made full description of the
study aim and procedures, written
informed consents were introduced by
the students who agreed to participate.
Reliability, confidentiality and privacy
were assured. Researcher assured
students that no harm will expose if they
express his / her opinion regarding
academic stressors.
Procedure:
An official permission was obtained
from the concerned authorities (vice
dean of education and student affairs at
the faculty of nursing, Cairo university)
and also from the head of each
department to conduct the study.
Researchers started data collection by
introducing themselves to nursing
students and explained the aim of the
study and the content of the tools to
establish an initial rapport between
students and researchers. All questions
were answered and detailed explanation
was given to obtain their acceptance and
cooperation during conducted the
interview session. Data collected through
individual interview with student using
different tools. Sources of stressors
Questionnaire took about 15-20 minutes
to be filled by students and 5 minutes to
score. Coping Orientation for Problem
Experiences (COPE) Questionnaire took
about 15-20 minutes to be filled by the
students.
Statistical analysis
The data were analyzed using the
Statistical Package for the Social
Sciences statistical software ( SPSS 18).
The internal consistency of all tools of
the questionnaires were assessed by
calculating Cronbach‘s alpha. In addition
34
July 2015
Stress and Coping Strategies.
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, descriptive and inferential statistics are
used.
related to health status, life style and
educational environment
Table (6): Showed mean scores of
highest coping strategies that used by the
students were; avoid situation, escape
from situation, being independent,
development of social support, solving
family problems (22.0000 +9.66437 ,
21.5161 + 4.57436 , 19.0645 +4.39648 ,
18.7742 +5.58396 , 17.6452 +5.13516 )
respectively.
Table (7): described a highly significant
difference between student's coping
strategies according to gender. Wher for
(t-test=3.965, P=0.001 ). For most of the
domains, there were statistically
significant difference in using coping
strategies (Emotional out let, Avoid
situation through peer experiences,
Family problem solving, Professional
support, Joking, and different activities)
respectively.
Table (8): Revealed the difference
between student's coping strategies and
level of education. There were statistical
significant relations between students'
coping strategies as escape from
situation domain, relaxation, family
problem solving and different activities
and their level of education respectively.
Table (9): showed student's coping
strategies according to type of residence,
there were statistically significant
between type of resident and domains of
student's coping strategies (Emotional
out let, Escape from situation,
Development of social support, Family
problem solving, Professional support,
and different activities) respectively.
Table (10 ): showed the highest
percentage of coping strategies among
nursing students were complaint to
friends 37.1%, escape from situation as
sleeping
55.2%
and
listen
to
music43.5%, development of social
support as say good for others 62.5%,
Results
Table (1): Of the 480 students, 293
(61.3%) were females, 187 (38.7 %)
were males , (31.2%) were first level,
(27.1%) were second level, (25% ) were
third level and (16.7%) were fourth
level. About two thirds of them (64.8%)
were resident at their home, while 35.2%
were resident in the hostel.
Table (2): There were statistically
significant differences between mean
scores of male and female students'
stressors in relation to" health- related
stressors "and" life style stressors"( ttest= -2.347 at p 0.019 , t- test= -2.919 at
p = 0.004 respectively), and there was
statistically
significant
differences
between
"educational environment
stressors" t- test= 2.843 at p 0.005.
Tables (3): Mean scores of highest
items that considered as sources of
students studying stressors were frequent
exams (theoretical and clinical), feeling
anxious as a result of instructors
discrimination among students in;
increase stress during exams that lead to
lifestyle changes routine administrative
procedures in the faculty stressors
(4.2167 , 5.1375 , 4.4042 , 4.2729 )
respectively.
Tables (4): There were statistically
significant differences regarding students
educational levels and their studying
stressors where F- test =25.31 . For
studying stressors, Health related
stressors, life style stressors, and
educational environment stressors F- test
were =24.48 , 12.63 , 19.82, 3.26
respectively.
Table (5): demonstrated
type of
resident and their stressors. There were
statistically
significant
difference
between students' residence and stressors
35
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Try to reach a decision by myself
60.5%, Help others to solve their
problems 64.4%, work useful things for
the family 38.6%, resorting to prayer
frequently 50.7%, get close to friend you
love 46.4%, and resorting to jokes and
kidding 37.9%.
Table (1): Demographic characteristics of the subjects (n=480 )
Demographic Characteristics
Number
Gender:
187
 Male
293
 Female
Total
480
Level of Education:
150
 First
130
 Second
120
 Third
80
 Fourth
Total
480
Residence:
169
 Hostel
311
 At home
Total
480
Percentage
38.7
61.3
100
31.2
27.1
25.00
16.7
100
35.2
64.8
100
Table (2) Comparison between males and females mean scores in relation to
stressors (n=480 )
Stressors
Gender
t
P
Male =187
Female =293
Mean +SD
Mean +SD
Studying
71.64+12.55
62.14+13.77
1.949
0.052
stressors
Health
110.98+18.95
112.71+34.55
2.347
0.019 **
stressors
Life style
35. 27+6.08
35.27+9.68
2.919
0.001 ***
stressors
Educational
31.72+7.05
28.46+7.90
2.843
0.005 **
environment
stressors
Total
249.70+37.62
237.87+52.50
1.021
0.308
** P< 0.01
***P< 0.001
36
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Tables (3) Mean scores of sources of stress among nursing students (n=480 )
stressors
Studying stressors :
1-Frequently exams (theoretical and clinical).
2-A lots of researches and academic demands annoyed me.
3-Annoyed me to determine time of study.
4- Annoyed me faculty members obligated standards of quality.
Health stressors
1- Feeling anxious in response of instructor's discrimination.
2-Anxiety caused my distraction and poor concentration
3-Study was considered to me psychological stress.
4-I suffered from frequently psychological conditions as frustration
and anxiety
Stressors life style:
1-Life style changes.
2-I feel tired and exhausted due to daily commuting
3- Difficulty in study affecting sleeping.
4-Changes in the social pattern affecting me negatively
Educational environment stressors :
1-Annoyed me some routine administrative procedures in the
faculty.
2-Annoyed me overcrowding sets and classes for students
3- Annoyed me the lack of cleaning and equipped bathrooms in the
college.
4-College does not pay much attention to students' complaints
Mean
4.2167
3.9646
3.8771
3.8167
5.1375
4.1146
4.0896
4.0271
4.4042
4.1938
4.1458
3.5417
4.2729
4.1375
4.0021
3.7125
Tables (4): Mean scores of sources of students' stressors and their educational level
(n=480 )
Stressors
Levels of education
Studying
stressors
Health related
stressors
Life style
stressors
Educational
environment
stressors
Total
F
p
First =150
Mean+SD
Second =130
Mean +SD
Third =120
Mean+SD
Fourth =80
Mean +SD
58.93+15.52
65.85+9.66
72.03+11.18
69.35+15.70
24.48
0.001 ***
101.66+37.60
113.84+12.45
122.90+27.86
112.30+28.20
12.63
0.001 ***
31.78+11.29
35.97+6.78
39.28+3.60
35.70+7.16
19.82
0.001 ***
28.46+9.27
29.34+7.52
31.25+5.48
30.45+7 .52
3.26
0.021 **
218.98+57.40
245.02+24.57
265.47+37.48
247.80+50.32
25.31
0.001 ***
** P< 0.01
***P< 0.001
37
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Table (5) Relation between student's stress and residence (n=480 )
Stressors
Resident
Hostile =169
At home =311
Mean +SD
Mean +SD
Stresses resulting
67.52+14.40
64.90+13.83
1.94
from study
Health status
107.78+32.87
114.36+27.26
2.34
t
p
0.052
0.019**
life style
33.92+7.63
36.27+8.79
2.91
0.004***
Educational
environment
Total
31.08+5.11
28.99+8.77
2.84
0.005**
239.45+48.02
244.09+47.37
1.02
0.308
** P< 0.01
***P< 0.001
Table (6) Mean scores of most frequent coping strategies used by students (n=480 )
Coping strategies
Mean +SD
Emotional out let
13.4516 +3.83700
Escape from situation
21.5161 + 4.57436
Relaxation
11.3548 +3.86909
Independency
19.0645 +4.39648
Development of social support
18.7742 +5.58396
Family problem solving
17.6452 +5.13516
Avoid situation through peer experiences 22.0000 +9.66437
Professional support
5.8710 +2.27658
Joking
4.9355 +1.84274
Different activities
10.9677 +3.64677
Laughing
15.8387 +52.98182
Total
161.4194 +61.18321
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Table (7): Mean scores of student’s coping strategies according to gender (n=480 )
Gender
Coping strategies
t-test
p
Male=186
Female=294
Mean +SD
Mean +SD
1- Emotional out let
12.50+3.13
13.74+4.42
-3.342
0.001***
2- Escape from situation
22.95+8.92
22.90+5.48
0.071
0.943
3- Relaxation
10.47+3.61
9.77+3.76
1.999
0.046**
4- Independency
18.75+3.95
19.19+4.81
-1.033
0.302
5- Development of social
19.47+2.80
18.86+3.27
2.128
0.034**
support
6- Family problem solving
18.04+3.87
16.29+4.73
4.2 0.001***
25
7- Avoid situation through
21.80+4.83
19.92+5.68
3.7 0.001***
peer experiences
37
8- Professional support
6.61+1.35
5.46+2.02
6.8 0.001***
41
9Joking
5.38+1.22
4.79+2.03
3.599
0.001***
10Different activities
11.98+2.25
10.12+3.16
6.969
0.001***
11Laughing
7.93+21.66
5.20+1.67
2.150
0.032**
Total
155.94+29.99
146.29+23.06
3.965
0.001***
** P< 0.01
***P< 0.001
Table (8): Relation between student's coping strategies and level of education
(n=480 )
Level of education
First =150
Second
Third=120
Four=80
Coping strategies
F
Mean+SD
=130
Mean+SD
Mean+SD
Mean+SD
13.20+4.87
1- Emotional out let
12.78+3.60
13.68+3.61 13.62+3.74 1.371
24.83+7.12
2- Escape from situation
21.66+7.65
22.66+4.45 22.56+8.08 5.067
10.95+4.42
3- Relaxation
9.59+3.36
9.67+3 .31
9.98+3.45
3.796
19.06+5.03
4- Independency
19.56+4.11
18.70+4.07 18.43+4.86 1.375
18.91+3.05
5- Development of social
19.42+4.07
18.75+2.08 19.30+2.27 1.299
support
17.00+4.30
6- Family problem solving
17.66+4.93
15.95+3.41 17.15+5.14 3.348
20.56+5.47
7- Avoid situation through
21.28+6.74
19.78+3.43 20.91+5.01 1.777
peer experiences
8- Professional support
5.86+1.96
5.73+1.80
6.06+1.93
6.05+1.77
0.810
9- Joking
5.14+1.95
5.00+1.56
5.03+1.64
4.82+1.98
0.550
10Different activities
11.59+3.28
9.33+2.62
11.55+2.10 10.85+3.18 18.218
11Laughing
8.24+24.14
5.41+1.80
5.18+1.06
5.56+1.52
1.555
150.03+26.44
147.05+18.38
149.26+20.96
Total
152.82+33.32
1.094
** P< 0.01
***P< 0.001
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p
0.251
0.002 **
0.010 **
0.250
0.274
0.019 **
0.151
0.489
0.649
0.001***
0.200
0.351
Stress and Coping Strategies.
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Table (9): Student's coping strategies according to type of residence (n=480 )
Resident
Hostel =169
At home
Coping strategies
t-test
p
Mean +SD
=311
Mean +SD
1- Emotional out let
12.6+2.97
13.85+4.37
- 4.497 0.001***
1Escape from situation
20.13+4.18
24.43+7.73
- 6.710 0.001***
2Relaxation
9.88+3.70
10.13+3.72
- 0.696 0.487
3Independency
18.60+4.73
19.25+4.36
-1.492 0.136
4Development of social
19.81+3.11
18.71+3.04
3.738
0.001***
support
5Family problem solving
18.57+4.60
16.09+4.19
5.982
0.001***
6Avoid situation through
20.95+4.06
20.48+6.06
0.903
0.367
peer experiences
7Professional support
6.40+1.80
5.64+1.87
4.279
0.001***
8910-
Joking
Different activities
Laughing
Total
** P< 0.01
5.14+1.55
11.68+2.58
11.68+2.58
10.39+3.09
6.09+1.67
6.35+16.84
149.47+19.82 150.33+29.33
***P< 0.001
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1.131
4.583
-202
-343
0.259
0.001***
0.840
0.732
Stress and Coping Strategies.
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Table (10 ): Coping strategies among nursing students (n=480 )
Most of
the time Somewhat
Coping strategies
Mean +SD
%
%
Emotional out let :
1-Complaint to friends.
2.9021
2-Complaint to family members.
2.7021
3-Crying for trivial reasons.
2.6313
4-Feeling angry and shouting at others. 2.5958
Escape from situation :
1- Sleeping.
3.8896
2- Listen to music.
3.1750
3- TV Show.
3.0979
4- Play video games.
2.8417
Relaxation :
1- Enjoy hobbies.
2.8646
2- Eating Gluttony.
2.4792
3- Enjoy vigilance dreams.
2.4083
4- Cycling and Motorcycles.
2.2958
Independency :
1-Try to reach a decision by myself.
3.6229
2-Organize my lifetime to be suited me. 3.5750
3-Think about the positive things.
3.5313
4-Work seriously.
3.1396
Development of social support:
1-Say good for others.
3.5750
2-Help others to solve their problems.
3.5750
3-Keep friends and establish new
3.5125
friendships.
Talk to others about what I feel.
3.1979
Family problem solving
1-Work useful things for the family.
3.1563
2-Talk to the brother or sister about
2.9729
what annoys me
3-Approval of the opinion / request a
2.9167
parent.
4-Talk to the parents and try to reach a
2.7187
compromise solution.
Avoid situation through peer experiences
1-Resorting to prayer frequently.
3.4250
2-Talk to the cleric
2.9208
3-Go to the religious places Mosque /
2.8750
Church.
4-Away from home for long as possible. 2.8521
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Never
%
37.1
23.1
22.3
16.7
20.8
37.9
30.6
40.6
42.1
39
47.1
42.7
55.2
43.5
42.1
38.7
25.0
25.6
22.7
17.1
18.6
30.6
35.2
44.1
32.1
23.1
25.2
26.7
22.3
27.7
18.3
9.8
45.6
49.2
56. 5
43.5
60.5
51.9
53.3
42.1
19.8
32.1
34.8
34.2
19.8
16
12.1
23.6
62.5
64.4
24.0
23.3
13.6
11.3
47.3
41.5
11.5
39.4
39.0
21.6
38.6
32.7
28.7
31.2
34.8
34.0
31.6
24.4
44.0
39.3
39.0
21.7
50.7
15.9
33.5
56.0
16.0
38.1
36.1
31.9
31.0
23.6
40.6
35.8
Stress and Coping Strategies.
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Professional support :
1-Get close to friend you love
3.1333
46.4
26.3
27.3
2-Get close to boyfriend / girlfriend of
2.7792
33.3
29.0
37.7
the opposite sex.
Joking
1-Resorting to professional counseling.
2.5229
15.4
36.7
47.9
2-Talk about what harassing you during
2.5000
15.4
36.5
48.1
professional counseling.
Different activities
1-Attempt to self-improving (get better
3.1292
34.8
42.9
22.3
grades – get fit body).
2-Attempt clearer methods that lead to
2.9396
31.9
36.9
31.2
solve problems.
3-Seriously deal in various activities
2.7125
23.5
37.9
38.6
and projects at the college
4-Exercise violently
2.0688
17.1
16.0
66.9
Laughing
1-Resorting to jokes and kidding
3.6750
37.9
26.5
35.6
2-Laugh not interested of the problem
2.5896
17.5
30.0
42.5
nursing students were females. Higher
prevalence of stress in female
Discussion:
studentsthan male students. This could
This study aimed to investigate
be due to their experience of working in
the sources of stress and the coping
an environment still largely populated by
strategies used by nursing students to
men than women, though this was
overcome their stress.
University
considerably over the years. These
students, however, often experience an
results supported by Lee, et al. (2011 ).
undue amount of stress, which can have
Who conducted a study to assess the
negative academic, emotional, or health
prevalence of Gastrointestinal symptoms
outcomes. This can occur at different
in Korean students which revealed that
time periods during a semester or years
(68) males (9.6%) and 641 females
of study, during the transition from
(90.4%) participated in this study.
undergraduate to professional or
Although gender differences were
graduate programs, or upon graduation.
reported among general university
Stress in university students has many
students, it has not been confirmed in
sources, including academics, personal
medical, dental, and nursing students
situations, environment, time, and
(Shen, Kong, & Hou. 2009 ).
economic circumstances.
As regard to gender (Table: 2)
Demographic characteristics of the
showed
that no difference was found as
nursing students:
regard perceived stress. This could be
The distribution of the sample
explained as the nursing students have
according to gender, level of education
the same academic stress and appeared
and type of residence of the present
to be mostly caused by heavy workload
study (Table: 1) showed that more than
and frequent exams. These findings were
half of the sample 61.3% were females
consistent with the previous study by
while the rest of the sample were males.
Evan, & Kelly (2004 ) who concluded
These results may be due to that most of
42
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that the nursing students have the same
stressors such as exams, papers, and
other assignments, preparatory work
before their clinical assignment were
highly stressful.
Regarding relation between
gender and health status stressors,
(Table:2) showed statistically significant
difference (t-test=-2.347 , P=0.019). This
result could be interpreted as the male
students tend to argue more frequently
with their parents over financial matter,
and can express feelings to their friends
when they become depressed. Female
students are more stressed in crowding
area, are often confused and they face
difficulties in decision making. Recently,
Mazumdar, et al. (2012), reported that,
the various symptoms which lead to
stress are mostly seen in more
percentage in females as compared to
males. Calaguas, (2011) demonstrated
five major provenances among the
females that respectively are failing in
their exams, the pressure of exams, to be
rejected by someone, the break up in
their relations and finally financial
problems.
Concerning relationship between
life style stressors and gender (Table:2)
showed that a significant statistically
differences (t- test =-2.919 , P = 0.004).
These results could be explained that, the
symptoms of stress were more during
exams, daily hassles, change sleep
patterns and negative changes in social
relations. These results were congruent
with Shaik, et al. (2004 ) who found a
positive relation between gender and life
style stressors among students and
highlighted the most common reasons
were exams and homesickness, family
and relationships problems.
As regarding relation between
gender and educational environment, the
present study (Table:2) indicated that,
there
was
statistical
significant
difference
between
gender
and
educational environment stress. This
result could be interpreted as educational
environment induces stress due to lack
of familiarity with operating procedures
and with hospital complexity of the
working environment, lack of familiarity
with regulations of the faculty and
learning incompetence. These results
were supported by Kaur et al. Al. (2009 )
who revealed that, more than 80% of the
students were stressed because of too
many assignments, long college hours,
study overload, and restrictions in the
college. About three fourth of the
students, the stressors experienced were
short holiday breaks, long hours of
working in the clinical areas, incomplete
log books, nursing as a profession and
lack of guidance in the ward. In the same
context, Kumar, & Bhukar. (2012 )
proved that, a healthy lifestyle is an
essential companion to any stress
reduction program.
As regard level of education, the
present study (Table:4) revealed that, it
has significant relations with students
stress (studying stress, health stress
lifestyle and educational environment)
and level of education. These findings
showed that more than one third of the
sample were first level, more than one
fourth of them (27.1%) were third level ,
one fourth of the sample (25%) were at
second level and the rest of the sample
were at forth level of education. Also,
this was congruent with the findings of
another study where the level of stress
increased progressively during the
course, to reach as high as 40% by the
end of the clinical training period
(Abdulghani, et al. 2011).
These
findings
could
be
explained as the level of stress increases
as the year of study level is progressed.
43
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Students are starting to shift from a life
that is dependent on others to a life that
needs them to release the dependency
and
start
carrying
their
own
responsibility. In addition, these findings
showed more stressors with students
were related to frequently exams
fatigued, a lot of researches and
academic demands annoyed me, to
determine time of study and faculty
members obligated standards of quality.
These findings were consistent
with the findings of an Iranian study
conducted by Seyedfatemi, et al. (2007)
among nursing students. This may be
due to students face more of stressors
when they come to faculty during first
year of their training because of being
placed in an unfamiliar environment,
separation from parents and the demand
of making new social group apart from
academic pressures and clinical training.
However, the nursing students were
constantly
facing
demands
and
challenges of the curriculum which had
being a source of stress during their total
training program.
Another study done by Evan &
Kelly. (2004 ) who concluded that,
nursing students have the same academic
stressors as other college students, such
as midterm and final exam-inactions,
research papers and other assignments.
In addition, nursing students experience
a clinical component, which is highly
stressful. Besides, students have a large
amount of preparatory work before their
clinical assignments.
Concerning students stress and
type of residence, Results of the present
study (Table:5) proved that, 64.8% of
students stayed at home and the rest of
the sample stayed in residence. These
findings could be interpreted as increase
stress with students staying at resident
due to away from family, the pressure to
earn good grades and to earn a degree is
very high. Parental expectation pressure,
peer rivalry, political conflicts, love
affairs, and lack of adequate socializing
opportunities. Academic requirements
relation with faculty members and time
pressures. In addition, relationships with
family, friends, eating, sleeping habits
and loneliness may affect students
adversely may also be source of stress.
The present study findings
showed that there were significant
relations between coping strategies with
selected demographic variables such as
gender, and
place of living ( ttest=3.965 , P 0.001 ). About 95% of the
participants were staying in the
hostel. The findings of the present study
were inconsistent with Prasad et al.
(2013 ) who conducted a study in Punjab
to assess the stress level and coping
strategies among nursing students. The
sample size was 180, the results of the
study showed that, there were no
significant associations between the
coping
strategies
with
selected
demographic variables (as age, gender
and place of living).
As regards the most coping
strategies used by nursing students as
showed in table (10) proved that the
percentage of coping strategies among
nursing students were complaint to
friends37.1%, escape from situation as
sleeping
55.2%
and
listen
to
music43.5%, development of social
support as say good for others 62.5%,
work useful things for the family 38.6%,
resorting to prayer frequently 50.7%, get
close to friend you love 46.4%, and
resorting to jokes and kidding 37.9%..
These results could be interpreted as the
student trying to overcome stress by
seeking help, stay around people, tension
reduction, talking to another seeking
social support and relaxation. These
44
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results were supported by Sharma, &
Kaur, (2011 ) who concluded that,
nursing students have different top most
of the coping strategies as listening to
music, praying to God and sharing and
seeking help during stressful situations
(88%), staying around people (58%).
of stress among students in all
the four years of undergraduate
nursing years and the associated
factors.
- Based on the results, it is
suggested to implement stress
management programs in formal
and informal curriculum for
nursing students.
- Therefore, future studies are
needed to investigate the
relationships among gender,
perceived stress between nursing
students and others types of
students
ACKNOWLEDGEMENTS:
The authors gratefully acknowledge all
those nursing students who participated
in and contributed to the study.
References
1. Abdulghani, H., AlKanhal,A.,
Mahmoud, E., Ponnamperuma,
G., & Alfaris, E.
(2011 ). Stress and Its Effects on
Medical Students: A Crosssectional Study at a College of
Medicine in Saudi Arabia. J
Health Popul Nutr. 29(5): 516–
522.
Limitations
This
study
has
several
limitations. First, current study students
consisted of a convenience sampling that
might influence the generalizations of
current results to the nursing students in
Egypt. Second, the design of this study
was cross-sectional, which does not
allow for a causal interpretation of
current results.
Conclusion:
It is clear that the Egyptian
student nurses were exposed to a variety
of sources of stress were frequent exams
fatigued in relation to studying stressors,
I feel anxious of discrimination among
students in relation to health stressors,
increase stress during exams that
affected on my lifestyle in relation to
lifestyle stressors, routine administrative
procedures in the faculty in relation to
educational environmental stressors.
The highest percentage of coping
strategies among nursing students were
complaining to friends 37.1%, escape
from situations as sleeping 55.2% and
listen to music43.5%, development of
social support as say good for others
62.5%, work useful things for the family
38.6%, resorting to prayer frequently
50.7%, get close to friends you love
46.4%, and resorting to jokes and
kidding37.9%.
Recommendation:
- Another longitudinal study could
be carried out with a cohort of
students to investigate the levels
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EL-Nady, M., &
Fayad, E. (2011). Sources of Stress
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Stress on Male and Female
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among Iranian Nursing Students.
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OALib
PrePrints
|
http://dx.doi.org/10.4236 /oalib.p
reprints.1200040 | CC-BY Open
Access Received: 2014/06/15 ,
published: 2014/06/16 .
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Effect of Nursing Guideline Instructions.
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Effect of Nursing Guideline Instructions on the Incidence of Post Cardiac
Catheterization Complications
Sahra Zaki Azer1 ; Nagwa Mohamed Ahmed2 ; Sahar Ali Abd-El mohsen3
1, 2, & 3 Lecturer Adult Nursing Dept., Faculty of Nursing, Assiut University, Egypt.
Abstract:
The present study aimed to investigate the effect of nursing guidelines instructions on the incidence of post
cardiac catheterization complications among cardiac catheterization patients. Design; quasi-experimental
design. Setting: This study was conducted at the cardiac catheterization unit at Assiut University Hospital.
Sample: A purposive 60 adult patients, having the following criteria; age between 20 – 65 years who were
randomly assigned into two equal groups (study and control group) 30 patients for each. The study group
received the nursing guidelines, while the control group received routine hospital care. Tools: data were
collected utilizing the following tools; 1 The Structure Interview Questionnaire, 2 Nursing Guidelines
Instructional sheet, and 3) Cardiac catheterization complications assessment sheet. Results: the study
findings revealed that the majority of the study subjects were male, married, and more than half of them
their age has ranged from (50 to 60 years), less than half of the studied sample were overweight and the
incidence of local, respiratory and gastrointestinal complications was much more higher in the control
group than in the study group. Conclusion: A highly statistical significant difference was found between
both the study and the control group regarding incidence of local complications, pneumonia,
gastrointestinal complications, while there was no statistical significant differences regarding circulatory
and urinary complications. Recommendion; A nursing guidelines booklet must be available to be applied
for patients undergoing cardiac catheterization to decrease incidence rate of post cardiac catheterization
complications.
Key words: Nursing guidelines, cardiac catheterization, complications.
doctor will take x-ray pictures of the
heart. The dye will make the coronary
arteries visible on the pictures. This test
is called coronary angiography. The dye
can show whether a waxy substance
called plaque has built up inside the
coronary arteries. Plaque can narrow or
block the arteries and restrict blood flow
to the heart. Ultrasound during cardiac
catheterization to see blockages in the
coronary arteries. Ultrasound uses sound
waves to create detailed pictures of the
heart's blood vessels. Samples of blood
and heart muscle during cardiac
catheterization or minor heart surgery
can be done during the procedure (Gary
& Gibbons, 2014). The test may last 30
- 60 minutes or longer if need special
procedures
(American
Heart
Association,
2007 ).
Percutaneous
1- Introduction:
Cardiac catheterization is a medical
procedure used to diagnose and treat
some heart conditions. A long, thin,
flexible tube called a catheter is
introduced into a blood vessel in arm,
groin (upper thigh), or neck and threaded
to the heart. Through the catheter, the
doctor can do diagnostic tests and
treatments on the heart can be done
(Gary & Gibbons, 2014). Cardiac
catheterization is used in the diagnosis
and evaluation of congenital, rheumatic,
and coronary artery lesions, thrombus in
coronary vessels, and to evaluate systolic
and diastolic cardiac function (Chulay &
Burns, 2007 ).
A special type of dye in the catheter may
be used. The dye will flow through the
bloodstream to the heart. Then, the
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coronary intervention (PCI) is similar to
coronary angiogram, but it is used to
open up a narrowed coronary artery with
special tools. The two common types of
PCI are: angioplasty with or without
coronary stents and atherectomy (Fraker,
et al. 2007 ).
Nurse's role in cardiac catheterization
lab is divided into; a) preparatory nurse
will be responsible for vital signs,
cannula insertion, ECG, prepare
medication, attain and document
patient's
history
for
allergy
(hydrocortisone), consent form, shaving,
and checking lab investigation as kidney
function test (KFT) – prothrombin time
(PT) – partial thromboplastin time (PTT)
– international ratio (INR) – complete
blood picture (CBC) –and Hepatitis
screen. b) Scrub nurse: responsible for
disinfection of site, draping, flushing, &
positioning. c) Control nurse: observing,
recording, documenting, & emergency
intervention. d) Recovery nurse:
responsible
for
sheath
removal,
monitoring,
post
catheterization
medication, & hydration for the patient
(Admin, 2011).
Patient preparation; the patient does not
eat or drink for 6 - 8 hours before the
test. The test takes place in a hospital
and the patient will be asked to wear a
hospital gown. Sometimes, the patient
will need to spend the night before the
test in the hospital. Otherwise, the
patient will be checked into the hospital
the morning of the procedure. The health
care provider should explain the
procedure and its risks. A witnessed,
signed consent form for the procedure is
required (Kern, 2001 ). Ask the patient
about any allergy to seafood or any
medications, previous reaction to
contrast dye or iodine, taking any
medicines, including Viagra or other
drugs for erectile dysfunction, and
pregnancy (Admin, 2011).
After cardiac catheterization, the patient
will be moved to a special care area, rest
there for several hours or overnight.
During that time, the patient will have to
limit the activity to avoid bleeding from
the site where the catheter was inserted.
In the recovery area; nurses will check
the heart rate and blood pressure
regularly. They also will check for
bleeding from the catheter insertion site.
A small bruise might form at the catheter
insertion site, and the area may feel sore
or tender for about a week. Unusual
pain, swelling, redness, or other signs of
infection at or near the insertion site
must be reported immediately. The
patient should be advised to avoid
certain activities, such as heavy lifting,
for a short time after the procedure
(Brinker, Davidson, & Laskey, 2005 ).
Applying pressure to the incision site for
about thirty minutes manually or with a
mechanical compression device; dress
the wound with adhesive bandages or
clear occlusive dressing (for pressure)
was done to protect the area and permit
visualization of the wound and allow the
nurse to absence bleeding that could
occurs and therefore take appropriate
action (Baim, 2006 ). The nurse should
ensure the patient is on bed rest for 8
hours after this procedure. If the catheter
was inserted through the femoral artery,
keep the patient's leg extended for 6 to 8
hours. If it was passed through the arm,
then keep it extended for at least 3 hours
(O‘Grady, 2007).
Monitoring vital signs every 15 minutes
for two hours after the procedure, then
every 30 minutes for two hours and then
every hour for another two hours. Then
check the vital signs every four hours if
there is no bleeding. Monitor the patient
every 5 minutes and notify the physician
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Effect of Nursing Guideline Instructions.
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if there is instability of vital signs after
cardiac catheterization (John & Sons,
2007), Assess patient's color, skin
temperature and pulses below the site of
catheter insertion. If the patient
underwent a cardiac catheterization
through the arm, the arm may be cool to
the touch and have weak pulses; this
condition typically resolves itself within
24 hours (O‘Grady, 2007 ). Schedule an
electrocardiograph (ECG) after the
cardiac catheterization procedure is
recommended to check for any damage
to the heart (Tortora & Derrickson,
2006).
Cardiac
catheterization
is
most
commonly used to diagnose coronary
artery disease and assess suitability for
revascularization. These procedures
include angiography, ventriculography
and right or left catheterization. As these
procedures are invasive, they are carried
out in a sterile fluoroscopy suite, also
referred to as a catheterization laboratory
(cath lab) (Brinker, Davidson, and
Laskey, 2005 ).
Risk of complications during left
ventriculography include patients with;
severe symptomatic aortic stenosis,
severe congestive heart failure or angina
at rest, left ventricular thrombus,
especially if mobile or protruding into
the left ventricle cavity, and left-sided
endocarditis (John et al., (2011 ).
The most common problem during rightsided
heart
catheterization
is
arrhythmias. From stimulation of the
right-ventricular outflow tract, which
may result in atrioventricular, block or,
rarely, right bundle branch block. The
majority of these arrhythmias are
transient and do not require treatment.
However, patients with known left
bundle branch block may require a
temporary pacemaker if right bundle
branch block occurs during right-sided
heart catheterization (O‘Grady, 2007 ).
Complications of catheterization include;
Cardiac tamponade, heart attack, injury
to a coronary artery, irregular heartbeat,
low blood pressure, reaction or kidney
damage due to the contrast dye (more
common in patients with diabetes or
kidney problems), and stroke (Julian,
Cowan, & McLenachan, 2005). Others
local complications may be occur as
bleeding, infection, and pain at the IV or
sheath insertion site, damage to the
blood vessels, and blood clots (Brinker,
Davidson, & Laskey, 2005).
1.1 . Aim of the study:
The aim of this study was to investigate
the effect of nursing guidelines
instructions on the incidence of post
cardiac catheterization complications.
1.2 . Research hypothesis:
After implementing nursing guideline
instruction, the study group will have
less
post
cardiac
catheterization
complication than the control group.
2. Subjects and methods:
2.1 . Design: Quasi-experimental study
design was utilized.
2.2 . Setting: This study was conducted in
the cardiac catheterization unit at Assiut
University Hospital.
2.3 . Sample:
60 adult male and female patients who
underwent cardiac catheterization were
included with the following criteria; age
between 20 – 65 years. Patients were
randomly assigned into two equal groups
(study and control group) 30 patients for
each. The study group received the
nursing guidelines, while the control
group received routine hospital care.
2.4 . Tools: Data of this study was
collected using the following tools:
2.4.1 .
Structure
Interview
Questionnaire: it was designed by the
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researcher based on literature review and
it included two parts:
Part one: Sociodemographic data about
the patients (age, sex, marital status,
educational level).
Part two: Patient Medical related
data: it includes; a) Medical history; as
common cardiovascular symptoms
(chest pain, palpitation, dyspnea, cough,
edema, extermity pain, nocturnal
dyspnea, and fatigue. b) Health habits
such as use of tea and coffee, use of
alcohol, smoking, and exercise. Risk
factors assessment (smoking, diabetes
mellitus, obesity ...etc), family history.
c) Physical examination; inspection
(face, thorax, abdomen, and cyanosis of
nail beds, lower extremities), measuring
of pulse and blood pressure, inspect
capillary refill, and edema.
2.4.2. Nursing
Guidelines
Instructional Sheet: it was developed by
the researchers based on literature review
and it included three parts: Part (1):
Information about anatomy of heart and
its function, meaning of heart disease,
definition of cardiac catheterization,
indications, complications and diagnostic
investigations done before cardiac
catheterization. Part (2): Nursing care
for cardiac catheterization: it includes
information about nursing care before,
during and after cardiac catheterization.
Part (3): Discharge instructions:
it
included instructions about rest and
sleep, exercise and walking, fluid intake
and output, nutrition, shower, lifting,
driving, work, smoking, indications for
doctor's advice and follow-up.
2.4.3.Cardiac
Catheterization
Complications Sheet:
It was developed by the researcher to
assess
cardiac
catheterization
complications depending on review of
national and international references. It
included; local complications as
bleeding, haematoma, pain, numbness,
swelling, edema and local wound
manifestations of infection. Systemic
complications
as
respiratory
complications
(pneumonia
and
respiratory
failure),
circulatory
complications (arterial or venous
infection, hypovolemic shock, stroke,
myocardial infraction, and heart failure),
urinary complications (urinary retention,
urinary tract infection, and kidney
failure),
and
gastrointestinal
complications (nausea & vomiting,
constipation, and paralytic ileus).
2.5 . Administrative approval:
Official approval and administration
permission was obtained from the head
of cardiac catheterization department to
collect the necessary data, the aim of the
study and the nursing guidelines
instructions were explained to them to
obtain their cooperation.
2.6 . Ethical consideration:
The study was approved by an
institutional ethics committee, informed
consent was obtained from patients to
participate in the study and the nature and
purpose of the study were explained. The
researcher initially introduced themselves
to all patients and they were assured that
the collected data will be absolutely
confidential. They were informed that
participation is voluntary and they can
withdraw at any time of the study.
2.7 . Validity:
The tools were tested for content validity
by 5 expertises from the cardiac
catheterization department and nursing
staff for content validity and reliability,
modifications were done accordingly
then the tools were designed in its final
format.
2.8 . Pilot study:
A pilot study was conducted during May
2013. It included 6 patients, in order to
test the clarity and applicability of the
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tools. Those patients who were involved
in the pilot study were included in the
study.
3. Data collection: The data collected
over a period of 6 months starting
from June 2013 till the end of
November 2013 . Data collection was
done through the following phases:
A. Assessment phase:
The researcher interviewed the patients
individually and took their oral
agreement to participate and they
answered the questions in the interview
questionnaire. Initial assessment for
study and control group was done and
recorded.
B. Implementation phase:
1. Patients were interviewed pre cardiac
catheterization and the guidelines
were explained by the research.
2. Four
teaching
sessions
were
conducted for each patient in addition
to one assessment session.
 The
first
session;
included
information related to heart function,
meaning of heart disease, cardiac
catheterization,
indications,
complications and diagnostic studies
procedure
related
to
cardiac
catheterization. The time taken for this
session was 20 to 30 minutes.
 The second session; the researcher
provided information about nursing
preparation
before
cardiac
catheterization from arrival of the
patient to the ward, recording the
patient‘s biographical details and past
medical history and allergy status.
Record the patient‘s height and weight.
Check that the patient had shaved
appropriately and a theatre gown is
available and the patient will be asked
to wear it for the procedure.
Information about the day of the
procedure and information about
nursing care during procedure. The
time taken for this session was 20 to
30 minutes.
 Third session: Information about
nursing care post procedure: Patients
should be advised to keep their leg
straight, and press over the puncture
site before coughing or sneezing. They
should inform nursing staff if they feel
any blood, wetness or stickiness. The
heart rate and blood pressure should be
recorded half-hourly. Patients should
be encouraged to drink plenty of fluid
following the procedure in order to
compensate for the diuretic action of
the contrast dye, as well as to flush out
the myocardial and vascular depressant
drugs in their system, and to prevent
hypotension. The time taken for this
session was 20 to 30 minutes.
 The
fourth
session;
included
information related to discharge
instructions for cardiac catheterization
patients. Prior to discharge, the patient
should be instructed about puncturesite care, and informed of any signs
and symptoms which require a
doctor‘s review such as sudden or
severe pain at puncture site, bleeding
at the site of puncture, burning
sensation and change skin color around
the puncture site, tingling or numbness
or sudden coolness in the leg, chest
pain, tachycardia, shortness of
breathing, redness, warmth or drainage
at the puncture site or the patient have
an unexplained fever. Inform the
patient about the medication that they
have been prescribed so that they will
take it correctly at home. The taken for
this session is 60 minutes.
 The duration of each session about 20
– 30 minutes according to patient
tolerance. The end of each session will
be make discussion and feedback,
except for the session for discharge
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instruction, which will be take 60
minutes.
C. Evaluation phase:
To evaluate incidence of post cardiac
catheterization complications two weeks
post implementation of the guidelines.
group regarding body mass index (pvalue 0.959 ) with less than half of the
studied sample (40%) were overweight,
the majority of both the study and
control group were hypertensive (73.3 %
and 86.7 %) respectively, (40 %) of the
study group were previously admitted to
the ICU, and finally there was a
statistically
significant
difference
between the study and control group
regarding admission to the ICU before
surgery (p-value 0.037 ).
4.4: physical assessment variable:
Table (4): Shows that there was no
statistically
significant
difference
between both the study and control
group regarding patient's physical
assessment (p= 0.4), the majority of the
studied sample were having a normal
finding regarding face color (63.3%),
thorax (83.3%), abdomen (60%) and
nail beds color (70%). As regard
assessment of lower extremities; the
highest percent of the studied sample
were complaining of lower limbs pain
and edema mostly of the pitting type.
4.5: Complications assessment:
Table (5): Shows that there was a
statistically
significant
difference
between both the study and control
group regarding incidence of local
complications; in the study group (33.3
%) had pain, (16.7 %) developed
hematoma, followed by (13.3 %)
swelling. While in the control group
(66.7 %) complained of pain, (63.3 %)
developed hematoma, (56.7 %) had
swelling, (43.3 %) numbness and nearly
half of them (40 %) developed infection.
Regarding respiratory complications
(36.7 %) of the control group developed
pneumonia compared to only (6.7 %) in
the study group, looking to circulatory
complications; (16.7 %) of the control
group had hypovolemic shock followed
by myocardial infarction (10 %) while
Analysis of the results:
Data was analyzed by the computer
program SPSS" version 19 " Chicago.
USA.
3. Results: The study came up with the
following results:
4.1: Subjects' Characteristics:
Table (1): the study results revealed that the
highest percentage of the studied sample
was between the ages 50 – 60 years old.
Also there was a predominance of male in
both the study and the control group (73.3
% and 80 %) respectively, as regard level
of education; the highest frequency in the
control group were having a secondary
education (23.3 %) while in the study
group they were highly educated (23.3 %).
Looking at the occupation in the study
group the highest percentage were not
working (30 %) and an equal percent in the
control group (26.7 %) were farmers and
professional workers.
4.2: Patient medical data and health
habits:
Table (2): Shows that there was no
statistically
significant
difference
between both the study and control
group
regarding
cardiovascular
symptoms, the highest percentage in
both groups were complaining of chest
pain, palpitation, fatigue and dyspnea
(96.7 %, 90%, 96.7%, and 80%)
respectively in the study group, while in
control group (96.7%, 100%, 100% and
83.3% respectively.
4.3: Risk factors:
Table (3): Shows that there was no
statistically
significant
difference
between both the study and control
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both of these percentages were only (3.3
%) in the study group. Comparing both
groups as regard urinary complications;
(32.3 %) developed urinary tract
infection, in the control group (20 %)
urinary retention and (10 %) went
through a kidney failure while in the
study group these percentages were only
(3.3 %), and finally as regard
gastrointestinal complications; (41.4 %)
of the control group had nausea and
vomiting followed by constipation (27.6
%).
Table (1): Distribution of the biosociodemographic patient characteristics in study
sample (n = 60 ).
Study
Control
Variable
(n= 30 )
(n= 30 )
No.
%
No.
%
Sex:
Male
22
73.3
24
80.0
Female
8
26.7
6
20.0
Marital status:
Single
1
3.3
1
3.3
Married
28
93.3
20
66.7
Divorced
0
0.0
3
10.0
Widowed
1
3.3
6
20.0
Age:
18 - < 30 years
1
3.3
1
3.3
30 - < 40 years
0
0.0
4
13.3
40 - < 50 years
6
20.0
10
33.3
50- 60 years
23
76.7
15
50.0
Educational level:
Illiterate
6
20.0
6
20.0
Read & write
5
16.7
6
20.0
Primary
2
6.7
2
6.7
Preparatory
4
13.3
4
13.3
Secondary
6
20.0
7
23.3
University
7
23.3
5
16.7
Occupation:
Not working
9
30.0
6
20.0
Farmer
5
16.7
8
26.7
Professional
2
6.7
8
26.7
Hospital member
0
0.0
2
6.7
Others
14
46.7
6
20.0
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Table (2): Frequency and percentage distribution of the common cardiovascular
symptoms and health habits for study sample (n = 60 ).
Variable
Common cardiovascular
symptoms:
Chest pain
Palpitation
Dyspnea
Cough
Edema
Extremity pain
Nocturnal dyspnea
Fatigue
Health habits:
Use of tea and coffee
Use alcohol
Smoking
Exercise
Study
(n= 30 )
No.
%
Control
(n= 30 )
No.
%
Pvalue
29
27
24
11
13
19
20
29
96.7
90.0
80.0
36.7
43.3
63.3
66.7
96.7
29
30
25
11
18
24
14
30
96.7
100.0
83.3
36.7
60.0
80.0
46.7
100.0
-0.236
0.739
-0.196
0.152
0.118
0.313
25
1
11
16
83.3
3.3
36.7
53.3
30
0
17
19
100.0
0.0
56.7
63.3
0.062
0.313
0.121
0.432
Table (3): Frequency and percentage distribution of the risk factors for both study
sample (n = 60 ).
Variable
BMI:
Standard
Overweight
Obese
Diabetes
Hypertension
Chronic obstructive pulmonary disease
Previous cardiac catheterization
Admission to the ICU before surgery
Use antibiotics
Use of anti-coagulant
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Study
(n= 30 )
No.
%
Control
(n= 30 )
No.
%
12
12
6
8
22
3
12
17
20
26
11
13
6
13
26
6
10
9
20
27
40.0
40.0
20.0
26.7
73.3
10.0
40.0
56.7
66.7
86.7
36.7
43.3
20.0
43.3
86.7
20.0
33.3
30.0
66.7
90.0
P-value
0.959
0.176
0.197
0.470
0.592
0.037 *
-0.688
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Table (4): Frequency and percentage distribution of physical examination pre
cardiac catheterization for both study and control group (n= 60 ).
Variable
Face:
Pink
Cyanosis
Pale
Thorax:
Normal
Skeletal deformities
Scars
Bruises
Wounds
Abdomen:
Normal
Distension
Scars
Nail beds:
Normal
Cyanosis
Clubbing
Lower extremities
Normal
Pale
Pain
Edema
Ulcer
Jugular veins:
Normal
Congested
Pulse:
Weak and thready
Normal pulse
Hyperdynamic pulse
Capillary refill:
Normal
Delay
Edema:
Not present
Present pitting
Non-pitting
Study
(n= 30 )
No.
%
Control
(n= 30 )
No.
%
19
0
11
63.3
0.0
36.7
15
1
14
50.0
3.3
46.7
25
1
3
0
1
83.3
3.3
10.0
0.0
3.3
19
0
4
1
6
63.3
0.0
13.3
3.3
20.0
18
4
8
60.0
13.3
26.7
16
6
8
53.3
20.0
26.7
21
3
6
70.0
10.0
20.0
17
3
10
56.7
10.0
33.3
10
11
13
11
0
33.3
36.7
43.3
36.7
0.0
11
17
19
16
3
36.7
56.7
63.3
53.3
10.0
0.787
0.121
0.121
0.194
0.236
19
11
63.3
36.7
22
8
73.3
26.7
0.405
14
14
2
46.7
46.7
6.7
15
15
0
50.0
50.0
0.0
20
10
66.7
33.3
20
10
66.7
33.3
18
6
6
60.0
20.0
20.0
15
11
4
50.0
36.7
13.3
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Pvalue
0.400
0.163
0.772
0.491
0.355
--
0.342
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Table (5): Comparison of complications for both study and control group on (follow
up after 15 days from discharge) (n= 60 ).
Study
Control
P(n= 30 )
(n= 30 )
Variable
value
No.
%
No.
%
Local complications:
Bleeding
0
0.0
8
26.7
0.008 *
Hematoma
5
16.7
19
63.3
0.000 *
Pain
10
33.3
20
66.7
0.010 *
Numbness
0
0.0
13
43.3
0.000 *
Swelling
4
13.3
17
56.7
0.000 *
Edema
1
3.3
12
40.0
0.001 *
Infection
0
0.0
12
40.0
0.000 *
Respiratory complications:
Pneumonia
2
6.7
11
36.7
0.005 *
Respiratory failure
0
0.0
3
10.0
0.472
Circulatory complications:
Arterial or venous infection
1
3.3
3
10.0
0.605
Hypovolemic shock
1
3.3
5
16.7
0.197
Stroke
1
3.3
1
3.3
-Myocardial infarction
1
3.3
3
10.0
0.605
Heart failure
1
3.3
1
3.3
-Urinary complications:
Urinary retention
1
3.3
6
20.0
0.108
Urinary tract infection
1
3.3
7
23.3
0.058
Kidney failure
1
3.3
3
10.0
0.605
Gastrointestinal complications:
Nausea & vomiting
3
10.0
12
41.4
0.006 *
Constipation
0
0.0
8
27.6
0.007 *
Paralytic ileus
0
0.0
1
3.4
0.986
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Part II: Risk Factors:
The present study assessed the risk
factors contributing to the cardiac
disease that led the patient to undergo a
cardiac catheterization procedure; fifth
of the studied sample were obese, third
of them were diabetics, and the majority
of them were hypertensive; these are all
considered risk factors for development
of cardiac conditions which lead them to
undergo cardiac catheterization. In
accordance with this study result; a study
that was carried out by Morton,
Fontaine, Hudak, and Gallo, (2005) and
Rosendorff, (2005 ); Hypertension and
coronary heart disease were found to be
predictive for the development of
congestive heart failure (CHF), diabetes
mellitus also emerged as an important
risk factor for cardiac disease, with
greater risk for older women than for
older men. Other independent risk
factors for the development of CHF were
(past) smoking behavior, obesity, and
(psychological) stress.
Part III: Complications Assessment:
The present study revealed that
regarding local complications of the
cardiac catheterization; nearly one third
of the control group had site bleeding,
two thirds had hematoma, and a little
more than half of them had swelling.
This was in agreement with those of
Morton and fountain (2005 & 2009) who
mentioned that the nurse must assess site
incision for redness, swelling, and
drainage. While regarding the level of
pain; only one third of the study group
complained of pain compared to two
thirds of the control group. The present
study in the line with those of Morton and
fountain (2005 & 2009), Okkonen and
Vanhanen (2006) who emphasized that
after cardiac catheterization the patient
may experience pain resulting from the
site incision. Davidson & Bonow (2011 )
4. Discussion:
The discussion of this study was
presented in the following sequence: 1st
part describes subjects' characteristics,
2nd part displayed the findings that
highlight variable related to risk factors,
and 3rd part presents complications
assessment.
Part 1: Subjects' Characteristics:
The present study included 60
adult patients; the highest percentage of
the studied sample was between the ages
50 – 60 years, this could be explained
cardiac diseases is much more common
in this is age group. This coincide with
Chih-Hung ku, (2005 ) who reported that
the number cardiac disease is increasing
in patient who are 50 years old or more.
Great male predominance was observed
in the studied groups, this is because the
incidence of cardiac disease is more
common in male than female; as the risk
factors for developing cardiac disease
e.g., smoking is more common in male
than female especially in rural area
These results are in agreement with
those of Drain and Forren (2009 ) and
Kern, (2005 ) who reported that, the
majority of sample in study and control
group were smokers and smoking is
considered one of the risk factors for
incidence of cardiac diseases. Regarding
their occupation; the highest percentages
were farmers and professional workers,
this may related to the nature of their
work as they are more subjected to stress
e.g., hard work and financial problems.
This results in the same line with Kern
(2011 ) who found that the majority of
participated patients with cardiac
catheterization were working. The
majority of the study subjects were
married, this finding is expected with
their age group.
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added that pain must be controlled to
enhance patient comfort.
Regarding respiratory complications; a
little more than one third of the control
group had pneumonia compared to only
two cases in the study group related to
implementation of nursing guidelines
instructions and taking medications that
were prescribed. Looking at the
incidence of circulatory complications;
there was no statistically significant
difference between the study and control
groups. As regard urinary complications
the present study revealed that; fifth of
the control group had urinary retention
and urinary tract infection compared to
only one case in the study group. The
present study showed a statistically
significant difference between both the
study and control groups regarding
incidence
of
gastrointestinal
complications as there was nearly half of
the control group had nausea and
vomiting and about third of them had
constipation. In the present study it was
clear that the guidelines instructions had
good effects in improvement of most of
the systematic manifestations. According
to Morton and Fontaine, (2005 & 2009)
effective
preoperative
guidelines
instructions for patient before cardiac
catheterization is important to help the
patient in rapid recovery and prevent
postoperative complications.
Kaplow R & Hardin S (2007 ) both
found that patients who received
educational information pre-operatively
were shown to have less nausea,
vomiting, pain and post catheterization
complications, and have decreased
length of stay. This was in accordance
with the present study results as there
was a highly statistical significant
difference and a positive correlation
between the incidence of post cardiac
catheterization complications between
the study and the control groups.
5. Conclusion and Recommendations:
Based on the results of the present study,
it can be concluded that; providing
written guidelines for patients was much
more effective in lowering the incidence
rate of complications for patients who
have undergone cardiac catheterization
than those patients in the control group
who have not received the guidelines.
The study recommended the importance
of nursing guideline for cardiac
catheterization patient. Instructional
guideline booklet to be available for
patients with simple explanation and
illustrative pictures. Also, recommended
to replicate the study in different
geographical areas.
6. References:
 Admin L. (2011): Nursing lecture,
Cardiac Catheterization and Nursing
Role, July 27th,
 American Heart Association (2007):
Task Force on Practice Guidelines
Writing Group to develop the focused
update of the 2002 Guidelines for the
management of patients with chronic
stable angina. Circulation; 116:27622772.
 Baim, D. S. (2006): Grossman‘s
Cardiac Catheterisation: Angiography
and Intervention, 7th (ed), Philadelphia,
PA, Lippincott Williams & Wilkins.
 Boztosun B., Guneş Y., Yıldız A.,
Bulut M., Sağlam M., Kargın R.,
(2008): Early ambulation after
diagnostic
heart
catheterization.
Angiology; 58: 743-6 .
 Brinker, J. A., Davidson, C. J. and
Laskey, W. (2005): ‗Preventing inhospital
cardiac
and
renal
complications in high-risk PCI
patients‘, European Heart Journal
Supplement, 7 (Suppl G): G13–25,
available
online
at
www.eurheartj/sui054.
 Chi-Hung Ku., (2005): School of
Public Health, National Defense
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








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Medical Center, National Defense
University, P.O. Box 90048-509 ,
Taipei, Taiwan 114.
Chulay, M., Burns, S. (2007): AACN
Essentials of Progressive Care
Nursing. McGraw-Hill Co. PP 187188.
Davidson CJ, Bonow RO. (2011):
Cardiac catheterization. In: Bonow
RO, Mann DL, Zipes DP, Libby P,
eds. Braunwald's Heart Disease: A
Textbook of Cardiovascular Medicine.
9th ed. Philadelphia, Pa: Saunders
Elsevier; chap 20.
Drain CD. and Forren JO., (2009):
Perianthesia Nursing Acritical Care
Approach. 5th (ed). Saunders Elsevier.
P.P 523-535 .
Fraker TD. Jr., Fihn SD., Gibbons RJ.,
Abrams J., Chatterjee K., Daley J.
(2007): chronic angina focused update
of the ACC/AHA 2002 Guidelines for
the management of patients with
chronic stable angina: a report of the
American College of Cardiology/
Gary H. G., (2014): What Is Cardiac
Catheterization?,
Cardiac
Catheterization
Clinical
Trials,
American Heart Journal, Volume 165,
Issue 3, September 2, Pages 421–426
John Wiley & Sons M., (2007): A
nurse's guide to caring for cardiac
intervention patients, Heart Lung
35(4): 245- 251.
John X., Yenna RN., Cynthia RN.,
Cheryl R.,& Patricia M., (2011):
Nursing clinical practice guidelines to
improve care for people undergoing
percutaneous coronary interventions,
Australian Critical Care (2011) 24,
18—38
Julian, D. G., Cowan, J. C. and
McLenachan,
J.
M.
(2005):
Cardiology, 8th edn, London, Elsevier
Saunders.
Kaplow R & Hardin S (2007): Critical
Care Nursing Synergy for optimal
outcomes. Jones & Bartlett Publishers
Sudbury,
Massachusetts
Boston








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Toronto. London Singapore. P.P (121124, 229-235 ).
Kern LS (2005 ): Postoperative arterial
fibrillation:
new
directions
in
prevention and treatment, J Cardiovasc
Nurs 19 (2): 103.
Kern M., (2011 ): Catheterization and
angiography. In: Goldman L, Schafer
AI, eds. Cecil Medicine. 24th ed.
Philadelphia, Pa: Saunders Elsevier;
chap 57.
Morton PG. & Fontaine DK., (2009):
Critical Care Nursing A holistic
Approach, 9th (ed) Wolters Kluwer/
Lippincott Williams & Wilkins. P.P
223-230 , 502- 507, 515- 522, -, 568569, 578- 584.
Morton, P. G., Fontaine, D. K., Hudak,
C. M. and Gallo, B. M. (2005) Critical
Care Nursing: A Holistic Approach,
8th (ed), Philadelphia, PA, Lippincott
Williams & Wilkins.
O‘Grady, E. (2007): ‗Removal of a
femoral sheath following coronary
angioplasty in cardiac patients‘,
Professional Nurse, 19 (11): P.P 651–
4.
Okkonen E. and Vanhanen H. (2006):
Family support, living alone, and
subjective health of patient in a
connection with acoronary artery
bypass surgery. Heart Lung 35(4):
234-244 .
Rosendorff, C. (2005) Essential
Cardiology: Principles and Practice,
2nd edn, Totowa, NJ, Humana Press.
Tortora, G. J. and Derrickson, B.
(2006): Principles of Anatomy and
Physiology, 8th edn, Hoboken, NJ,
John Wiley and Sons Inc. volume and
outcome: Does it matter?‘, Journal in
Interventional Cardiology, 18 (1).
Nurses ' Knowledge and Practice.
enj@nursing.cu.edu.eg
Nurses ' Knowledge and Practice about Oxygen Therapy to High Risk Neonates
Mona Khalf Allah 1
Sohier Dabash2,
Hanan Rashad 3
1- Clinical Instructor of Pediatric Nursing, Technical Nursing Institute, Cairo
University.
2- Assist. Prof. of Pediatric Nursing Faculty of Nursing, Cairo University.
3- Assist. Prof. of Pediatric Nursing Faculty of Nursing, Cairo University.
Abstract
One of the issues requiring special knowledge, skill and experience for neonatal nurses is oxygen
therapy. Aim: to assess nurses' knowledge and practice about oxygen therapy to high risk neonates.
Methodology: A Descriptive exploratory design was conducted on a convenient sample of all nurses
(seventy nurse) working throughout three neonatal intensive care units (NICUs) at two pediatric and
one gynecological hospitals of Cairo University, Egypt. Tools: A structured questionnaire sheet and
observational checklist were used. Data were collected from January to June 2014. Results: Majority
of nurses were less than thirty years old, their mean years of experience in NICUs were seven, half of
them had secondary nursing school graduates while less than one third of the sample had bachelor
degree of nursing followed by technical nursing institute certificate. The mean scores and levels of
nurses' knowledge and practice regarding oxygen therapy were 29.8± 27.6 out of 76 (unsatisfactory)
and 28.9±6.3 out of 38 (good) respectively. A positive correlation was found between nurses' mean
scores of knowledge and practice (p <0.001). Bachelor degree nurses' mean scores of knowledge and
practice were significantly higher followed by technical nursing institute and secondary nursing school
graduates. Nurses who had more than five years of experience working in NICUs had higher mean
practice scores than those less than five years. In conclusion: The findings of this study concluded a
need for development of nurses' knowledge and practice in relation to oxygen therapy.
Recommendations: It is important to raise awareness and increase skills in this area. Therefore,
educational and training programs are recommended means for implementing effective nursing care at
NICU, as they improve knowledge, and in turn change work practice.
Key words: nurses, knowledge, practice, oxygen therapy, high risk neonates.
Oxygen therapy aims to increase the
partial pressure of oxygen in arterial
blood by increasing the oxygen
concentration of inspired air. In
addition to its therapeutic effects, the
adverse effects and drawbacks of
oxygen should be known (Fulmer &
Sinder, 2009 ). Administration of
oxygen is a life saving intervention in
neonates and important skills for
neonatal nurse to practice (Adams,
Martin & Skim, 2014). Several
methods and devices for the
administration
of
supplementary
oxygen are available. The selection of
the method should be individualized
according to the patient‘s age and
disease (Fulmer & Sinder, 2009 ).
Nurses who perform appropriate
observations and assessments before
and during oxygen therapy can prevent
injury in preterm infants also the most
important nurse role is to observe and
Introduction
One of the issues requiring
special
knowledge,
skill
and
experience for neonatal nurses is
oxygen therapy. Optimal oxygen
therapy in preterm infants has been
discussed for over 50 years (Sola &
Deulofeut, 2006 ). Researchers suggest
that, there is a need for greater
awareness regarding the use of oxygen
in neonatal units because it is more
harmful than previously recognized
(Sola, Saldeno & Favareto, 2009 ).
Oxygen therapy is perceived to be an
integrated part of respiratory support
(Tin & Gupta, 2007 ), and because
premature infants are at risk, the
margins are small in terms of what
constitutes excess or insufficient
oxygen. Administration of oxygen in
neonatal units is a responsibility
commonly delegated to nurses by
physicians (Fouzas, et. al, 2010).
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assess infant response to oxygen
therapy and provides hour-by-hour
care of each infant on oxygen
(Cataletto, 2011). The NICU nurses
require
frequent
and
careful
assessment to determine oxygen
therapy, effectiveness and readiness
for weaning and monitoring for
complications (Solberg, Hansen, &
Torunn, 2011 ).
safer limit values should be established
or the technology used by health
personnel should be improved
(Castillo, et.al, 2008 ). Oxygen
administered to neonates, even short
periods of saturation in excess of 95%
should be avoided. Oxygen has both
therapeutic and toxic character; it
should be treated with a respect equal
to
that
accorded
prescription
medications
(Saugstad,
2005).
Although high oxygen values should
be avoided, targeting low values is not
necessarily the preferred strategy
because of the risk of increased
mortality in extremely preterm infants.
(Neonatal Research Network, 2010 ). It
is claimed that health care personnel
lack knowledge about the fundamental
principles of pulse oximetry (Solab,
2008 ), or what the neonates oxygen
level actually is. The monitoring of
oxygen saturation prevents hypoxia or
excessive fluctuations in saturation
(Fouzas, et. al, 2010 & Saugstad,
2007 ). To rely on oxygen saturation,
good capillary circulation where the
nurse attaches the sensor is crucial
(Elliott, Tate & Page, 2006 ).
Education of health care personnel
seems to be unsatisfactory, and better
education in neonatal oxygenation
might play a role in reducing the
theory– practice gap (Solaa, 2008).
From the available literature reviewed
it is evident that, there is little
information for health professionals
regarding indications for initiating and
discontinuing
oxygen
therapy,
selecting appropriate methods of
oxygen administration and deciding on
the source for oxygen consequently.
2- Aim of the study was to:
Assess knowledge and practice of
neonatal
intensive
care
nurses
regarding oxygen therapy.
3-Research Questions:
1- What is the nurses' knowledge level
about oxygen therapy to high risk
neonates?
Studies have shown that excess
administration of oxygen can cause
oxidative stress and injury, including
chronic lung disease, retinopathy of
prematurity,
periventricular
leukomalasia, patent ductus arteriosus,
necrotizing enterocholitis, reduced
myocardial contraction and alveolar
collapse (Solaa, 2008 ). The physicians
prescribe limits for oxygen saturation,
and within these limits, the nursing
staff must continually monitor the
child‘s oxygen requirements and
assess what percentage of oxygen
should be administered. There is a
need
for
uniform
practice
internationally in terms of adjustment
of oxygen therapy (Solab, 2008 &
Saugstad, 2007 ). The target is to avoid
hyperoxia or hypoxia (Walsh, Brooks
& Grenier, 2009 ), and fluctuations
between them (Chow, Wright, Sola,
2003). How such administration can
be optimized remains unclear (Walsh,
Brooks & Grenier, 2009 ). Preterm
infants should have limits for oxygen
saturation which differ from those of
term infants (Sola & Deulofeut, 2006 ).
Although there is a lack of consensus
about limits, there appears to be
increasing acceptance of limits around
85–90%
oxygen
saturation
(Greenspan, Jay & Goldsmith, 2006).
Studies recently confirmed that
saturation limits between 85% and
93% will rarely result in either too
high or too low PO2 values. Similarly,
they suggested that to eliminate
hyperoxia or hypoxia in the future,
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2- What is the nurses' practice level
about oxygen therapy to high risk
neonates?
classified as follows, 70% or more or
grades 53.2 or more was considered
good, score of 60% to 69% or grades
45.6 to 52.4 considered satisfactory
and score less than 60 % or grads 45.6
or less considered unsatisfactory.
4.4.2 - Tool (2): Observational
checklist: it was designed by the
researchers through literature review to
assess NICUs nurses' actual practice in
providing oxygen therapy for high risk
neonates. It consisted of 19 steps that
covered practices regarding hand
washing before the procedure, prepare
needed equipment, connect the flow
meter to either the oxygen wall unit or
the freestanding, fill in the reservoir
with distilled water, connect the
humidifier to the oxygen set up, attach
the tubing to the oxygen source, select
the appropriate size of the oxygen
delivery system, connect the distal end
of the oxygen tubing to the delivery
device (nasal, mask, or hood), turn on
the flow meter to the prescribed
amount, the neonate's head should be
placed in mid line or elevated ''sniffing
position'', apply the oxygen delivery
system to the neonate's face, nose or
head, measure oxygen concentration
every (1-2 hours), dispose equipment
and hand washing after procedure. A
total score of the observational
checklist was 38 grades. Every item
evaluated as follow: competent
(correct and complete done) had been
scored (2), incompetent (correct and
incomplete done) had been scored
(zero) incorrect or not done had been
scored (zero) .The scoring system of
the practice including zero point for
either incorrectly or not done, because
this result will affect the survival of
the neonates. The scoring system
classified as follows: score of 85% or
more or grades 32.3 or more was
considered good, score of 84% to 70%
or grades 31.9 to 26.6 considered
satisfactory and .score less than 70 %
4-Subjects and Methods:4.1 . Research design: A descriptive exploratory design was
used to accomplish this study.
4.2 . Setting:
This study was carried out in three
neonatal intensive care units (NICUs)
at two pediatric and one gynecological
hospital of Cairo University, Egypt.
4.3 . Sample:
A convenient sample of all bedside
nurses (70 nurses) working in NICUs
responsible for providing direct care to
neonates with health problems in the
previously mentioned setting.
4.4 . Tools: - two tools were used for
data collection:
4.4.1 - Tool (1): A Structured
questionnaire sheet: it was designed by
the researchers to assess nurses'
knowledge regarding oxygen therapy it
consisted of two parts:
a) Personal characteristics of nurses:
it covered data related to age, sex,
educational level, years of experiences
in NICUs and attending previous
training program about oxygen therapy
for high risk neonates.
b) Knowledge regarding oxygen
therapy: It consisted of 38 multiple
choice
questions
that
covered
knowledge related to anatomy and
physiology of respiratory system,
definition, indications, types, methods,
concentrations,
complications,
advantages and disadvantages of each
method of oxygen therapy and their
nursing role before, during and after
oxygen administration. A total score
was 76 scores. Every item was
evaluated as follow:
Correct and complete answer was
scored (2), correct and incomplete
answer had been scored (1), incorrect
or don't know answer had been scored
(zero). The scoring system was
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or grades 26.2 or less considered
unsatisfactory.
4.5 . Tools validity and reliability:
Tools were developed by the
researches after extensive review of
the related recent literature and it was
tested for content validity by 5 experts
in the field of neonatologist and
pediatric nursing and approved from
committee of ethics at faculty of
nursing, Cairo University to determine
whether the included items are clear
and suitable to achieve the aim of the
current
study.
The
designed
knowledge questionnaire was tested
for
reliability
with
Cohen's
kappa=0.90. In relation to testing the
reliability of observational checklist
Test retest was carried out and
correlation coefficient was = 0.65.
4.6 . A pilot study:
Was conducted on 7 nurses
who were working in the three NICUs
to test the feasibility, objectivity, and
applicability of the study tools. Based
on the results of the pilot study, no
modifications were made; those nurses
were included in the study sample.
5- Ethical Considerations
Primary and final ethical
approval was obtained from the
relevant Ethics Committee in the
Faculty of Nursing; Cairo-University
to carry out the study. An informed
written consent was obtained from
nurses. They were informed about the
aim, nature of the study, and they have
a right to withdraw from the study at
any time without any rational. Also,
nurses were informed that data will not
be included in any further researches
without
their
permission.
Confidentiality and anonymity of each
subject were assured through coding of
all data.
6- Methods of data collection:
Official
written
approval
consent for conducting the study was
obtained
from
the
responsible
administrative personnel at the three
hospitals and NICUs. The knowledge
assessment questionnaire sheet was
filled out by the nurses on an
individual basis during working time
in an average of 15 to 20 minutes, in
the presence of the researchers before
skill assessment. The checklist
assessment was filled in by the
researchers via an observation method.
Each nurse was followed once for
oxygen administration procedure for
high risk neonates through different
three shifts. The skill checklist was
filled out by the researchers in a 15–
20-min time
period
for
each
observation. Data collection of these
tools lasted approximately six months
between January to June 2014.
7- Statistical analysis:
Data were coded and transferred into
specially designed formats to be
suitable for computer feeding. Data
were analyzed using a personal
computer with statistical package for
social sciences (SPSS) version 20.0.
The following statistical measures
were used: Descriptive measures
included: Percentage, mean and
standard
deviation.
Inferential
measures included: Mann-Whitney
Test and correlation coefficient were
used. The P< 0.05 levels was used as
the cut off values for statistical
significance.
8- Results:
Table (1): Clarifies the personal
characteristics
of
nurses
in
percentage distribution. It showed
that, 87.2% were females, their mean
age 26.8± 5.77, 50% were diploma
nurses, 55.7% of them had less than 5
years of experience as neonatal nurses,
and only 8.6% had previous training
program about oxygen therapy.
Table (2): Clarifies the nurses
knowledage about anatomy and
physiology of respiratory tract in
precentage distribution. It showed
that, 71.4%, 65.7%, 80% and 81.4%
gave incorrect answers regarding
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upper and lower parts of respiratory
system , function, and the diffrences
between the adult and neonate
respiratory tract respectively while
only 1.4% gave correct and incomplete
answers about function. The mean
score of nurses knowledge about
anatomy and physiology was 1.9 ±3.3
out of 8 which was unsasifactory .
Table (3): Presents the nurses
knowledage about oxygen therapy in
precentage distribution. It reveled
that, 84.3% and 80% of nurses gave
correct
and
complete
answers
regarding definition of oxygen therapy
and
incubator
disadvantages
respectively. 85.7%, 75.7, 74.3%,
71.4, 70% and 70%, of nurses gave
incorrect answers about concentration
of head box and face mask, advantages
of head box ,face mask, nasal pronge
and nasal contionus positive air way
pressure respectively . The mean score
of nurses' knowledge regarding oxygen
therapy 16.1±14.7 out of 42 which was
unsasifactory.
Table (4): Calrifies the nurses'
knowledage about their role for
oxygen adminstration in precentage
distribution, it showed that, 60%,
50%, 48.6%, gave correct and
complete answers about their role
during the use of mechincal ventilation
, face mask and nasal prong
respectively.While 72.9%, 57.1%,
55.7%, 55.7%, 54.3%, 51.4%, 51.4
and 50% gave incorrect answers
regarding oxygen precuations, their
role after NCPAP, before and afetr
oxygen adminstration, head box,
during oxygen adminstration and
mechanical ventilation and before
NCPAP respectively. The mean score
of nurses' knowledge level on their
role about oxygen adminstration by
different methods was 11.9±11.1 out
of 26 which was unsasifactory.
Figure (1): Presents the distribution
of nurses total knowledge level
about oxygen therapy to high risk
neonates. It showed that, 90% of
nurses had unsatisfactory knowledge
level and only 10% of them had
satisfactory level about oxygen therapy
to high risk neonates.
Table (5): Presents the nurses'
performance about oxygen therapy
administration
in
precentage
distribution. It revealed that, 71.4%,
98.6%, 100%, 100%, 100%, 100%,
100% and 100% prepared complete
equipment, connected oxygen flow
meter with oxygen source, connected
the humidifier to oxygen setup,
attached the tube to oxygen source,
checked that all of electrical
equipment are grounded, connected
the tube with oxygen delivery device,
truned flowmeter to prescribed amount
and put the neonate in ''sniffing
position'' respectively.100%, 85.7%,
57.1% of nurses didn't measured
oxygen
concentration.
didn't
documened Sao2, O2 rate and method
of oxygen administration and didn't
wash
hands
before
procedure
respectively.The mean score of nurses'
performance
regarding
oxygen
administration was determined as 28.9
± 6.3out of 38 which considered good.
Figure (2): Presents the distribution
of nurses total practice level of
oxygen therapy. It showed that,
(70%) of nurses had good performance
regarding oxygen therapy while (30%)
of nurses had satisfactory performance
about oxygen therapy to high risk
neonates.
Figure (3): Presents the relation
between total knowledge and
practice of nurses about O2 therapy.
It showed that, there was a positive
correlation between total mean
knowledge & practice scores of the
studied sample (r=0.745 , P = 0.001 ).
Table (6): Clarifies the relationship
between mean scores of Knowledge,
Practice and Educational Level. It
showed that, there was a significant
statistical differences among the means
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of the knowledge and practice scores
of the studied nurses by their
educational level where (f = 17.2,
p=0.001 & f = 5.7, P =0.005
respectively). As the participants who
carrying bachelor degree had got
higher means in knowledge and
practice when compared to participants
carrying technical and secondary
school nurses.
Table (7): Clarifies the relationship
between mean scores of knowledge,
practice and experience years. It
revealed that, the mean practice score
was significantly higher for those who
had experience more than 5years than
those with experience less than 5 years
( t= 3.5 , P=0.001). On the other hand,
there was no significant statistical
difference between years of experience
in NICUs and total mean knowledge
(t= 0.9, P =0.93).
Table (8): Clarifies the relationship
between mean scores of knowledge,
practice and training program
attending about oxygen therapy to
high risk neonates. It showed that,
nurses who attended training program
had higher mean score of knowledge
and practice than who did not
(63.2±24.5 & 31.3±5 ) respectively.
Also there was a statistical significant
difference between nurses mean score
knowledge and attended training
program about oxygen therapy for
high risk neonates but no significant
relation was detected for practice (t=
5.1, P=0.001 & t=0.97, P = 0.333 )
respectively.
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Table (1): Personal characteristics of nurses in percentage distribution (n=70 ):
Personal characteristics
No
%
Gender:
Male
9
Female
Age (years):
20<31 years old
31<41 years old
41<51 years old
Mean ± SD
12.8
87.2
61
Educational level:
Diploma nurses
Technical institute
Bachelor degree
Years of experience:
< 5 years
5 and more years
Mean ± SD
Previous training program about oxygen
therapy:
Yes
No
55
13
2
26.8 ±5.77
78.6
18.5
2.9
35
15
20
50.0
21.4
28.6
39
31
7.1 ± 3.1
55.7
44.3
6
8.6
64
91.4
Table (2): Nurses knowledage about anatomy and physiology of respiratory
tract in precentage distribution (n=70 ):
Anatomy & Physiology
of respiratory tract
Correct &
complete
Correct
&Incomplete
Incorrect /Don't
Know
No
18
%
25.7
No
2
%
2.9
No
50
%
71.4
21
30.0
3
4.3
46
65.7
Difference between adult
& neonates
10
14.3
3
4.3
57
81.4
Function
13
18.6
1
1.4
56
80.0
Upper parts
Lower parts
1.9±3.3
Mean±SD
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Table (3): Nurses knowledage about oxygen therapy in precentage distribution (n=70 ):
Oxygen therapy
Correct
Correct
&
&
Incorrect/ Don't Know
Definition
Indications
Types
Complete
No
%
59
84.3
21
30
22
31.4
Incomplete
No
%
--14
20
3
4.3
Methods
43
61.4
3
4.3
24
34.3
Complications
Advantages of:
18
25.7
34
48.6
18
25.7
Incubator
Head box
Face mask
Nasal prong
NCPAP
MV
Disadvantages of:
22
9
15
19
17
31
31.4
12.9
21.4
27.1
24.2
44.3
10
9
5
2
4
11
14.3
12.9
7.1
2.9
5.7
15.7
38
52
50
49
49
28
54.3
74.3
71.4
70
70
40
Incubator
Head box
Face mask
Nasal prong
NCPAP
MV
Oxygen concentration:
56
21
16
22
23
18
80
30
22.9
31.4
32.9
25.7
-3
6
11
5
7
-4.3
8.6
15.7
7.1
10
14
46
48
37
42
45
20
65.7
68.6
52.9
60
64.3
45
60
47
53
63.3
85.7
67.1
75.7
Incubator
25
35.7
--Head box
10
14.3
--Nasal prong
23
32.9
--Face mask
17
24.3
--Mean±SD
16.1±14.7
Note: NCPAP= Nasal Continues positive airway pressure
MV= Mechanical Ventilation
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No
11
35
45
%
15.7
50
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Table(4): Nurses' knowledage about their role of oxygen adminstration in precentage
distribution (n=70 ):
Nursing role:
O2 adminstration:
Before
During
After
Precautions of using O2
Nasal prong
Face mask
Head box
Before NCPAP
During NCPAP
after NCPAP
Before MV
During MV
After MV
Mean±SD
Correct
&
Complete
No
%
Correct
&
Incomplete
No
%
27
28
28
15
34
35
24
32
31
24
38.6
40.0
40.0
21.4
48.6
50.0
34.3
45.7
44.3
34.3
4
6
3
4
19
2
8
3
8
6
42
29
28
60.0
3
41.4
5
40
8
11.9±11.1
Don't know/
Incorrect
No
%
5.7
8.6
4.3
5.7
27.1
2.9
11.4
4.3
11.4
8.6
39
36
39
51
17
33
38
35
31
40
55.7
51.4
55.7
72.9
24.3
47.1
54.3
50
44.3
57.1
4.3
7.1
11.4
25
36
34
35.7
51.4
48.6
Note: NCPAP= Nasal Continues positive airway pressure
MV= Mechanical Ventilation
Figure (1): Distribution of nurses total knowledge level about oxygen therapy to
high risk neonates.
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Table (5): Nurses' performance about oxygen therapy administration in precentage distribution (n=70 ):
Incompletely done
Correctly done
Performance :
No
%
No
%
30
42.9
--1- Hand washing before the procedure
Incorrect/not
Done
No
%
40
57.1
2- Prepare needed equipment
50
71.4
10
14.3
10
14.3
3- Connect the flow meter to either the oxygen
wall unit or the freestanding.
69
98.6
--
--
1
1.4
4- Fill in the reservoir with distilled water.
40
57.1
10
14.3
20
28.5
5- Connect the humidifier to the oxygen set up.
70
100
--
--
--
--
6- Attach the tubing to the oxygen source.
70
100
--
--
--
--
7- Check all electrical equipment in the area to
ensure that it is grounded.
70
100
--
--
--
--
8- Select the appropriate size of the oxygen
delivery system.
50
71.4
10
14.3
10
14.3
70
100
--
--
--
--
70
100
--
--
--
--
70
100
--
--
--
--
70
100
--
--
--
--
--
--
--
--
70
100
70
100
--
--
--
--
60
85.7
--
--
10
14.3
50
71.4
28.6
14.3
---
20
10
---
60
85.7
50
71.4
--
--
20
28.6
33
47.1
--
--
37
52.9
9- Connect the distal end of the oxygen tubing to
the delivery device (nasal, mask, or hood).
10- Turn on the flow meter to the prescribed
amount.
11- The neonate's head should be placed in mid
line or elevated ''sniffing position''.
12- Apply the oxygen delivery system to the
neonate's face, nose or head.
13- Measure oxygen concentration every (1-2
hours).
- In case of administration of oxygen by head box:
14 - Place head box over the neonate's head, face,
neck and shoulders.
In case of administration of oxygen by nasal
prong:
15- Place the nasal prongs just on the external
opening of the nose.
16- Tight the straps attached to the nasal prong
17- Document SaO2, O2 rate & method of
administration.
18- Dispose the used equipment.
19- Hand washing after the procedure
Total mean ±SD
28.9 ± 6.3
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Figure (2): Distribution of nurses total practice level of oxygen therapy.
Figure (3): Relation between total knowledge and practice of nurses about oxygen
therapy
r=0.745 P > 0.001**
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Table (6): Relationship between total mean scores of Knowledge, Practice and
Educational Level (n=70 ):
Variables
Educational level
Nursing
diploma
Technical
institute
Mean ± SD
Bachelor
degree
Mean ± SD
Mean ± SD
f
p
Total knowledge
16.1±13.2
30.4±32.4
53.7±27.2
17.2
Total practice
27.2±6.3
27.8±6.9
32.7±4.3
5.7
Table (7): Relationship between total mean scores of Knowledge, Practice and
Experience Years (n=70 ):
Variables
0.001
0.005
Years of experience
Less than 5
years
Mean ± SD
Five or more years
t-test
Mean ± SD
p
Total knowledge
32.2±29.7
26.9±24.8
0.9
0.93
Total practice
26.1±6.3
31.1±5.5
3.5
0.001
Table (8): Relationship between total mean scores of knowledge, practice and
attending training program about oxygen therapy to high risk neonates (n=70 ):
Variables
Total knowledge
Total practice
training program about oxygen therapy to high
risk neonates
Yes
No
Mean ± SD
Mean ± SD
t-test
63.2±24.5
19.2 ± 18.8
5.1
0.001
31.3± 5
28.7±6.4
0.97
0.333
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Discussion:
The results of this study revealed
that, the majority of nurses were females
and had secondary school nursing
graduates; this is mainly related to the
dominance of females in the nursing
profession in Egypt. Their age under
thirty years, this was in agreement with
study done by (Abd Allah, 2013), who
studied assessment of pediatric nurses'
performance regarding oxygen therapy
in pediatric intensive care unit, and
found that majority of the studied nurses
were in the age group of twenty to thirty
years old, In addition the researchers
point of view this might be related to
that this age is the common age of nurses
who give care in the intensive care units
and are able to work hardly.
certification and secondary nursing
school graduates. This finding was in
agreement with (Abd Allah, 2013 ) who
found that, there was a significant
difference between nurses' knowledge,
performance and their qualifications and
disagree with (Hussein, 2012 ) who
studied ventilator-associated pneumonia
among children: nurses' knowledge and
practice, and reported that there was a
significant statistical relation between
nurses' qualifications and knowledge
only, and not with practice.
Regarding nurses' years of
experience in NICUs, the current study
revealed that, the majority of studied
nurses had less than five years and the
minority had more than five years
working in NICUs. These results were
contradicted with (Mohammed, 2009),
who studied nursing care given to high
risk neonates and found that, the highest
percentage of nurses working in NICUs
between five to ten years of experiences.
The researchers believed that, these
findings may be related to shortage of
nursing staff in these units, beside there
were new recruitments of nurses who
had experience less than five years. In
the current study there was no statistical
significant relation was existed between
years of experience and total mean
knowledge score of nurses while a
significant relation was detected between
years of experience and their mean
practice scores. Nurses who had more
than five years of experience working in
NICU had higher mean practice scores
than nurses who had less than five years.
This was in agreement with (Abd Allah,
2013& Hussein, 2012 ) who reported
that the majority of studied nurses who
had five years and more experience had
competent performance only.
Zin & Gilbert, (2006 ) mentioned
that nurses have a key role to play in the
care of high-risk infants, however, many
countries have a severe shortage of
qualified nurses and a great deal of care
is administered by nurse who may have
only minimal training. Nursing care of
neonates with life threatening conditions
and care of greater technical complexity
requires scientific knowledge and ability
to take immediate decisions. Also the
National Association of Neonatal
Nurses, (2012 ) added that, nurses who
are working in NICUs must be graduated
from colleague to be prepared for a
highly qualified care. Findings of the
current study revealed that, half of the
nurses had secondary nursing school
graduates followed by bachelor degree
and technical institute certification. A
statistical significant relation was existed
between knowledge, practice and their
educational level. In which nurses who
had bachelor degree had higher
knowledge and practice mean scores
rather than who had technical institute
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The training programs are very
helpful for all staff especially newly one
to find their places in the particular
setting and to be able to adjust to the
new
assigned
work
functions
(McMachan, 2000). On assessing the
attendance of the studied nurses to
training programs about oxygen therapy,
the current study revealed that, most of
them didn't attend any related programs.
The findings of this study also showed
that, there was statistical significant
relation between nurses' total mean
knowledge and their training program
about oxygen therapy. Nurses who
attended training program had higher
total mean score knowledge level than
those didn‘t. This was in agreement with
Hussein, 2012 & Abd Allah, 2013 ) who
found that, majority of studied nurses
who attended training program had
higher mean knowledge scores than who
didn't but no relation was detected with
practice. The previous findings were
disagree with a study done by Said,
(2012 ), in Tanzania as he found that,
ICU nurses knowledge on prevention of
ventilator associated pneumonia is
statistically not associated neither with
ICU training, level of education nor
years of experience.
(Botwinski, 2005 ). Also understanding
the
developmental
anatomy and
physiology of the respiratory system is
essential for all healthcare professionals
dealing with neonates (Chamley, Carson,
Randall, & Sandwell, 2010). The current
study revealed that, the majority of
nurses didn't know the anatomy and
physiology of upper and lower
respiratory system, the differences
between adult and neonate respiratory
system and functions of respiratory
system. From the investigators point of
view, this may be related to lack of
nurses' continuing education courses
related to oxygen therapy in their clinical
practice setting, protocols and time to
refresh their knowledge.
Oxygen
therapy
is
the
administration
of
oxygen
at
concentrations greater than in ambient
air and it is the most important aspect of
supportive care to prevent hypoxia
(Fulmer & Snider, 2007 ). Oxygen is a
drug and should be prescribed in proper
dosage with proper mode of delivery and
duration. The current study showed that,
most of nurses' had correct and complete
answers about definition of oxygen
therapy and its methods. These finding
was in agreement with Abd Allah,
(2013 ), who reported that, the majority
of the studied nurses had satisfactory
knowledge level about definition oxygen
therapy and its methods.
In the current study, the data that
answered the first research question
regarding nurses' knowledge about
oxygen therapy to high risk neonates
revealed that, the majority of the studied
nurses had unsatisfactory level of
knowledge. The nurse who provides
care for neonates with respiratory
disease should have a basic knowledge
about the anatomy and physiology of
respiratory
system.
This
basic
knowledge helps the nurse to identify
and describe the structural features and
functions of the respiratory system
Oxygen can be given in high or
low concentration in all the conditions
associated with hypoxaemia (Singh &
Brar, 2001 ). Regarding indications and
types of oxygen therapy, the results of
the current study revealed that, nurses
didn‘t know the correct answers, and this
was in agreement with Nader, (2010 ),
who studied the evidence based
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guidelines for care of neonates with
respiratory distress and reported that, the
majority of the studied nurses had
unsatisfactory
knowledge
about
indications and types of oxygen therapy
in NICU.
that, the majority of NICU nurses had
correct and complete answers about
advantages of mechanical ventilation
and disadvantage of incubator used to
gave oxygen to high risk neonates while
most of nurses didn't know about
advantages and disadvantages of using
face mask, nasal prong, and nasal
continues positive airway pressure
(NCPAP). This may be due to lack of
follow up or lack of evaluation policy to
assess the nurses' knowledge in the
related NICUs.
Maintaining oxygen saturation
(Spo2) in a range to avoid hyperoxia that
may result in improved retinopathy of
prematurity (ROP) outcomes. Nurses
must recognize the importance of
managing oxygen delivery effectively to
prevent progression to severe ROP or
blindness. And high concentration of
oxygen is thought to be the major
contributing factor to the development of
(ROP). Prolonged exposure to high
concentrations of oxygen may cause
irreversible damage to the eyes of very
low birth weight preterm infants
(Saugstad, 2010). This study showed
that, the highest percentages of nurses
didn't know the oxygen concentrations
of using head box, face mask, nasal
prong and incubator used to give oxygen
to neonates. This may be due to lack of
training programs or insufficient
knowledge.
The most important nursing role
is to assess high risk neonate response to
oxygen therapy and provides hour-byhour care of each infant on oxygen
therapy (Cataletto, 2011 ). The findings
of the current study revealed that, about
half of the nurses didn't know their role
before, during and after oxygen
administration to high risk neonates.
Also majority of nurses' didn't know
precautions of using oxygen therapy.
These findings were in agreement with
Hassan, (1993), who assessed nursing
care of newborn infant suffering from
respiratory distress in the neonatal
intensive care unit in obstetrics and
gynecology hospital. (Abed El Menem,
2007), who studied nursing care for
neonates undergoing positive airway
pressure and found that, the majority of
nurses had inadequate knowledge,
regarding
their
role
during
administration of oxygen therapy. From
the researchers point of view this may be
related to inadequate training programs,
in-service training to bedside care
providers in NICUs oxygen therapy and
lake of working knowledge.
There are a multitude of oxygen
delivery devices, adapters, ventilator
systems, and resuscitation devices,
nurses should become familiar with the
equipment used in their facility and work
sites especially NICU. It is important
when new equipment is purchased and
periodic
retraining
should
be
incorporated into clinical nursing
updates (American Association for
Respiratory Care (AARC), 2007).
Nurses should be aware of advantages
and disadvantages of oxygen delivery
devices which are necessary for safe and
effective use (Sola, et. al, 2009 ). The
findings of the current study revealed
Oxygen may be administered to
neonates by nasal prong, face mask, or
head box in most facilities, a respiratory
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therapist is responsible for the setup,
maintenance, and management of
oxygen equipment. However the nurse
needs to have a working knowledge of
oxygen delivery system used (Tashiro &
Ihlenfeld, 2012 ). The findings of this
study showed that, half of nurses had
correct answers about their role during
use of nasal prong and face mask.
7L/min, don‘t obstruct any openings in
the head box it is necessary for exhaled
gases to escape and ensure that
temperature inside the head box is
suitable (Jatana, et. el, 2007). The
findings of the current study revealed
that, half of them didn't know about their
role in using of head box to give oxygen
to neonates.
Head box is an effective and a
widely used device to administer oxygen
in neonates with mild to moderate
respiratory dysfunction. It is well
tolerated, there is no increase in risk of
airway obstruction or gastric distension
and allows the oxygen concentration to
be determined precisely which depends
on the flow rate of oxygen, size, shape,
and volume of the hood (Jatana,
Dhingra, Nair, & Gupta, 2007 ). The
disadvantages are the inability to
ascertain the oxygen concentration
without the use of oxygen analyzer,
inability to use oxygen flow rates of less
than two litters per minute and inability
to maintain uniform oxygenation while
carrying out routine nursing care (Jain,
Shenoi & Paramesh, 2002 ). Different
brands are available and there is lack of
standardization of the above parameters
thus requiring the use of an oxygen
analyzer to measure the oxygen
concentration (Frey, Shann, 2003 ). In
contemporary literature there is no
information available on controlling
oxygen concentration in head box
without the use of oxygen analyzer. The
findings of this study showed that, most
of NICUs nurses didn't know about
advantages and disadvantages of using
head box. The NICUs nurse had
important role when head box is used to
give oxygen place the box above the
head, neck and shoulders of the neonate,
ensure oxygen rate don't exceeds
Using of NCPAP is increasing as
a means of respiratory support for many
premature neonates. Nursing care is
directed
toward
assessing
the
effectiveness of NCPAP, managing the
airway, and assessing for, preventing,
and managing the complications of
CPAP. Important role of neonatal nurse
is ongoing assessment of the infant's
clinical condition and response to
therapy (Newborn Services Clinical
Guidelines, 2004 ). The majority of
NICUs nurses in the current study didn't
know about care provided before, during
and after using of NCPAP. This was in
agreement with Nader, (2010 ) who
found that, majority of nurses had
unsatisfactory knowledge about their
role in care of neonate receive
noninvasive
nasal
CPAP
and
contradicted with Abed El- Menem,
(2007 ) who found that, the majority of
nurses had good knowledge related to
care of neonates on noninvasive nasal
CPAP, and near half of them had good
knowledge.
Mechanical ventilation is one of
the most commonly used technologies in
critical
care.
Neonatal
nurses‘
knowledge and understanding of
mechanical ventilation are central to
ensuring patients‘ safe passage from the
acute stage of ventilation to weaning
(Burns, 2012 ). The results of this study
showed that, the majority of nurses gave
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correct answers about their role before
using of mechanical ventilation. The
nurse should understand the function and
detect the signs of malfunction and
deviations from desired sitting for safe
use, prevention of accidental or
unplanned extubation, monitoring of its
side effects and provide comfort to the
neonates
(Hockenberry,
Marilyn,
Wilson, & Wong, 2013). The results of
this study showed that, NICUs nurses
didn't know about their role during and
after the use of mechanical ventilator to
give oxygen to high risk neonates. This
was in matching with Nader, (2010 ) who
found that, nurses had unsatisfactory
knowledge regarding care of neonate on
mechanical ventilation.
a cheap, primary infection control
procedure, simple action, well accepted
modes of reducing infection and
enhancing patient safety but lack of
compliance among health-care providers
is problematic worldwide (World Health
Organization, 2009 ). Hand washing
practice of nurses during their routine
activities was expressed in percentages
and number values. In this study, it was
found that, of the seventy nurses
observed, none washed hands before
were fifty seven while fifty two of them
didn't washed their hands after
contacting a neonates. This result was in
agreement with Said, (2012), who
observed that majority of nurses didn't
wash their hands before contacting the
patient and wash it after patient contact.
Oxygen is the most common
procedure carried out in the management
of neonates' with respiratory diseases
and other illness so the pediatric nurse
should
have
knowledge
good
observation skills and ability for
assessment of need for oxygen therapy
(Datta, 2009 ). The findings of the
current study revealed that, the majority
of the studied nurses had unsatisfactory
level of knowledge about oxygen
therapy this finding was in agreement
with Nader, (2010 ) who mentioned that
the majority of the studied nurses
unsatisfactory knowledge about oxygen
therapy in NICU and contradicted with
the finding of King, (2012) who found
that, most of the studied nurses had
satisfactory knowledge about oxygen
therapy.
Humidification
of
oxygen
therapy is necessary to prevent
hypothermia, inspiration of airway
secretions, destruction of airway
epithelium, and atelectasis (Gomella,
Douglas, Eyal & Zenk, 2009). The
administration of supplemental oxygen
to neonatal patients requires the selection
of an oxygen delivery system that suits
the patient's size and emphasized that
administration of oxygen is a rescue
therapy for neonates with progressive
signs of respiratory distress and it must
be warmed and humidified before
entering the respiratory tract (AARC,
2009). The results of this study revealed
that, the majority of nurses connected
humidifier with oxygen source attached
the oxygen tube to oxygen source, and
prepared complete equipment, connected
oxygen flow meter with oxygen source
correctly and filled in reservoir with
distilled water. This study was supported
by (Peter, 2009) who found that, most of
the studied nurses had passed O2 on
distilled water.
Regarding the second research
question of the current study finding
about nurses' practice level about oxygen
therapy to high risk neonates revealed
that, the majority of nurses had good
practice level. Hand washing hygiene is
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The
administration
of
supplemental oxygen to neonatal
patients requires the selection of an
oxygen delivery system that suits the
patient's size, needs, and the therapeutic
goals (AARC, 2009 ). The results of the
current study revealed that, the majority
of nurses selected the appropriate size of
oxygen delivery device and connected
the oxygen tube with the oxygen
delivery device and turned on oxygen to
the prescribed amount. The researchers
interpreted these findings in the practice
may be attributed to that nurses practices
were based on imitations.
The findings of this study
revealed that, all nurses placed head box
over the neonate's head, face, neck and
shoulders and placed the nasal prongs
just on the external opening of the nose
correctly, those findings were in
agreement with Abd Allah, (2013) who
found that, two thirds of the studied
nurses were competent when place the
head box on the head of the child and
three quarters of the studied sample are
competent when tighten the nasal
cannula, while it was contradicted with
Nader, (2010 ) who mentioned that, most
of the studied nurses were incompetent
in providing oxygen therapy to neonates.
Advantageous
positions
for
facilitating an infant's open airway are
on one side with head supported in
alignment by a small folded blanket or,
when on back, positioned to keep the
neck slightly extended. With head in the
''sniffing'' position will help to open the
trachea to maximum (Beevi, 2012 ). The
findings of this study revealed that, the
majority of nurses put the neonates in
sniffing position during oxygen therapy
and this may be because they followed
the prescribed doctor order and
imitation.
Oxygen must be considered as a
medication and the use of oxygen must
be documented for each neonate. There
remains a lack of consensus regarding
fundamental issues in pediatric oxygen
therapy, but principle differences from
adult care must be taken into account in
the care of children (Kozier, et.al,
2010).The finding of this study revealed
that the majority of nurses didn‘t
document saturation (SaO2), oxygen rate
and the method of administration in the
neonatal nursing file. This finding was in
matching with Kafil, (2007) & Nader,
(2010 ) who found that, more than two
thirds of studied nurses had incompetent
performance regarding documentation in
neonate's nursing sheet.
Prolonged exposure to high
oxygen concentrations can be toxic to
some body tissue such as retina in
preterm babies and lungs, so it is
necessary
to
measure
oxygen
concentration at regular intervals with an
oxygen analyzer, the nurse must be sure
that the procedure is carried out on the
assigned patient (Price & Gwin, 2013 ).
The findings of this study revealed that,
all nurses didn't use oxygen analyzer in
measuring level of oxygen concentration
for high risk neonates and this may be
due to lack of knowledge about the
importance of this device.
The findings of this study
revealed that, the majority of nurses had
good practice level about oxygen therapy
and this was in match with Abd Allah,
(2013 ), who found that, more than half
of the studied neonatal nurses were
competent before, during and after
providing
oxygen
therapy
and
contradicted with the findings of Nader,
(2010 ) who mentioned in similar study
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that most of the studied nurses was
incompetent on providing oxygen
therapy for children.
the nurses knew they were being
observed).
10 -Recommendation:
The findings of this study recommend
that:
- It is important to raise awareness and
increase skills in this area. Therefore,
training about oxygen therapy for
neonates is advocated on orientation
programs and in-service training, as well
as on courses relating to this area of
nursing.
- The importance of hand washing needs
to be addressed in collaboration with the
infection control department. With the
care that can be provided by
appropriately trained and skilled nurses,
-Maintaining and improving neonatal
care requires active involvement of
everyone in health care system, in order
to meet the needs for evaluating health
care in its totality as well as to identify
whether effective and appropriate care
has been provided. Education and
training are potential means for
implementing effective nursing care at
Neonatal Intensive Care Unit (NICU),
increase knowledge, and in turn change
work practice.
Limitations:
This study was conducted in one
area and in only university hospitals.
Therefore, the results cannot be
generalized to other institutions.
Acknowledgement
The authors wish to acknowledge
all neonatal Nurses who participated in
this study; for their cooperation to
achieve this work. We also express our
gratitude to the all clinical staff at the
neonatal intensive care units in the
Pediatric Hospitals of Cairo University
(CU) for your patience, flexibility and
great cooperation. We are most grateful
to the editor and the anonymous referees
NICU nurse is the key person to
protect the newborn from harm of
improperly administered oxygen. So in
order to practice safely, nurses' needs to
think in critical manner about all
activities
and
intervention
they
undertake based upon sufficient amount
of knowledge (Kenner, & Lott, 2010 ).
The current study revealed that there was
a relation between nurses' total
knowledge and their total practice
scores. That nurses who had high mean
knowledge scores had high mean
practice scores. This was in agreement
with Abd Allah, (2013 ), who found that,
there was a highly statistical significant
relation between nurses' total knowledge
and their total performance, but this
finding was contradictory with Hussein,
(2012 ) who found that, there was no
relation between total knowledge and
practice of studied nurses.
9-Conclusion:
This study concluded that nurses'
knowledge levels, especially regarding
the anatomy and physiology of
respiratory system, oxygen therapy
(definition, indications, complications,
methods, concentration, and their role)
were unsatisfactory. When the skill
levels on oxygen therapy procedures
were analyzed, it was found that some
materials, such as oxygen analyzer was
generally not prepared before the
procedure and these material was often
not used during the process..In addition,
the SaO2, rate, method of administration
and nurse's signature were often not
recorded. A particularly worrying
finding is that there was 57.1% not wash
hands before the procedure (even though
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for their most helpful and constructive
comments on earlier versions of this
article.
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Effect of Health Education Program
enj@nursing.cu.edu.eg
Effect of Health Education Program on the Knowledge Related To
Hiv/Aids among Secondary School Students at Khartoum State
Dr. Duria Abdelraheim Mohammed Ahmed Omer
MBBS. MD. Ain Shams University, Egypt
Associate prof. of pediatrics - Omdurman Islamic University
Abstract
Background: HIV/AIDS seriously affects adolescents throughout the world. One-third of all currently
infected individuals are youth, ages 15 to 24, and half of all new infections occur in youth the same age.
More than five young people acquire HIV infection every minute; over 7,000, each day; and more than 2.6
million each year.(Policy Fact Sheet, 2011)
Globally, the spread of HIV/AIDS remains on the rise especially among adolescents who are at increased
risk of infection. Improving and correcting Knowledge are the most effective ways of preventing further
transmission among this vulnerable group.
Objective: To assess the effect of HIV health education program on knowledge (General Knowledge and
Knowledge about mode of transmission towards HIV and AIDS among secondary school students in
Khartoum state.
Methodology: Interventional study (Quasi experimental study) ,(500 student) were enrolled in the study by
multi stage random sample, the study was done in three phases: phase one pre-test questionnaire of 32
questions .Phase two SNAP's health education program in secondary schools (beside and inside the
curriculum) for 8 months, phase three post-test questionnaire.
Results: Up to (96.4%) of the students had the knowledge about HIV/AIDS after implementation of the
program & the improvement was significant (P= 0.001 ). After intervention the improvement was
statistically significant (P value=0.042).
Conclusion: The Health education program was effective in improving knowledge towards HIV/AIDS
people.
Key words: Secondary school students, knowledge, HIV, Education program, Sudan.
Thus, gaining insight
into
student
perceptions
and
management of HIV/AIDS patients is
essential for assessing the adequacy of
HIV/AIDS education in the secondary
schools.
Quest for knowledge is an innate quality
of human beings especially adolescents
which make them distinct from all other
creation of God and this can be fulfilled
by education, which merely to impart
knowledge (Chacko, 2007) .
There is no single model of AIDS
education that is appropriate to every
country; different situations call for
different responses. However, AIDS
education is important for ensuring that
young people are prepared for situations
that will put them at risk as they grow
older (AVERT Organization, 2013).
Introduction
In Sudan the youth are at risk of HIV
infection due to high unemployment,
delay in marital sex, increased premarital
sex, peer pressure and changing lifestyle.
Students constitute a segment of the
youth that is particularly vulnerable to
HIV infection. UNAIDS (United
National Acquired immune deficiency
syndrome) suggests that it is 0.53
percent with 98,922 people living with
HIV in 2012 , the prevalence of the
disease is prone to rise due to the large
scale population movement (refugees,
returnees) and changing livelihoods
which are reflected in high rates of
urbanization and changing community
structures (SNAP, 2012)
Appropriate knowledge may instill
confidence in students about their own
ability to manage HIV-positive patients
(Gilbert & Nuttall, 1994).
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The purpose of the study was to assess
the effect of HIV health education
program on knowledge (General
Knowledge and Knowledge about mode
of transmission), towards HIV and AIDS
among secondary school students in
Khartoum state.
about HIV), phase three post test
questionnaire using the same question in
phase one with same technique.
General knowledge about modes of HIV
and AIDS using the statements
Do you know what HIV stands for, do
you know what AIDS stands for, do you
understand how the disease works, do
you know the difference between HIV,
and AIDS Can a person who looks
healthy have the HIV virus.
Knowledge about modes of HIV and
AIDS transmission was assessed using
the statements
"HIV and AIDS can be transmitted by
Mosquito Bites, by Breast Feeding, by
Traditional circumcision or treatment
with razor blades, by receiving blood, by
having a Sexually transmitted disease
(STD). In addition, the students feedback
to each statement was either (1) = "Yes",
(2) = "No", or (3) = "Don't know".
(1) = "Correct overall knowledge" and
(0) = "Incorrect overall knowledge".
Methods
Interventional study, Quasi experimental
study (Pre-Post test study), 500 students
were enrolled in the study by multi stage
random sample including class one &
class tow students using the following
formula:
n = z2 (p*q)
d2
z = Confidence level = 2.58
corresponds to 99 % in Z table
p = prevalence = 0.5
q = 1-p = 0.5
d = desired margin of
error = 0.05766
n = 500.53 ≈ 500
Verbal and written informed consent was
obtained from all participants. The study
was done in three phases, a personal
administered questionnaires using a
combination of closed- and open-ended
questions:
Phase one questionnaire composed of
11questions,
Arabic-language
questionnaire
was
adapted
for
HIV/AIDS related general knowledge (5
questions), Knowledge about HIV/AIDS
mode of transmission (6 questions).
Phase two health education programs
(Participants were debriefed to Sudan
National AIDS control Program (SNAP)
health education program in secondary
schools (beside and inside the
curriculum) for 8 months.
The program included the following:
Lectures (One lectures per week 2 hours
per each), Posters, Handouts and CDs
Results
Characteristics of participants
A total of 500 students was selected
randomly, their social and demographic
profile were as follows:
Females 48%, Males 42%, from
(Khartoum211, Khartoum North119,
Collected from Governmental & nonGovernmental school.
Regard The students who had the correct
general knowledge related to HIV/AIDS
questions were (25.4%-60% ) before
intervention and (63.0%-96.4% ) after
intervention. Students were confused
about the difference between HIV and
AIDS 26.0% before intervention and
12.4% after intervention. improvement
was significant (P-value = .001)
And regard mode of transmission nearly
half of the students (49.4%) knew that
HIV can be transmitted from the infected
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mother to their babies by breast feeding
increased to (82.0%) after intervention&
About Vertical transmission (66.6%) of
the students before intervention and
knew to (87.2%) after intervention,
Traditional circumcision and treatment
with razor blades were well known as
mode of transmission by the students
even before intervention (82.6%) for, yet
they still sharing razor blades, Can a
person get HIV/AIDS by receiving blood
before
intervention
72.8%
after
intervention was 91.0% . Improvement
was significant in the post-test than that
in the pre-test (P-value = .042 ).
Table 1: HIV/AIDS health education program efficiency in improving secondary
school student's general knowledge about HIV/AIDS
Measuring
Time
Means
10.451
SD
Calculated
value
T Df
Prob.
Statistical Inference
2.909
Pre
499 .001
9.154
Post
11.916
2.001
The difference
significant
is
Table 2: HIV/AIDS health education program efficiency in increasing secondary
school student's knowledge about mode of HIV/AIDS transmission
Measuring
Time
Means
Pre
SD
Calculated
value
T Df
Prob.
2.470
15.088
1.736
499 .042
Post
15.392
2.662
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Statistical Inference
The difference
significant
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from infected mother to her child
through the placenta (Kwee et. al., 2013).
Traditional circumcision and treatment
with razor blades were well known as
mode of transmission by the students
even before intervention (82.6%) for, yet
they still sharing razor blades (shaving
for each other's and sharpening their
pencils).
In study done in sub-Saharan Africa
(89%) thought that individuals could
avoid infection by behavioral changes.
Such as avoiding sharing razor blades
and shaving instruments (Jogunosimi, 2001).
These obvious differences may be
because this study was done among
secondary school students in Khartoum
state (the capital of Sudan) where
different kinds of media are available.
Also the percent of education is high in
the capital. (This considered one of the
limitation of the study)
Conclusions
Knowledge was available throw
different kinds of media.
There was significant difference in
general knowledge about HIV/AIDS
before and after Introduction of
HIV/AIDS health education program
into
secondary
school
student's
curriculum (P-value = 0.001 ).
The improvement in knowledge about
HIV/AIDS mode of transmission among
students
after
intervention
was
statistically significant (P-value=0.042 ).
Health education program was effective
in
correcting
knowledge
about
HIV/AIDs among secondary school
students (P-value= 0.001)
Recommendation
Effective HIV/AIDS education and
prevention is needed in all schools for all
children so that no one is left behind.
School nurses should raise student‘s
awareness towards HIV/AIDs mode of
transmission.
Discussion
The present study is the first to assess
detailed knowledge about HIV/AIDS
regard meaning, understanding of how
the disease works, the difference
between
HIV and AIDS, a healthy looked patient
can be infected with HIV/AIDS and
knowledge about mode of transmission
of the disease.
In comparison to the study done in subSaharan Africa, only 21% of young
women and 30% of young men (15 to
24) had the knowledge needed to protect
themselves against HIV infections (Linda,
2012).
Although it is intellectual knowledge,
the students knew the difference between
HIV/AIDS (25.4% pre-test - 63.0%
post-test), however (26.0%) of the
students answered by don't know and
still the percentage a bit high after
intervention (12.4%).
In this study knowledge about mode of
transmission was beyond the expectation
nearly half of the students (49.4%) knew
that HIV can be transmitted from the
infected mother to their babies by breast
feeding increased to (82.0%) after
intervention, this was came at variance
with study conducted in Sanaa Alyamen
only (38%) the participants knew this
mode of transmission (Al-Serouri & Takioldin,
2002).
About Vertical transmission (66.6%) of
the students before and (87.2%) after
intervention said they know. This was
similar to the findings of a study done in
Sanaa Alyamen 86% (Al-Serouri & Takioldin,
2002).
Also in study conducted in Malaysia,
(54.5%) of the students knew that HIV
can be transmitted by breast feeding
from the infected mother and (75.2%) of
students knew that HIV can be passed
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References
1. AIDS Education and Young People
AVERT Organization – Averting
HIV/AIDS.
http://www.avert.org/aids-youngpeople.htm.
Accessed on march 2013
7. HIV/AIDS Policy Fact Sheet. The
global impact of HIV/AIDS on youth.
http://www.pbs.org/newshour/health/aid
s_in_africa/kff_youth_factsheet.pdf
Accessed on December 2011
8. Jogunosimi T. The HIV/AIDS
pandemic among youth in sub-Saharan
Africa. February 2001
http//www.advcatesforyoth.org.
Accessed on Jan/2012
2. Al-Serouri AW, Takioldin IM, Oshish
H, et al. Knowledge, attitudes and beliefs
about HIV/AIDS in Sana‘a, Yemen. East
n Mediterran Health J Nov. 2002 ; 8(6):
706–15pages. November 2002
9. Ministory of Health, SNAP, Global
AIDS response progress reporting, p:6.
2012.
3. Chacko. S. impact of learning package
regarding HIV / AIDS on knowledge,
attitude and practice of hospital
housekeeping personnel in a selected
hospital at mangalore, published master
thesis in sciences, Rajiv Gandhi
University
of
Health
Sciences,
Karnataka, Bangalore :p 5-9. 2007 .
4. Choy Koh Kwee, Huo Aaron Lai Kuo
and Ratnasingam Lee Jeremy Edward.
Frequent Misconceptions and Low-toModerate Knowledge of HIV and AIDS
amongst High-School Students in
Malaysia, Hindawi, Volume 2013,
Article
ID
749490 ,
6
pages
http://dx.doi.org/10.5402/2013/749490
5. Fraim Nalan Linda. Knowledge
Levels and Misconceptions about
HIV/AIDS: What do University Students
in Turkey Really Know? International
Journal of Humanities and Social
Science: June 2012 Vol. 2 No. 12.
www.ijhssnet.com/journals/Vol_2_No_1
2.../8.pd.
6. Gilbert AD, Nuttall NM. Knowledge
of the human immunodeficiency virus
among final year dental students. J Dent
1994; 22(4):229–35.
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The Impact of Massage on Reducing Post-Operative Pain Among Infants in Zagazig
University Hospitals
Amal El- Dakhakhny(1), Tarek Gobran(2), Shimmaa Mansour(1), Asmaa Ahmed
Salem(1).
1- Department of Pediatric Nursing, Faculty of Nursing, Zagazig University, Egypt.
2- Department of Pediatrics, Faculty of Medicine, Zagazig University, Egypt.
Abstract
Pain is a critical problem in the health care system; Pain refers to an unpleasant, distressful and
uncomfortable feeling it is the most frequent nursing diagnosis and the more common problem for which
patients in the clinical setting seek help. Accurate assessment of pain is crucial for the effective pain
management. Infant pain must be considered as' the fifth vital sign". Pain management includes
pharmacological and non-pharmacological interventions. One of the effective non-pharmacological
methods to relieve the pain is massage technique.
The aim of the present study was to investigate the impact of massage on reducing post-operative
pain among infants. A quasi experimental design was utilized. The present study was conducted at Pediatric
Surgical unit at Zagazig University Hospital. The study subjects included 60 infants having postoperative
abdominal pain. Structured interview questionnaire was used to collect biosocial data about the studied
children and Riley infant pain scale which was used to measure the intensity of post-operative pain in
infants. The study results indicated there was a statistically significant difference between the two groups in
the mean value of the heart rate, respiratory rate, and post-operative pain scoring which decreased after
applying massage technique. The study findings concluded that massage technique was effective on
reducing postoperative pain in infants under going abdominal surgery. The main study recommendation
included that; massage technique should be integrated into the routine nursing care along with
pharmacological interventions.
Key words: massage technique, infants, post-operative abdominal pain.
the immediate post-operative period and
continue until the pain resolves, whether
the child is at home or in the hospital
(Rawal, 2007 ).
Accurate assessment of pain is
crucial
for
the
effective
pain
management. Infant pain must be
considered as ''the fifth vital sign"
(Rothrock, 2003 ).Without an adequate
assessment of pain, the efficiency of a
therapy can't be determined. Assessment
has to be appropriate for the child's stage
development, severity and chronicity of
the illness, surgical or medical procedure
and medical environment (Carbaja et al.,
2004 ).
Children
of
various
developmental ages respond differently
to pain and perceive pain in different
ways. Research has demonstrated that
infants, including preterm infants,
experience pain and can distinguish pain
Introduction
Surgery and the effect of
anesthesia impose a significant stress on
the infant. Stress may result in
decreasing respiratory effort, alteration
in acid-base balance and a decrease in
cardiac output and evoke acute pain
(Ziegler et al., 2003 ). Pain may result in
behavioral and physiological changes
such as an alteration in vital signs and a
change in facial expression (American
Journal of MCN, 2004 ).
Post-operative pain encompasses
a complex phenomenon that involves
physical, psychological, social, cultural,
and
environmental
factors
that
interconnect and affect how the pain is
perceived, managed, and evaluated
(Twycross, 2006 ). Children experience
high level of pain during several days
after surgery, and often have pain above
their treatment threshold. Appropriate
pain management should be initiated in
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from other tactile experience (McGrath
& Hillier, 2003 ).
In preterm and term newborns,
behavioral and physiologic indicators are
used for determining pain behavioral
indicators include facial expression,
body
movements,
and
crying.
Physiologic indicators include changes
in heart rate, respiratory rate, blood
pressure, oxygen saturation levels, vagal
tone, palmar sweating, and plasma
cortisol
or
catecholamine
levels
(American Academy of Pediatrics,
2002 ).
Pediatric pain management is
achieved by combining multi-modalities
including pharmacological and nonpharmacological
interventions;
pharmacological interventions include
opioids, non opioids analgesics, nonsteroidal anti-inflammatory drugs, and
adjuvant therapy (Yenbut et al.,
2005 ).While
non-pharmacologic
methods as physical and cognitivebehavioral measures are used to relieve
children's pain such as: comforting, hot
and
cold
application,
massage,
acupuncture, trans-cutaneous electrical
nerve stimulation, relaxation, distraction,
imagery,
biofeedback,
parental
involvement and hypnosis (Adams &
Arminio, 2008 ).
Children respond well to nonpharmacologic pain reduction measures,
especially when they are used in
conjunction
with
appropriate
pharmacologic interventions (Polkki et
al., 2001 ). The degree of using nonpharmacological
interventions is
contingent on many factors, including
the family‘s and the child‘s willingness
to participate in the interventions but
mostly on health provider's knowledge,
willingness, and understanding of the
benefits
associated
with
non-
pharmacological therapies (Sinha et al.,
2006 ).
Massage technique, in general is
a "healing" therapy where the muscles
and other soft tissues of the body are
manipulated to improve the health and
well being. It involves different strokes
and pressure techniques that are
supposed to enhance blood flow to the
heart, remove wastes from tissues,
stretch ligaments and tendons and ease
physical and emotional tension (Dieter et
al., 2003 ). Massage technique calls up
the body's natural pain killers; it
stimulates the release of endorphins, the
morphine-like substances that the body
manufactures, into the brain and nervous
system (Mcgrath et al., 2002 ).
Significance of the study:
Since pain is a common
phenomenon that occurs in every child's
life, so the role of the present study is to
investigate the impact of massage
technique on reducing post-operative
pain among infants.
Aim of the study:
The aim of the present study was
to identify the impact of massage on
reducing post-operative pain of infants.
Research hypothesis
The use of massage is effective
in reducing the post-operative pain of
infant.
Subject and Method
Research Design:
Aquasi experimental research
design was used in the present study.
Setting
The study was conducted at the
pediatric surgical unit in pediatric ward,
pediatric hospital at Zagazig University
Hospital.
Subjects
A convenient sample of 60
infants having postoperative abdominal
surgery was selected who fulfilled the
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following criteria:- Age ranged from one month to one
year.
- Both sexes.
- Free from any other chronic diseases.
- Conscious.
The subjects were randomly
divided into two groups; thirty infants in
each group; one study and the other
control group.
The study group who received
routine hospital care and massage
technique and control group who
received routine hospital care only.
Tools for data collection:
In the present study, two tools
were used to collect the necessary data.
Tool (I): Structured interview
questionnaire
Structured
interview
questionnaire
was
developed
by
researcher to collect personal data of the
studied infants and their medical history
and vital signs. It includes 3 parts:
Part (I):- Characteristics of infants and
their mothers as age, sex, weight, birth
order as well as mother's education and
occupation.
Part (II):- Medical history of the studied
infant, included diagnosis, duration of
surgery, type of wound and preoperative
physiological parameter as heart rate,
respiration and temperature.
Part (III):- Vital signs record:
It was developed by researcher to
assess the effect of massage technique
on the vital signs and consists of
measuring heart rate, respiratory rate,
and temperature before and after
massage technique sessions for study
group, also before and after routine care
of control group.
Tool II: Riley Infant Pain Scale
(RIPS)
Riley Infant Pain Scale is a
behavioral assessment tool which was
developed by schade J G, 1996 to assess
the degree of severity of pain and was
used for infants who lack verbal ability.
It has six parameter; facial expression,
body movements, sleep, verbal or vocal
ability, consolability, response to
movement and touch.
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Parameter
(a) Facial expression
- Natural smiling
- Frowning, grimacing
- Clenched teeth
- Full cry expressing
(b) Body movement
- Calm, relaxed
- Restless, fidgeting
- Moderate agitation, Thrashing
- Voluntary immobility
(c) Sleep
- Sleeping with easy respiration
- Restless while asleep
- Sleep intermittently
- Inability to sleep
(d) Verbal vocal
- No cry
- Whimpering, complaining
- Pain crying
- Screaming, high Pitched cry
(e) Consolability
- Neutral
- Easy to console
- Not easy to console
- Inconsolable
(f) Response to movement and touch
- Moves easily
-Winces when touched or moved
- Cries out when moved
- High-pitched cry
Score
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
and the sample was added to the total
study.
Field Work:
The data were collected over a
period of 6 months starting from July,
2009 to January, 2010 .
Procedure:
Every infant with his mother was
individually interviewed by using tool (I)
in a quite room to obtain necessary data
about the infants and to identify the
severity of pain. The time consumed to
obtain the data ranged from 20-25
minutes. Vital singes were measured
Riley Infant Pain Scale Scoring
System:
Each parameter is scored as 0, 1,
2, 3, According to the increased intensity
of the pain.
the total score was
calculated by obtaining the sum of points
for all the six parameters (18 scores),
where 0 indicated no pain, 1-6 indicated
minimum pain, 7-12 indicated moderate
pain, and 13-18 indicated sever pain.
Pilot Study:
A pilot study was conducted on 6 infants
to test the feasibility and applicability of
tools used. No modifications were done
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immediately before and after applying
massage technique. The degree of
severity of pain was estimated on postoperative day for both groups using
physiological response and Riley infant
pain scale.
For study group, Massage technique was
conducted for 5 minutes twice daily
starting from the first post-operative day
for three consecutive days. One time at
the morning shift and another time at the
evening shift. Progressive massage
techniques consist of gently rubbing the
infant with the nurse palms for 5min
periods (12 strokes at every minute,
approximately one rubbing motion every
5 second) over each region in the
following consequence:
- From the infant's head and face
to the neck.
- From the neck across the
shoulder.
- From the thigh to the foot of
both legs.
- From the shoulder to the hand of
both arms.
- Hold the infant upright position
and stroke him from the upper
back to the waist.
Administrative design:
An official permission was
obtained from board of the pediatric
surgical
department
at
Zagazig
University Hospital to carry out the
study.
Ethical consideration
An informed consent obtained
from the mothers to accept to participate
in the study. Total confidentiality of any
obtained information will be ensured.
Statistical Analysis:
The collected data was coded and
entered in a data base file using the
FoxPro for windows program. After
complete entry, data was transferred to
the SPSS version 15 statistical program
by which the analysis was conducted
applying Paired t-test was performed to
test mean values of studied groups
before and after massage technique.
McNamara and T-test for qualitative
variables, the number and percent
distribution were calculated, value is
considered significant if it is ≤ 0.05.
Results:
Table (1) shows the biosocial
characteristics of the studied infants as
age, sex, weight and birth order. It was
found that the age 1-4 months
constituted 40%-46% of the study and
control groups. Males were found to
have the high percentage among the
study (60%) and control (63.3%)
groups.
Concerning the birth order, it was
founded that 36.7% of the study group
were at the 1st and 2nd birth order
compared to 46.7% in the control group,
while the 3rd and more birth order was
represented in 63.3% and 53.3% in the
study and control group respectively.
Regarding infant's weight, it was
found that 60.0% in the study group
compared to 56.7 % in the control group
were below the normal weight according
to their age with a mean value of 6.4+
1.62 and 6.46+1.7 for study and control
group respectively.
Tables
(2)
illustrate
the
characteristics of the infants according to
their diagnosis and duration of operation.
Intussusceptions represented in 26.7% in
control group. Colostomy was founded
in 26.7% in the study group. The mean
values of duration of operation were
2.60.6 and 2.30.5 hours in study and
control group respectively.
Table (3) shows the mean
differences between heart rates of the
study and control groups before and after
applying massage technique in the
morning and evening shifts. The mean
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value of the heart rate in study group
was 112.97±5.2 beat/minute which
decreased to be 109.4±4.9 beat/minute
after applying massages technique in the
third day. A statistically significant
difference was found between the mean
values of heart rate at the morning shift
after applying massage technique
(P=0.02). After applying massage, there
was a statistically significant difference
found between the two groups when
compared with each other (P=0.02).
Study group had a mean value of
the heart rate at the evening shift was
110.5±5.1 beat/minute before massage
and decreased after applying massage to
become 108.8±4.8 beat/minute in the
third day. There was a statistically
significant differences between the mean
value of the heart rate after applying
massage technique (P=0.02).
Furthermore, the mean value of
the heart rate at the evening shift in
control
group
was
108.3±6.3
beat/minute which decreased very
slightly to become 107±6.1 beat/minute
after applying routine hospital care. No
statistically significant difference was
found between the mean values of heart
rate at the evening shift after applying
routine hospital care (P=0.23).
A statistically significant difference was
found between the two groups when
compared with each other (P=0.02),
after applying massage technique.
Table (4) shows the mean
differences between respiratory rates of
the study and control group before and
after applying massage technique in
morning and evening shifts. Study group
had a mean value of respiratory rate
43.3±2.5 cycle/ minute in the morning
shift then after applying massage
technique it slightly decreased to 41.7±
4.9 cycle /minute in the third day. A
statistically significant difference was
found between the mean value of
respiratory rate after applying massage
technique (P=0.00017 ).
Furthermore, the mean value of
respiratory rate at the morning shift in
control group was 48.3± 5.6 cycle/
minute and it slightly decreased to 47.3±
5.0 cycle/ minute after applying routine
hospital care. No statistically significant
difference was found between the mean
value of respiratory rate at the morning
shift after applying routine hospital care
(P=0.185 ).
There
was
a
statistically
significant difference between the two
groups when compared with each other
(p=0.013 ) after applying massage
technique.
Study group had a mean value of
respiratory rate 42.9±5.4 cycle/ minute
in the evening shift before massage
technique and decreased to be 42.0± 5.2
cycle/ minute. A statistically significant
difference was found between the mean
value of respiratory rate at the evening
shift after applying massage technique
(P=0.003 ).
Furthermore, the mean value of
respiratory rate at the evening shift in
control group was 46.6± 5.5 cycle/
minute not changed after applying of
routine hospital care. No statistically
significant difference between the mean
value of respiratory rate at the evening
shift after applying routine hospital care
(P=0.55).
There
was
a
statistically
significant difference between the two
groups when compared to each other
(P=0.003 ), after applying massage
technique.
Table (5) shows the Effect of Applying
Massage Technique on Infant post
Operative Pain Scoring at morning and
Evening Shifts.
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On the third day morning shift, in
study group, more than half of infants
(63.3%) had minimum pain changed to
96.7% after application of massage.
While 36.7% of whom had moderate
pain decreased to 3.3% after massage
technique. A Statistically significant
difference was found between infant's
pain scoring after massage technique
(P<0.001 ).
Further
more,
before
the
application of the routine hospital care,
16.7% and 83.3% of control group had
minimum and moderate pain slightly
decreased after the application of the
routine nursing care to 23.3% and
76.7% respectively. No Statistically
significant difference was found between
infant's behavioral pain scoring after the
application of the routine hospital care
(P>0.05).
A
statistically
significant
difference was found between infant's
pain scoring after applying massage
technique compared to the control group
who
received
routine
hospital
care(P=0.001 ).
On the third day evening shift,
90% of study group who had minimum
pain decreased to 100% after applying
massage. While 10% of those who
scored moderate pain slightly decreased
to become 0.0%. A statistically
significant difference was found between
infant's behavioral pain scoring after
applying massage technique (P<0.01).
By applying the routine hospital
care, 23.3% and 76.7% of control group
who scored minimum and moderate pain
respectively slightly decreased to 26.7%
and 73.3% who received the routine
hospital care. No statistically significant
difference was found between infant's
behavioral pain scoring after application
of the routine hospital care (P>0.05).
There
was
a
statistically
significant difference found between
infant's behavioral pain scoring after
applying massage and routine hospital
care when compared with each other
(P=0.001 ) after applying massage
technique.
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Table (1): Characteristics of the studied infants
Variables
Age\months:
1-4
5-8
9-12
Sex
- Male
- Female
Birth order
1-2
3 or more
Weight
- Within normal range
- Below normal range
Mean + SD
Study group
(n=30 )
No.
%
Control Group
(n=30 )
No.
%
12
13
5
40.0
43.3
16.7
14
9
7
46.7
30.0
23.3
18
12
60
40
19
11
63.3
36.7
11
19
36.7
63.3
14
16
46.7
53.3
12
18
40.0
60.0
6.4+ 1.62
13
17
43.3
56.7
6.46+1.7
Table (2): Characteristics of Infants According to their Diagnosis and Duration of
Operation
Study group
Control Group
(n=30 )
(n=30 )
Characteristics
No.
%
No.
%
Diagnosis
- Inguinal hernia
2
6.7
1
3.3
- Hirschsprung
7
23.3
6
20.0
- Intussusceptions
6
20.0
8
26.7
- Colostomy
8
26.7
7
23.3
- Intestinal obstruction
4
13.3
4
13.3
- Duodenal obstruction
0
0.0
1
3.3
- Iliostomy
1
3.3
0
0.0
- Congenital hypertrophic
pyloric
0
0.0
2
6.7
stenosis
2
6.7
1
3.3
- Imperforated anus
Duration of operation
-Range
1.5-3.5 hrs
1.5-4.0 hrs
- Mean + SD
2.60.6
2.30.5
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Table (3): The Mean Differences between Heart Rates of the Study and control
Groups before and after Applying Massage Technique in the Morning and Evening
Shifts.
Morning Shift
Pulse
st
1 day
Morning X±SD
(P value)
2 nd day
Morning X±SD
(P value)
3 rd day
Morning X±SD
(P value)
Pulse
st
1 day
Evening X±SD
(P value)
2 nd day
Evening X±SD
(P value)
3 rd day
Evening X±SD
Study Group
(n=30 )
Before
115.2± 9.1
Control Group
(n=30 )
After
114.7± 8.5
After
112.4± 8.5
(0.41)
118.6± 6.4
116.2± 6.2
(0.19)
115.5± 6.0
114.1± 6.3
(0.01)*
112.97± 5.2
109.4± 4.9
(0.16)
110.4± 6.88
109.7± 6.6
Before
113.96± 7.4
(0.45)
Evening Shift
After
Before
After
111.6± 6.6
110.1± 7.3
109.6± 7.2
1.75 (0.08)
2.2 (0.02)*
1.65 (0.1)
2.12 (0.02)*
(0.02)*
(0.006 )*
111.7± 6.1
115.2± 5.8
(0.08)
112.4± 8.1
111.0± 7.5
(0.0016 )*
110.5± 5.1
108.8± 4.8
(0.19)
108.3± 6.3
107± 6.1
(0.02)*
(P value)
*Significant p value (<0.05 )
(0.023 )
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Before
112.9± 8.9
T test
(p value)
before and
after
0.34 (0.94)
1.01(0.3)
T test
(p value)
1.54 (0.12)
1. 2(0.02)*
1.51 (0.13)
0.43(0.03)*
1.5 (0.13)
1. 2(0.02)*
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Table (4): The Mean Differences between Respiratory Rates of the Study and
Control Groups before and after Applying massage Technique in the morning and
Evening Shifts.
Morning shift
T test
Study Group
Control Group
(p value)
Respiration
(n=30 )
(n=30 )
before and
after
Before
After
Before
After
st
46.9± 7.5
2.85 (0.012 )
1 day
46.3± 6.5
52.2± 8.3
51.2± 8.29
Morning X±SD
2.5(0.011 )*
(0.15)
(0.14)
(P value)
nd
44.7± 6
43.0± 5.1
48.8± 6.4
48.0± 6.2
2.6 (0.011 )
2 day
Morning X±SD
3.54(0.001)*
(0.001 )*
(0.31)
(P value)
rd
43.3± 2.5
41.7± 4.9
48.3± 5.6
47.3± 5.0
3.4 (0.001 )
3 day
Morning X±SD
3.37(0.013)*
(0.0017 )*
(0.185 )
(P value)
Evening shift
T test
Respiration
(p value)
Before
After
Before
After
45.3± 6.9
45.2± 5.4
51.2± 6.96
50.7± 7.1
3.1 (0.0012 )
1 st day
Evening X±SD
3.15(0.002*)
(P value)
2 nd day
Evening X±SD
(P value)
3 rd day
Evening X±SD
(0.30)
43.9± 5.4
(0.18)
41.3± 3.7
49.1± 7.1
(0.04)*
42.9± 5.4
42.0± 5.2
3.19 (0.002 )
4.36(0.0001 )*
(0.2)
46.6± 5.5
(0.003 )*
(P value)
*Significant p value (<0.05 )
46.5± 5.5
(0.55)
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48.5± 6.3
3.57 (0.012 )
3.0(0.003 )*
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Table (5): The Effect of Applying Massage Technique on Infant post Operative Pain scoring
at morning and Evening Shifts.
Morning shift
Study Group
Control Group
(n = 30 )
(n = 30 )
T test
(p value)
Before
After
Before
After
Pain Scoring
before and
massage
massage
routine
routine
after
hospital care hospital
care
No.
%
No.
%
No.
%
No. %
1 st day
1.38(058)
2
6.7
16
53.3
3
10.0
7
23.3
 Minimum pain (1-6)
27
90.0 14
46.7
24
80.0
22 73.3
 Moderate pain (7-12)
2.43(0.03)*
1
3.3
0
0.0
3
10.0
1
3.3
 Severe pain (13-18)
(p value)
2 nd day
 Minimum pain (1-6)
 Moderate pain (7-12)
 Severe pain (13-18)
(p value)
3 rd day
 Minimum pain (1-6)
 Moderate pain (7-12)
 Severe pain (13-18)
(p value)
Pain Scoring
1 st day
 Minimum pain (1-6)
 Moderate pain (7-12)
 Severe pain (13-18)
(p value)
2 nd day
 Minimum pain (1-6)
 Moderate pain (7-12)
 Severe pain (13-18)
(p value)
3 rd day
 Minimum pain (1-6)
 Moderate pain (7-12)
 Severe pain (13-18)
(p value)
0.001*
0.05
7
23
0
23.0 25
76.7
5
0.0
0
0.001*
83.3
16.7
0.0
3
26
1
10.0
4
86.7
25
3.3
1
0.05
2.78(0.24)
13.3
83.3
3.3 13.61(0.001)*
19
11
0
63.3 29
36.7
1
0.0
0
0.001*
96.7
3.3
0.0
5
25
0
16.7
7
83.3
23
0.0
0
0.05
23.3
76.7
0.0
Before
massage
Evening shift
After
Before
massage
routine
hospital care
No.
%
No.
%
No.
%
0
30
0
0.0
100.0
0.0
15
15
0
50.0
50.0
0.0
2
28
0
6.7
93.3
0.0
0.001*
15.2(0.001)*
After
routine
hospital
care
No. %
T test
(p value)
before and
after
4
26
0
0.52(0.47)
13.4
86.6
0.0
0.43(0.02)*
0.05
13
17
0
43.3 26
56.7
4
0.0
0
0.001*
86.7
13.3
0.0
3
27
0
10.0 5
90.0 25
0.0
0
0.05
16.7 8.52(0.003)*
83.3
0.0 15.86(0.001)*
27
3
0
90.0
10.0
0.0
100.0
0.0
0.0
7
23
0
23.3
76.7
0.0
26.7 7.2(0.007)*
73.3
0.0 13.47(0.001)*
30
0
0
0. 01*
0.05
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4.27(0.03)*
8
22
0
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*Significant p value (<0.05 )
The result of present study
revealed that males were affected more
than females in both groups as they
constituted about two third of subjects.
This result is in agreement with Wyllie
(2004 ) who stated that intestinal
obstruction is more common in males
than females. This finding was also
supported by Kimura (2004 ) who
reported that the incidence ratio of males
to females in Hirshsprung's disease and
duodenal atresia is 4:1.
The present study illustrated that
more than half of the studied infant's
weight was below normal range, This
finding can be attributed to the fact that
infants with gastro-intestinal anomalies
as neonatal intestinal obstruction suffer
from anorexia, vomiting and progressive
abdominal
distension
which
are
symptoms making weight gain very
difficult. This finding also goes in line
with Khalil (2008 ) who found that the
majority of infant's weight was below
normal (table 1).
The study results revealed that
the mean values of heart rate and
respiration in the study group before
massage were 115.2±9 and 46.9±75
respectively and continued to decrease
allover the three days after massage
technique to 108.8±4.8 and 41.7±4.9 .
Because touch stimulates pressure
receptors which in turn stimulate the
vagus nerve (one of the cranial nerves)
and increase the vagal activity. This
leads to slow heart rate, blood pressure
and respiration. Massage has effect on
deepness and normalizes the breathing
pattern through relaxation and release of
tension in the breathing structures; both
the rib cage and muscles of respiration.
It also stimulates the blood flow to and
from the lungs, helps in the elimination
of waste and the absorption of oxygen
DISCUSSION
Postoperative pain is one of the
most common complaints after surgery
and continues to be challenging
especially among neonates and infants.
Acute pain associated with surgical
procedures, trauma or disease is
experienced by thousands of hospitalized
children each year (Tsao et al., 2007 ).
There are different measures
used to minimize infant's pain which
include non pharmacological measures
as gentle handling, reduction of
environmental stimuli and massage
technique (Lucky et al., 2005 ). Massage
supports gate control theory. When skin
has an abundance of (A) fibers, it is
hypothesized that different types of
cutaneous stimulation have the potential
to relive pain by stimulating these fibers
by closing the gate to the transmission of
pain impulses (Lund, 2000 ).
Pain management can speed
mobilization after surgery, shorten
hospital stay, and reduce costs as well as
improving
patient
comfort
and
satisfaction. Pain should be routinely
evaluated and recorded in daily clinical
examination. In fact, it should be
considered as the "fifth vital sign", in
addition to the four traditional vital signs
of temperature, pulse, blood pressure,
and respiratory rate (Yuen & Irwin,
2005).
The characteristics of the present
study reflected that most of infants in the
study and control groups who had
surgery were in the age group ranged
from 1-4 months. This result may be
related to infant's diagnosis that included
congenital
abnormalities
and
its
discovery begins either at birth or during
infancy period and need immediate
surgical treatment as Hirshsprung's
disease and intussusception.
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(Thomas, 2003). This results is in
agreement with Weiss (2003) who cited
that massage produce changes in heart
rate and respiratory rate.
1. Pain assessment should be
documented as a vital sign in
the post operative sheet.
2. Non-pharmacological
interventions
should
be
integrated into the routine
nursing care along with
pharmacological interventions.
3. Written booklets about childhood
pain
and
its
relieving
techniques should be available
for both the health team
members and the families.
The finding of the current study
revealed that the pain level of the
majority of study group decreased from
severe and moderate to minimum pain
after massage technique allover the three
postoperative days. On the contrary, the
majority of the infants of the control
group had severe and moderate pain and
few of them had minimum pain. This
finding can be explained in the light of
that massage technique calls up the
body's natural pain killers as it simulates
the release of endorphins, the morphine
like
substances
that
the
body
manufactures into the brain and nervous
system
(Wall,
melzack,
2003 )
(University of Michigan, 2006),this
result is in congruent with Vessey
(2003 ) who stated that massage is
considered to be the most save
modalities that the nurse can use to
relieve neonatal pain and also goes in
line with Piotrowskid et al, (2003) who
demonstrated that massage is a good
intervention for postoperative pain.
CONCLUSION
Based on the results of the present
study it could be concluded that:
infants experienced post operative pain
through many physiological and
behavioral signs. Massage technique is
one of the most effective nonpharmacological methods as well as less
cost and effective on reducing
postoperative pain in infants undergoing
abdominal surgery.
Based upon the findings
obtained from the present study, the
following recommendations can be
deduced:
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Impact of interventional program on undergraduate nursing students' perception
of worry and comfort in pediatric clinical setting
Shimmaa Mansour Moustafa Mohamed
Lecturer of Pediatric Nursing, Faculty of Nursing, Zagazig University, Egypt.
Abstract:
It has been well documented that nursing students across the world experience
stress and anxiety throughout their education and training. Clinical experiences have been
identified by nursing students as one of the most anxiety-producing components of the
nursing program. Preparation for practice entails more than developing skills in the on
campus lab, it requires developing an ability to provide safe and effective care to other
human beings in various clinical settings. The aim of the present study was to assess the
level of worry and comfort in undergraduate nursing students in pediatric clinical training
and to investigate the impact of the interventional program on undergraduate nursing
students' level of worry and comfort during their pediatric clinical training. A quasi
experimental study was utilized. The present study was conducted at Nursing College,
Zagazig University. The study subjects included 60 participants on third-year
baccalaureate nursing student. A pre/post test Pediatric Student Comfort and Worry
Assessment Tool was used to evaluate student's perception of comfort and worry. A
likert-type scale with four choices ranging from strongly disagree to strongly agree, these
choices were assigned a numerical value of 1 to 4.with 1 relating to strongly disagree and
4 to strongly agree. The study results indicated that there was a statistically significant
difference in nursing students comfort and worry level after implementing the program.
The study findings concluded that areas of concern that mostly changed after program
implementation were comfort in performing a pediatric assessment and administering
medications to a child. The least changed in worry was about worry of helping families
and ill children to cope during painful procedures and at time of grief and crisis. The
study recommended that Faculty should direct their efforts to areas most concerning
students worries to incorporate in teaching strategies to decrease worries which can
increase student's performance in the pediatric nursing setting.
Key wards: worry, comfort, Pediatric clinical settings.
Introduction
It has been well documented that nursing
students across the world experience
stress and anxiety throughout their
education and training (Tully etal.,
2004). Over the past two decades, many
forms of interventions have suggested to
help nursing students with their stress
and anxiety, such as a study of
implementation of relaxation practices,
found that mindfulness meditation over
8-weeks timeframe is helpful in reducing
stress and anxiety among nursing
students (Kang etal., 2009 ).
Nursing programs provide learning
experiences in the classroom and
through a variety of clinical rotations in
hospitals, clinics, and community
settings to gain hands-on experience and
to apply theory to practice. Clinical
experiences have been identified by
nursing students as one of the most
anxiety-producing components of the
nursing program (Sharif & Armitage,
2004).
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Preparation for practice entails more
than developing skills in the campus lab,
it requires developing an ability to
provide safe and effective care to other
human beings in various clinical
settings. This aspect of developing
expertise as a student nurse can be very
stressful to nursing students and create
anxiety. High levels of anxiety can affect
student‘s learning, performance and in
some cases retention within a nursing
program. Oermann and Standfest (1997 )
reported that pediatrics as the most
threatening, challenging, and stressful
experience for clinical nursing students
in nursing schools. The two major
categories that seem to provoke the
highest levels of worry are psychomotor
skills
and
psychosocial
support.
Oermann
and
Lukomski
(2001)
suggested that students fear from
psychomotor skills such as tasks and
procedures. The most significant worryprovoking
psychomotor
skill
is
administering medications to children.
Other psychomotor worries include
administering therapies, performing
procedures, and performing a pediatric
assessment. Sources of psychosocial
worry for nursing students include how
to connect with patients and how to best
support and work with sick children and
families (Coetzee, 2004).
improving learning and decreasing
anxiety in nursing students. Symptoms
of anxiety that appear in nursing students
could include tremors, sweating,
increased heart rate, and increased blood
pressure. The negative impact of anxiety
may be reduced when faculty
acknowledges anxiety and provide a
supportive learning environment for
nursing students where mistakes are
accepted as a part of the learning process
(Moscaritolo, 2009 ).
On this study, the construct of ―clinical
comfort‖ was used to assess nursing
students' familiarity, exposure, and
knowledge of pediatric situations and
experiences. We define clinical comfort
as
knowledge,
confidence,
and
familiarity with a particular clinical area
and population as a result of experience
or education in that area (Blanzola,
Lindeman, & King, 2004), student
worry is defined as excessive amounts of
concern, angst, and thoughts about a
particular course, environment, or other
school-related issue. (Oermann &
Lukomski, 2001 ).
Student
nurses
perceive
clinical
experiences involving children to be the
most worry provoking. It is important
for clinical nursing faculty to be aware
of the heightened sense of anxiety
students may experience during their
clinical rotations. Strategies found in the
literature to help reduce anxiety in
nursing students include providing
consistent clinical placement, peer
mentoring, counseling, faculty role
modeling, and developing positive
student and staff relationships(Chen,
2010).
It is important for clinical faculty to
reduce student anxiety through support
and promote a positive learning
environment. Most of nursing programs
are willing to integrate anxiety reducing
interventional strategies into curriculum
if nursing research provided evidencebased practice models to improve
students‘ clinical performance, success,
and retention. Research is needed to
address faculty teaching techniques and
to make aware what is helpful for
For example, Yucha etal., 2009 found
that nursing students who are assigned to
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one consistent clinical placement
experience less stress and improved
performance.
Moscaritolo,
(2009 )
mentioned that peer mentoring are
interventional strategies that can be
implemented at all levels in the
undergraduate nursing programs, help
developing the collaborative skills,
improve communication skills and
develop professional responsibility
comfort that students may experience
during their pediatric clinical training.
Aim of the study:
1.
To assess the level of worry and
comfort in undergraduate nursing
students in pediatric clinical training.
2.
To investigate the impact of the
interventional program on undergraduate
nursing students' level of worry and
comfort during their pediatric clinical
training.
Research hypothesis:
Studied students will have reduced level
of worry and increased comfort in their
clinical training after exposure to
interventional program.
Subjects and methods:
Design:
A quasi experimental study was done.
Setting:
Nursing College Zagazig University,
Egypt.
Subjects:
A sample of 60 participants on thirdyear baccalaureate nursing student
received training on how to manage
anxiety on pediatric clinical setting for
four weeks led by the researcher.
Students were selected to fulfill the
following criteria:
 Agree to participate in the study
 Regularly attending the pediatric
nursing course.
 Upgrade from 2 nd year for the
first time.
 Both sexes.
The study excluded students:
 Who were absent for only one
time.
 Who were repeaters on third
year.
Tool:
The Pediatric Student Comfort and
Worry
Assessment
Tool
(AlQaaydeh,2012 ) was used to evaluate
students perception of comfort and
The comfortable feelings gave students a
sense of confidence and usefulness and a
goal that introduced basic emotional
needs, thoughts, intuitions, physical
sensation, and emotions into the picture.
Student emotional changes can be
affected by many individual and
personal factors such as confidence,
motivation, competence, and willingness
to perform assigned tasks to achieve
growth and progress, which supports the
definition given by the (American
Heritage Dictionary ,2008 ).
The role of nursing students in pediatric
wards, in particular, is to develop self
direction, expectation, comfort, energy,
and the ability to organize and to take
initiative in learning to care for children
with love. If students are continually
satisfied with the quality of their clinical
experiences, they may be expected to
achieve confidence, competence, and
idealization in the clinical program.
When a healthy practicum environment
exists, students feel good about each
other and, at the same time, feel a sense
of comfort from their practices (JihYuan Chen , 2010 )
Significance of the study:
Clinical experiences involving
children perceived by student nurses to
be the most worry provoking. So, it is
important to assess sense of worry and
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worry. A likert-type scale with four
choices ranging from strongly disagree
to strongly agree, these choices were
assigned a numerical value of 1 to 4.with
1 relating to strongly disagree and 4 to
strongly agree. Items 3 and 5 were
worded to indicate lack of comfort and
were therefore reverse coded before final
scoring of the instrument.
Internal consistency was evaluated by
calculating (Cronbach's alpha) of the
tool for the current sample was .77 for
the preintervention and .80 for the
postintervention and the values were
founded to fall within generally accepted
ranges.
Pilot study:
A pilot study on 6 students was
conducted to test the applicability of the
tool. No modifications were done in the
tool.
Procedure:
Study was conducted in the period from
November to December 2014.
Participant students were divided into
four groups, each group received
training on how to manage anxiety on
pediatric clinical setting for four weeks
led by the researcher by ratio of one
training per one week.
Participants completed the tool in pre
and post tests in about 10 minutes, and
no missing data were found among all
response questions.
Usability was also determined by
question response placement with
participants marking: between columns,
2% of the time; two answers, less than
1% of the time.
Administrative design:
An official permission was obtained
from pediatric nursing department board
to carry out the study.
Ethical consideration:
An informed consent was obtained from
participant students to accept to
participate in the study.
Statistical analysis:
Data were entered and analyzed using
SPSS version 16. The most appropriate
tool to analyze data was Wilcoxon for
frequency distribution in pre and post
tests. The t test for paired samples was
used for mean values before and after
implementing the program. To assess the
relative effect of the interventional
program we calculated P-value at ≤ 0.05.
Results:
Regarding the comfort level with
pediatric clinical setting (table 1), before
program implementation only 11.6% of
the sample were strongly agree in
performing pediatric assessment with
comfort while after implementing the
program the percentage became 38.3%
and the difference was highly
statistically significant (P= 0.002 **).
48.3% and 61.7% of the sample before
and after program implementation
respectively
were
agreed
about
explaining procedures and medication to
the child and the difference wasn't
significant (P= 0.48).
Before program implementation 36.7%
of sample were agreed to be
uncomfortable
in
medication
administration to children and after
program implementation the percentage
was changed to be only 13.3% of them
and the difference was highly
statistically significant (P=0.001 ***).
Regarding
comfort
ability
in
administering therapies or performing
procedure 6.7% of sample were agreed
before program implementation and
28.3%
of them after program
implementation and it was highly
statistically significant (P=0.001 **).
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As regard students uncomfortably in
helping children and their families in
coping during painful procedures, 20.0%
of them were disagree before program
implementation and slightly decreased to
be 16.7% after implementing the
program the difference wasn't significant
(P= 0.48).
Concerning comfortability in providing
support to children and their families
during time of crisis and grief, about one
third of the students (30.0%) were
agreed before program implementation
and slightly increased after program
implementation to be 35.0% and the
difference wasn't significant (P= 0.47).
and difference was highly significant
(P=0.001 ***).
Concerning students worries about
interacting with children families, 38.3%
of them were disagree before
implementing the program and increased
after program implementation to be
50.0% , the difference wasn't significant
(P=0.6).
Regarding mean and standard deviation
of the comfort level with pediatric
clinical setting (table 3), before program
implementation was 2.45±0.97 , while
after implementing the program changed
to be 3.38±0.643 (t=5.822 ) and (P=
0.001***).
As regard comfortability in providing
support to children and their families
during time of crisis and grief, before
program implementation
mean and
standard deviation was 3.033±1.301
compared to 2.983±0.965 after program
implementation (t=0.233) and (P=
0.816).
Regarding student's worries during
clinical rotation about caring ill child
before program implementation mean
and standard deviation was 2.816±0.77
which significantly changed after
implementing the program to be
2.166±0.642
(t=4.925 )
and
(P=0.001 ***) (table 4).
Concerning students worries about
interacting with children families, mean
and standard deviation before and after
implementing
the
program
was
2.55±0.909
and 2.25 ± 0.772
respectively (t=1.855 ) and (P=0.069 ).
Regarding student's worries during
clinical rotation (table 2), 43.3% of
students were agreed to be worried in
caring ill child before program
implementation which significantly
changed after implementing the program
to 31.7%, difference was significant
(P=0.02*).
Only 16.7% of them were disagree to be
worried about causing physical harm to
child during the rotation before program
implementation
while
after
implementing
the
program
this
percentage changed to be 58.3%,
difference was highly significant
(P=0.001 ***).
More than half of the students (53.3%)
before program implementation were
agree to be worried about causing
emotional harm to child, while after
implementing the program 20.0% of
them were agree and the difference was
highly significant (P=0.001***).
Regarding the students worry about
causing child pain, less than half
(43.3%) of them were agree before
program implementation and decreased
to 16.7% after program implementation
Table (5) shows the significant change in
anxiety level the nursing students
anxiety before and after implementing
the program (P= 0.000), while the
change in comfort level among students
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before and after program implementation
wasn't significant (p=0.64).
was statistically significant
(p=
0.94).
Concerning
percentage
distribution of anxiety level among
nursing students before implementing
the program was 37.66% compared to
19.8% of them felt anxious after
program implementation, the difference
was highly statistically significant (p=
0.001)**
Fig. (1) illustrate the percentage
distribution of comfort level among
nursing students before implementing
the program was 35.16% compared to
40.8% of them felt comfort after
program implementation, the difference
Table (1): Comfort Frequency Distribution in Pre and Post intervention Tests.
Item
Pre
Post
P Value
Wilcoxon
Comfort
No.
%
No.
%
1
Strongly Disagree
13
21.7
4
6.7
0.002**
Disagree
13
21.7
7
11.7
Strongly Agree
7
11.6
22
33.3
Agree
27
45.0
26
43.3
2
Strongly Disagree
4
6.7
3
5 .0
0.48
Disagree
17
28.3
11
18.3
Strongly Agree
10
16.7
9
15.0
Agree
29
48.3
37
61.7
3
Strongly Disagree
Disagree
Strongly Agree
Agree
4
Strongly Disagree
Disagree
Strongly Agree
Agree
5
Strongly Disagree
Disagree
Strongly Agree
Agree
6
Strongly Disagree
Disagree
Strongly Agree
Agree
8
20
10
22
8
17
4
31
10
12
13
25
12
15
15
18
13.3
33.3
16.7
36.7
13.3
28.3
6.7
51.7
16.7
20.0
21.7
41.6
20.0
25.0
25.0
30.0
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10
40
2
8
9
4
17
30
12
10
8
30
6
18
15
21
16.7
66.7
3.3
13.3
15.0
6.7
28.3
50.0
20.0
16.7
13.3
50.0
10.0
30.0
25.0
35.0
0.001***
0.001**
0.57
0.47
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Table (2): Anxiety Frequency Distribution in Pre and Post intervention Tests.
Item
Pre
Post
P Value
Wilcoxon
Anxiety
No.
%
No.
%
test
7
Strongly
Disagree
Disagree
Strongly Agree
Agree
8
Strongly
Disagree
Disagree
Strongly Agree
Agree
9
Strongly
Disagree
Disagree
Strongly Agree
Agree
10 Strongly
Disagree
Disagree
Strongly Agree
Agree
11 Strongly
Disagree
Disagree
Strongly Agree
Agree
1
21
12
26
4
10
17
29
1.7
35.0
20.0
43.3
6.7
16.7
28.3
48.4
3
34
4
19
5
35
1
19
5.0
56.7
6.6
31.7
8.3
58.3
1.7
31.7
4
7
17
32
5
14
15
26
7
23
10
20
6.7
11.7
28.3
53.3
8.3
23.3
25.0
43.3
11.7
38.3
16.7
33.3
7
36
5
12
4
40
6
10
7
30
8
15
11.7
60.0
8.3
20.0
6.7
66.7
10.0
16.7
11.7
50.0
13.3
25.0
0.02*
<0.001 ***
<0.001 ***
<0.001 ***
0.6
Table (3): Comparison between Pre and Post Intervention Tests in Comfort Items:
Item
Pre
Post
Paired
Comfort
Intervention
intervention
t-test
P-value
(m ± SD)
(m ± SD)
1
2
2.45 ± 0.97
2.75 ± 0.815
3
2.56 ± 0.927
4
2.516 ± 0.812
5
6
2.533 ± 1.016
3.033 ± 1.301
3.38 ± 0.643
3.133 ±
0.872
2.133 ±
0.724
2.033 ±
0.662
2.00 ± 0.843
2.983 ±
0.965
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5.822
2.302
<0.001 ***
0.025 *
2.801
0.007 **
3.744
<0.001 ***
3.572
0.233
0.001 **
0.816
Impact of interventional program
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Table (4): Comparison between Pre and Post Intervention Tests in Anxiety Items:
Item
Pre
Post
Paired
Anxiety
Intervention
intervention
t-test
P-value
(m ± SD)
(m ± SD)
7
2.816 ± 0.770
8
9
10
11
3.050 ± 0.723
3.03 ± 0.822
2.93 ± 0.756
2.55 ± 0.909
2.166 ±
0.642
2.40 ± 0.693
2.30 ± 0.743
2.26 ± 0.634
2.25 ± 0.772
4.925
<0.001 ***
4.925
6.187
4.834
1.855
<0.001 ***
<0.001 ***
<0.001 ***
0.069
Table (5): The Relation between Pre and Post Intervention Tests in Comfort and
Anxiety Items:
Item
Comfort
Anxiety
Total
Pre
Intervention
(m ± SD)
Post
intervention
(m ± SD)
P-value
15.89 ± 3.38
14.38 ± 2.97
30.27 ± 5.11
15.64 ± 2.74
11.38 ± 2.68
27.06 ± 4.30
0.64
0.000
0.000
Figure (1): Percentage Distribution of Comfort and Anxiety Items in Pre and Post
Intervention Tests.
Percentage Distribution of Comfort and Anxiety in Pre and Post Tests
40.8
45
40
37.66
35.16
35
30
19.8
25
Pre
Post
Percentage
20
15
10
5
0
Comfort
Anxiety
Comfort and Anxiety Distribution Pre and Post Tests
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with previous literature and demonstrate
a core area for educational improvement.
Similar to previous studies, the worry of
potentially inflicting pain on a child was
found to be a significant source of worry
and anxiety which had a great concern
for participants (Oermann & Lulomski,
2001). The frequency and similarity in
these results suggest a significant lack in
student preparation for the pediatric
experience.
Discussion:
Comfort level and worries perceived by
nursing students in pediatric clinical
settings are not only significant but also
manageable. College students experience
stress, as nursing programs are intense,
complex and require long hours in the
clinical setting (Yucha et al., 2009).
Before
program
implementation,
participants reported the least comfort
with
explaining
procedures
and
medication to the child, helping children
to cope during painful procedures and
providing support to children and their
families during time of crisis and grief
(table 1). This may be because of
relative inexperience in pediatrics and
unfamiliarity with pediatric procedures.
This is consistent with Blanzola et al.,
(2004 ) in his study about novice learner
and inexperience with a new setting.
After program implementation there was
improvement in the participants' comfort
with performing a pediatric assessment,
delivering and explaining medications,
and performing procedures with the
greatest change seen in comfort in
performing a pediatric assessment. This
goes with Madeline etal., (2013 ), found
that post pediatric clinical data suggest
improvement
in
comfort
with
performing pediatric assessment. This
may be related to the importance of
faculty members indirectly place on
performing psychomotor skills and
medication education because these
skills are often easier to evaluate through
direct observation.
After implementing the program (table
3,4), supporting children and their
families and interacting with them
remained the most worrisome aspect
among both the comfort and worry
perceptions in undergraduate nursing
students. This may be correlated to the
traditional methods in preparing nursing
students for clinical environment which
emphasizes the mastery of psychomotor
skills such as assessment and medication
administration. However, the results of
this study suggest that greater emphasis
should also be placed on the affective
domain as seen in worry of interacting
and supporting ill children and their
families.
The total change in comfort perception
in under graduate nursing students after
implementing the program was little and
not significant, this may be as a result
the children families aren't trusted too
much in the undergraduate students'
knowledge and considering them not
efficient enough to care for their children
and to give health education or
emotional support because they are still
under training. So little chance is
provided for undergraduate students to
explain procedures or support and help
them
to
cope
with
painful
procedures(table 5).
Concerning the change in participants
perception of worry (table 2). Before
program implementation, participants
had the greatest worry of caring ill child,
causing physical harm to the child,
causing a child pain and interacting with
children families. This closely correlates
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Finally, research into coping strategies
for nursing students dealing with
pediatric patients in pain and supporting
them during times of suffering will be
beneficial for future students.
Conclusion:
Clinical training is one of the
most vital components of the nursing
education, it is imperative that nurse
educators continue the effort to help
nursing students manage their worries
and improve their comfort perceptions
during this important process. The area
of concern that mostly changed after
program implementation was comfort in
performing a pediatric assessment and
administering medications to a child.
The least changed in worry was about
worry of helping families and ill children
to cope during painful procedures and at
time of grief and crisis
Recommendations:
Faculty should direct their efforts
to areas most concerning students
worries to incorporate in teaching
strategies to decrease worries to increase
student's performance in the pediatric
nursing setting.
Intensive orientation programs
should be conducted to all nursing
students before starting clinical training.
pediatric clinical setting. Journal of
Nursing Research, 18:144-153
References:
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2008, from
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Jih-Yuan (2010): Morale and Role
Strain of Undergraduate Nursing
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Experiences of students in pediatric
nursing clinical courses. Journal of
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(2004 ): Nurse internship pathway to
clinical comfort, confidence and
competency. Journal for Nurses in Staff
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Differences in stress and challenge in
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clinical practice among ADN and BSN
students in varying clinical courses.
Journal of Nursing Education, 36:228333
Sharif F and Masoumi S. (2005):
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Osteoporosis health guidelines.
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Osteoporosis health guidelines to prevent its silent progression among male
and female Attending Cairo University Hospital
Gehan M. Ismail*; Enass H. El-Shair*; Heba M. Sharaa**
*Assistant Prof. of Community Health Nursing, ** lecturer of Community Health
NursingFaculty of Nursing, Cairo University,
Abstract
Background, Osteoporosis is an important health problem with serious consequences. Aim, To
assess risk factors of osteoporosis among both sexes over 40 years attending outpatient clinics at Cairo
university hospital and develop health guidelines to prevent/reduce osteoporosis. Design, A descriptive
correlational research design was utilized. Setting, Data were collected from the orthopedic outpatient
clinic at El-Manial University Hospital. Sample, A convinent sample of all cases coming to the orthopedic
outpatient clinic who fit the criteria were included in the study. Tool for data collection, One tool was
developed by the researchers; Osteoprosis Structured Interviewing Questionnaire Sheet: consisted of 3
parts: Part I. Personal data: age, sex, marital status, residence, educational level, etc….. Part II. Medical
and family history: it included the following; 1) family history of osteoporosis, health problems. 2)
Disease duration, history of falls and fracures. 3) Treatment; medications (thyroid treatment, hormonal
treatment, corticosteroid, antidepressant, antiepileptic, anticoagulant drugs and immune-suppresive). Part
III. Risk factors of osteoporosis and life style: exercise, smoking, alcohol and caffeine intake, appetite
loss, protein eating, sun exposure, body mass index. Results, it was found that, 72.4% of the study
subjects were married, mean age of them was 59.11+8.904 years, 75% of them were females. Also, 44.7%
can read and write, 60.7% of them were retired and 14.5% were housewives and 78% of the study subjects
are from urban area. It was found that, 63.4% of study subjects with osteoporosis had family history of
osteoporosis. Also, 81.5% of the study subjects are suffering from osteoporosis. The majority of
osteoporotic study subjects were taking corticosteroid, anticoagulant drugs, antiepileptic drugs and
hormonal therapy. The findings revealed that, 30.2% were obese, 10.3% of osteoporotic study subjects
were practicing exercises. only 13.4% of those with osteoporosis exposed themselves regularly to sunlight
and 94.8% of osteoprotic females had their menopause between the ages of 45-55 years. Conclusion, the
study concluded that, the common risk factors identified were; family history, lack of excersies, irregular
exposure to sun light, being a female. Also, osteoporosis health guidelines were needed for
prevention/reduction of osteoporosis. Recommendations, the study recommended to dissiminate
osteoporosis health guidelines in orthopedic outpatient clinics and further studies are needed to evaluate the
effect of osteorosis health guidelines in the prevention of osteoporosis.
Keywords: Osteoporosis, health guidelines, risk factors.
compromised bone strength and an
increase in the risk of fracture (Kanis,
Burlet & Cooper, et al., 2008 ). There
are significant differences in skeletal size
and structure between men and women
that account for differences in fracture
incidence, location and outcomes
(Watts, 2013 ).
Introduction
Osteoporosis is the most
common bone disease in humans,
representing a major public health
problem
(National
Osteoporosis
Foundation,
2014 ).
Just
like
Hypertension, Osteoporosis, or porous
bone, is a silent killer disease. As the
longetivity of life has increased, the
prevalence
of
Osteoporosis
has
increased, it become a disease of modern
air conditioned lifestyle (Khot, 2014 ).
Osteoporosis is characterized by low
bone mass, deterioration of bone tissue
and disruption of bone architecture,
It is a silent ―epidemic‖ that has
become a major health hazard in recent
years, afflicting over 2000 million
people worldwide (Kanis, Burlet &
Cooper, et al., 2008 ). As projected by
WHO, (2012 ) the prevalence of
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osteoporosis has reached to endemic
proportions where approximately 75
million people in Europe and America
are suffering from osteoporosis and
worldwide 9 million fractures are solely
due to osteoporosis every year. The
International
Osteoporosis
Foundation, (2010 ) estimated that,
approximately 30% of all postmenopausal women have osteoporosis in
the US and Europe. Women are 8 times
more at risk of osteoporosis than men
(Adachi et al., 2010 ) so that, about 200
million women worldwide suffer from
the disease (Shirazi et al., 2007 ). Based
on data from the National Health and
Nutrition Examination Survey III
(NHANES III), National Osteoporosis
Foundation has estimated that more than
9.9 million Americans have osteoporosis
and an additional 43.1 million have low
bone density (National Osteoporosis
Foundation, 2014 ).
lifetime (Kanis, Burlet & Cooper, et
al., 2008 ). Osteoporosis leads to nearly
9 million fractures annually worldwide
and over 300,000 patients present with
fragility fractures to hospitals in the UK
each
year.
The
prevalence of
osteoporosis increases markedly with
age, from 2% at 50 years to more than
25% at 80 years in women. More than
one-third of adult women and one in five
men will sustain one or more
osteoporotic fractures in their lifetime
(Leicestershire Medicines Strategy
Group, 2013 ).
Many
factors
have
been
associated with an increased risk of
osteoporosis-related fracture (National
Osteoporosis
Foundation,
2014 ).
Although genetic factors (e.g., age, race,
family history, and gender) are major
determinants of peak bone mass and
subsequent bone status, osteoporosis is
one of diseases which are influenced by
nutrition and lifestyle; it is preventable
by means of adequate nutrition and
sufficient physical activity. Because
lifestyle practices formed early in life
and may be carried into adulthood, there
is an immediate need to increase
osteoporosis awareness and subsequent
beliefs, not only in older women, but
also in younger women (Siegrist, 2008 ;
Miura, Yagi, Saavedra & Yamamoto,
2010 ).
Although the prevalence of
osteoporosis is lower in men than in
postmenopausal women globally, the
mortality and morbidity of osteoporosis
among men are higher than among
women(Watts, 2013 ; Gennari &
Bilezikian, 2007 ). The International
Osteoporosis Foundation, (2012 )
found that, more than 1 million
Malaysians are at risk of developing
osteoporosis, of which 20 percent are
men, while 51.8 percent of urban
Malaysian
women
suffer
from
osteoporosis near the age of menopause.
It has been estimated that by 2050, more
than 50 percent of all osteoporotic
fractures will occur in Asia (Lau, 2009 ).
Osteoporosis and related fractures
represent a serious and global public
health problem. It's estimated that 30%50% of women and 15%-30% of men
suffers an osteoporotic fracture in their
Osteoporosis includes several
controllable and uncontrollable risk
factors. The controllable risk factors
(environmental) include low activity
level, sedentary lifestyle over many
years, smoking, alcohol abuse and
inadequate diet including eating
disorders, low calcium intake, low
vitamin
D
intake.
Excessive
consumption of soft drinks and
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caffeinated drinks cause calcium loss via
the kidney. Caffeine use of more than
three cups of coffee every day might
increase calcium excretion in the urine
and it affects bone health (National
Osteoporosis
Foundation,
2014 ).
Achieving a higher peak bone mass
through exercise and proper nutrition
during adolescence is important for the
prevention of osteoporosis. Exercise and
nutrition throughout the rest of the life
delays bone degeneration (Osteoporosis
Australia,
2011 ).
Whilst
the
uncontrollable factors include gender,
family history, ethnicity and race,
advancing age, postmenopausal status
and body frame size (National
Osteoporosis Foundation, 2011 ). Since
osteoporosis is asymptomatic, early
detection of the risk level for a person
can help monitor wear and tear of bones
and be instrumental in lowering the
incidence of the disease through
appropriate lifestyle modifications (diet
and exercise) and medication use (Deo,
Nayak & Rajpura, 2013 ).
The Royal College of Nursing,
(2012 ) mentioned that nurses have key
roles in initiating care to prevent people
becoming ill in the first place and in
minimizing the impact of illness.
Community health nurses are an
important influence in public health
because they can contribute to the
lifespan approach to bone-health
protection and improvement. Nurses in a
variety of settings have opportunities
across the lifespan to promote bone
health and to change attitudes throughout
the community on bone health,
osteoporosis and fracture risk. By taking
a long-term view of bone health from
conception to older life and using a
public health approach in a variety of
settings, it is possible to provide unified
care across a community.
Significance of the study:
Osteoporosis poses a huge
challenge in developing countries due to
demographic transition and aging of the
population coupled with limited
availability of resources. The exact
Disease burden is difficult to quantify
because of the paucity of data
(International
Osteoporosis
Foundation, 2010 ). Sallam, Galal &
Rashed, (2006 ) found that, Egyptian
women have a lower bone mineral
density compared to their western
counterparts. According to the recent
International
Osteoporosis
Foundation (IOF) report, 28.4% of
postmenopausal women in Egypt are
estimated
to
have
Osteoporosis
(International
Osteoporosis
Foundation, 2010 ; Taha, 2011 ).
Based on a research by Barzanji,
(2013 ) considerable number of adult
males and females are unaware about
osteoporosis. There is a deficiency in
knowledge and poor application of the
preventive actions; therefore, health
education is needed to improve
awareness and motivating healthy
behaviors. Cline & Worley, (2006 )
stated that, early assessment and
prevention programs should start at an
early age to avoid the behavioral risk
factors. Also, Chang, (2006 -a) added
that,
effective
community-based
educational programs proved to have a
profound effect on improvement of
knowledge and health behavior related to
osteoporosis and its care.
The Middle East and Africa
Audit about epidemiology, cost and
burden of osteoporosis was published in
2011 by the International Osteoporosis
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Setting
Data were collected from the
orthopedic outpatient clinic at ElManial Cairo University Hospital. This
clinic is in the ground floor with the
other outpatient clinics and it is
composed of 7 rooms. It is working
from Saturday to Tuesday 9am to
1pm. The total number of cases
coming to the clinic is 295 (125 new
cases & 170 follow up) daily.
Foundation (IOF). The audit focused on
17 countries including 11 Arab countries
in the Middle East, Turkey, Iran and few
other countries in Africa. According to
the executive summary of the IOF audit
report, osteoporosis is a neglected
disease, not being integrated in medical
curricula of most countries, and the level
of awareness about osteoporosis is
estimated as poor to medium in most
studied
countries
(International
Osteoporosis Foundation, 2011 ).
Sample
A convinent sample of all cases
coming to the orthopedic outpatient
clinic who fit the criteria were
included in the study. The total
number was 275 males & female
clients was recruited within a period
of 6 months. The inclusion criteria
was age over 40 years
Increasing public knowledge
about osteoporosis should be a priority
for future intervention programs, health
education programs should be directed
toward improving public and school
children's knowledge and awareness in
order to prevent and lower the effect of
osteoporosis. So this research aimed at
assessing the risk factors of osteoporosis
among males and females over 40 years
attending outpatient clinics at Cairo
university hospital and develop health
guidelines
to
prevent/reduce
osteoporosis.
Tool for data collection:
One tool was developed by the
researchers after extensive review of the
related literature.
Osteoprosis Structured Interviewing
Questionnaire Sheet: It consisted of 3
parts:
Part I. Personal data: age, sex, marital
status, residence, educational level,
number of children and occupation.
Part II. Medical and family history: it
included the following; 1) family history
of osteoporosis, health problems. 2)
Disease duration, history of falls and
fracures. 3) Treatment; medications
(thyroid treatment, hormonal treatment,
corticosteroid,
antidepressant,
antiepileptic, anticoagulant drugs and
immune-suppresive).
Part III. Risk factors of osteoporosis
and life style: exercise, smoking,
alcohol and caffeine intake, appetite loss,
protein eating, sun exposure, body mass
index.
Aim:
- To assess risk factors of
osteoporosis among both sexes
over
40
years
attending
outpatient clinics at Cairo
university hospital.
- Develop health guidelines to
prevent/reduce osteoporosis.
Subjects and Methods
Design
A
descriptive
correlational
research design was utilized for the
study as it suites its purpose.
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months from beginning of September
2011 to the end of March 2012, two
days/week from 9.00 a.m. to 12.00 p.m.
Tool validity
The study tool was submitted to a
panel of five experts in the field of
community health nursing and medical
surgical nursing to test the content
validity. Modifications were carried out
according to the panel‘s judgment on
clarity
of
sentences
and
the
appropriateness of the content.
Each client was interviewed to
complete the questionnaire. Researchers
faced the clients, asked them the
questions in Arabic and recorded their
answers in the structured interviewing
questionnaire sheet. The interview was
carried out in the waiting area at the
orthopedic outpatient clinic and it took
about 30 minutes for each one.
Ethical consideration
Each client was informed about the
purpose of the study and its importance.
Researchers
emphasized
that,
participation in the study was entirely
voluntary.
Anonymity
and
confidentiality were also assured through
coding the data. An informed written
consent was obtained from the clients
who met the criteria for inclusion and
accepted to be included in the study. All
clients were informed that they can
withdraw anytime without any penalty.
Based on the results of the risk
factors, osteoporosis health guidelines
were developed by the researchers after
extensive review of related literature.
For ethical reasons thought it was not
intended in the research, these developed
guidelines were distributed to the study
subjects.
Recognizing osteoporosis risk
factors early in life and taking
appropriate action can have enormous
positive impact on bone health in later
years. The objective of this guidelines
was to help people to change their
unhealthy behavior in order to alter the
modifiable factors of osteoporosis.
Pilot Study
A sample of 10% of the subjects
who met the criteria of selection were
included in the pilot study in order to
assess the feasibility and the clarity of the
tool and determine the needed time to
answer the questions. Based on its result,
minimal changes were carried out. Pilot
study revealed that the average length of
time needed to complete the structured
interview schedule was approximately 30
minutes with each client.The sample
included in the pilot study were excluded
from the study sample.
Procedure
An official permit was taken
from El-Manial University Hospital
administrators and the manager of the
outpatient clinics. Permission was also
obtained from the head nurse of the
orthopedic clinic to gain her cooperation.
Data was collected through a period of 6
Description of guidelines:
Osteoporosis health guidelines
included the modifiable risk factors of
osteoporosis in the form of:
1. Alcohols and smoking
prevention: Alcohol Intake of 3
or moreunits per day is
detrimental to bone health and
increases the risk of falling.
Smoking also increases the risk
of
osteoporotic
fractures.
Although the risk of fracture
from smoking increases with age,
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 Home
safety
interventions,
particularly for persons with visual
impairments.
 Evaluate
any
neurological
problems, dizziness, poor vision,
psychotropic medications & urinary
frequency and toileting issues.
cigarette smoke has an early
effect on bones.
2. Balanced diet and exposure to sun:
 Help reduce fracture risk via
adequate daily calcium and vitamin
D.
 Correction
of
nutritional
deficiencies, particularly of calcium,
vitamin D and protein, should be
advised.
 Patients should be advised to
have a calcium intake of at least
700mg daily (equivalent to 1 cup of
milk, 300g yoghurt or 100g cheese).
 Vitamin D insufficiency can be
prevented by exposure of face, arms
and legs to sunlight for 15-20
minutes daily.
 There are many good sources of
protein, of both animal and
vegetable origin as lean red meat,
poultry and fish are excellent
sources of animal protein, as are
eggs and dairy foods. Vegetable
sources of protein include pulses,
nuts, grains and soya products.
5. Low Body Mass Index:
The body mass index, or
BMI, is a measure of how
lean someone is and can be
used as a guide to measure
his or her osteoporosis risk.
Doctors believe that a BMI of
20 to 25 is ideal.
6. Medical treatments affecting bone
health:
Some medication may have side
effects that directly weaken bone or
increase the risk of fracture due to
fall or trauma. Patients taking any of
the following medication should
consult with their doctor about
increased risk to bone health:
corticosteroids,
certain
immunosuppressant,
thyroid
hormone
treatment,
certain
antipsychotics
certain
anticonvulsants & antiepileptic
drugs,
3. Exercises: Adequate physical exercise
is essential for normal bone formation,
walking three to four days per week, at a
brisk pace is necessary. Musclestrengthening exercises will improve
vertebral bone strength; reduce the risk
of falls and
fractures by improving
posture, and balance, as well as general
health benefit.
7. Follow up especially for postmenopausal women and those with
family history of osteoporosis. They are
at greatest risk of osteoporosis and need
to be aware of any special risk factors
and consult with their doctor about
taking routine bone mineral density tests.
8. Periodic follow up especially in case
of chronic diseases. Secondary risk
factors, including other diseases and
medication, can lead to osteoporosis.
People who are concerned about
osteoporosis should seek advice from
their healthcare provider.
4. Falls prevention: Effective fall
prevention includes:
 Ask about falls in the past year.
 Assess the time taken to
stand from sitting.
 Assess muscle strength, balance,
and gait.
 Exercise programs.
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Statistical Analysis
Data were analyzed using
Statistical Package for Social Science
(SPSS windows) version 20. Numerical
data were expressed as mean ± SD, and
range. Relations between different
numerical variables were tested using
Pearson correlation. Probability (pvalue) less than 0.05 was considered
significant and less than 0.001 was
considered as highly significant.
Results
Findings of the study are
presented in three main parts: 1)
description of the study subjects 2)
description of medical history, 3)
distribution
of
risk factors
of
osteoporosis and lifestyle among the
study subjects and 3) The relations
between risk factors and osteoporosis
among the study subjects.
Part 1: Description of the Study
subjects
Results reveal that, 72.4% of the
study subjects are married and less than
one quarter (21.5%) are widowed. In
relation to the age, (61.1%) of the study
subjects are 40 to 60 years while 38.9%
are 61 years and more with a mean age
of 59.11+8.904 years. It is found that,
75% of the study subjects are females.
More than half (54.2%) of the study
subjects do not have any children while
35.6% has 1-5 children while only
10.2% has more than 5 children.
Regarding study subject's education, it is
found that, 44.7% can read and write,
25.9% had secondary education, 12%
has a university education and only 1.8%
is unable to read and write. Results
reveal that, 60.7% of the study subjects
are retired, 24.7% are employees and
14.5% are housewives. It is found that,
78% of the study subjects are from urban
area.
Part 2: Medical and family history
a. Family history: Figure (2)
reveals that, 39.2% and 63.4% of the
study subjects without osteoporosis and
those with osteoporosis respectively
have family history of the disease. Also,
62.7% of those without osteoporosis and
56.7% of those with osteoporosis have
chronic diseases in the form of
hypertension, diabetes and heart
diseases.
b.
Disease
duration
and
fractures: Results also found that, 44.6%
of them have the disease for one to 5
years, 34.9% of the study subjects have
the disease for more than 5 years and
only 20.5% suffer from osteoporosis for
less than one year with a mean
2.23+.715 years. Also, 39.2% and
45.1% of those without osteoporosis and
those with osteoporosis respectively
have previous fractures (figure 2).
Results reveal that, 74.5% and 60.7% of
study subjects without osteoporosis and
those with osteoporosis respectively
have history of falling down during the
previous two years (figure 2). Results
illustrate that, 18.5% do not have
osteoporosis while 81.5% of the study
subjects are suffering from it (figure 1).
Females having osteoporosis accounts
for 76.8%.
c. Treatement: Results revealed
that, only 8.9% of study subjects with
osteoporosis
take
corticosteroid
treatment. Results find that, 67.4% of
study subjects with osteoporosis and
41.1% of those without osteoporosis
take anticoagulant drugs. Results reveal
that, 42.9% of those with osteoporosis
take antiepileptic drugs and 2.7% take
immune-suppressive drugs. Also, 19.6%
and 21.4% respectively of those who do
not have osteoporosis and those with
osteoporosis take hormonal therapy
(figure 3).
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significant correlation was found
between osteoporosis and family history
(p=0.001), hormonal therapy (p=0.001 ),
eating proteins (p=0.022 ), anticoagulant
(p=0.000), loss of appetite (p=0.005 ),
anti convulsion drugs (p= 0.000 ),
drinking alcohol (p=0.017 ) and drinking
tea and coffee (p= 0.010). A statistically
significant correlation was found
between osteoporosis and age at
menopause among females with and
without osteoporosis (p=0.001 ). While
no statistically significant correlation
was found between osteoporosis and
cortisone therapy, place of residence,
chronic diseases, previous fractures,
antidepressant medications, exposure to
sunlight
&
immune-suppressive
medications.
Part 3: Risk factors of osteoporosis
and lifestyle
The findings reveal that, 28% are
overweight, 30.2% are obese, and 26.2%
are obese class 2 with a mean weight
31+6.87 (table 1). Concerning smoking,
only 18.75% of study subjects with
osteoporosis are smokers. As for
drinking alcohol, 37.3% & 21.4% of
those without osteoporosis and those
with osteoporosis respectively drink
alcohol, while 52.9% and 17% of those
with
and
without
osteoporosis
respectively drink tea and coffee (table
2). Table (3) reveals that, 35.3% of those
without osteoporosis and 10.3% of those
with osteoporosis practic exercises.
Also, 52.9%
of those without
osteoporosis and 23.2% of those with
osteoporosis eat enough proteins.
Results find that, 43.1% of those without
osteoporosis and only 13.4% of
osteoporotic study subjects expose
themselves regularly to sunlight.
Regarding appetite loss, 33.33% and
30.8% of study subjects without and
with osteoporosis respectively were
suffering from appetite loss. Results
revealed that, 93.8% and 94.8% of non
osteoprotic and osteoprotic females
respectively have their menopause
between the ages of 45-55 years (table
4).
Part 3: The relations between risk
factors and osteoporosis among the
study subjects.
A
statistically
significant
correlation
was
found
between
osteoporosis and smoking (p=0.002 ),
practicing exercises or sports (p=0.000 ),
sex (p=0.000 ), age (p=0.050 ), education
(p=0.080 ), BMI (p=0.032 ), falls 2 years
ago (p=0.052 ). Also a statistically
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Figure (1): Percentage distribution of osteoporosis among the study subjects
(n=275 ).
Table (1): Distribution of the study subjects in relation to their body mass index
(n=275 ).
Body mass index
No.
%
20 - 25.9
43
15.6
26 -30.9
77
28.0
31-35.9
83
30.2
36+
72
26.2
Mean ± SD = 31.00±6.87
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Figure (2): Percentage distribution of family history of osteoporosis, chronic illness,
falls within previous two years and previous fractures among the study subjects
(n=275 ).
80.00%
70.00%
60.00%
50.00%
40.00%
no osteoprosis
30.00%
osteoprosis
20.00%
10.00%
0.00%
Family history chronic illness falls during last
of osteoprosis
two years
previous
fractures
Table (2): Percentage distribution of smoking, alcohol drinking and drinking tea
and coffee among the study subjects (n=275 ).
Risk factors
Study subjects without Study
subjects
with
osteoporosis
osteoporosis
(n=51 )
(n=224 )
No
%
No
%
Yes
20
39.2
42
18.75
No
31
60.8
182
81.25
19
37.3
48
21.4%
32
No
Drinking tea and coffee:
62.7
176
78.6%
27
24
52.9
47.1
38
186
17
83
Smoking:
Drinking alcohol:
Yes
Yes
No
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Table (3): Percentage distribution of excercises, eating enough protein, loss of
appetite and sun exposure among the study subjects (n=275 ).
Risk factors
Study
subjects Study
subjects
without osteoporosis
osteoporosis
(n=51 )
(n=224 )
No
%
No
%
Yes
18
35.3%
23
10.3%
No
33
64.7%
201
89.7%
52.9
47.1
52
172
23.2%
76.8%
33.33
66.66
69
155
30.8
69.2
43.1
56.9
30
194
13.4
86.6
Practicing exercises
Eating enough protein
Yes
No
Loss of appetite
27
24
17
Yes
34
No
Exposure to sunlight
Yes
No
22
29
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Figure (3): Percentage distribution of drugs taken among the study subjects
(n=275 ).
Table (4): distribution of the age at menopause among females (n=188 )*
Age at Menopause
Less than 45 years
45-55 years
55 +
Non osteoprotic females
(16 )
Osteoporotic females
(172 )
No
%
No
%
15
1
93.8%
6.25%
8
163
1
4.3%
94.8%
0.6%
* 19 females are still in the reproductive age.
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Table (5): Correlation between age, sex, education, family history of osteoporosis,
fall down 2 years age and osteoporosis among the study subjects (n=275 ).
osteoprosis
Study variables
R
P
Age
0.377
0.000
Sex
0.109
0.050
Education
-0.107
0.080
Family history of osteoporosis
0.191
0.001
Fall down 2 years age
0.143
0.017
Table (6): Correlation between drugs, hormonal therapy, smoking, drinking
alcohol, drinking tea and coffee and the presence of osteoporosis among the study
subjects (n=275 )
osteoprosis
Study variables
R
P
Anticoagulant
0.221
0.000
Anticonvulsants
0.216
0.000
Hormonal therapy
0.267
0.001
Smoking
0.190
0.002
Drinking alcohol
0.143
0.017
Drinking tea and coffee
0.270
0.010
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Table (7): Correlation between eating protein, loss of appetitee and the presence of
osteoporosis among the study subjects (n=275 )
osteoprosis
Study variables
R
P
Eating protein
-0.181
0.022
Body mss index
0.131
0.032
Loss of appetitee
0.267
0.001
Excercises
0.383
0.000
Jacobs et al., (2012 ) explained that
osteoporosis was common among
females than males due to the fact that
bone loss in men starts later and the
progression is slow, men also have an
advantage of not having a period of rapid
hormonal change and accompanying
rapid bone loss. In women the peak bone
mass is lower due to the hormonal
changes that occur at menopause and the
effect of pregnancy. The same results
were found by Kahsay et al., (31 ) who
made a study to assess risk factors of
osteoporosis among adults in Ethiopia
on 396 participants (130 with
osteoporosis
and
266
healthy
participant) where the majority of
Ethiopian clients with and without
osteoporosis were females. A recent
study done by Asaoka et al.,(39 ) to
examine the relationship between
various patient characteristics and
osteoporosis among 255 Japanese
patients and found that, female sex was
associated with osteoporosis.
Discussion:
Risk factors fall into two main
categories, modifiable, which are those
we can change, and fixed, those we can‘t
change. Though there is no way to
control the fixed risk factors, which
include age, gender, and family history,
there are strategies that can lessen their
effect
(International
osteoporosis
foundation, 2012 ).
It was found that, three quarters
of the study subjects were females. A
statistically significant correlation was
found between osteoporosis among the
study
subjects
and
their
sex.
Alexandraki et al., (2008 ) reported
that, osteoporosis is more common in
women after the menopause, but is
nevertheless also an important concern
in men. According to Yeap, (2010 )
osteoporosis is considered as a major
and growing public health problem in
both sexes but particularly in women.
Researches done by Ebelin, (2008 );
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The mean age of the study
subjects was 59.11+8.904 years and a
statistically significant correlation was
found between osteoporosis among the
study subjects and their age. On the
same line, Pérez et al.,(40 ) who studied
osteoporosis in Spanish women, found
that osteoporosis was significantly
associated with age. The same results
was revealed by Alqahtani, (2014 ) who
studied 375 women aged 40 -65 years to
assess
their
knowledge
toward
osteoporosis in King Abdul-Aziz
military hospital in Tabuk and showed
that, most of participants 65% were 50
years old or above. Also, Londono et
al.,(33 ) who studied osteoporosis in
premenopausal women in Colombia
revealed that, the studied sample had a
higher risk for osteoporosis if they were
older than 45 years. The study done by
Kahsay et al.,(2014 ) in Ethiopia
revealed that, sixty seven (51.5%) of
clients with osteoporosis (89.5%) of
healthy clients were in the age group of
40 to 50 years. A recent study done by
Asaoka et al., (2015 ) in Japane found
that, advanced age was risk factor for
osteoporosis.
that, (79.2%) were housewives. The
difference between the two studies could
be related to the sample selection. Still
the large number of the retired and
housewives study subjects can increase
their liability for osteoporosis due to lack
of movement.
It was found that, more than three
quarters of the study subjects were from
urban area but no statistically significant
correlation was found. In contrast to the
study results, Kahsay et al., (2014 ) who
made a study to assess risk factors of
osteoporosis among adults in Ethiopia
on 396 participants (130 with
osteoporosis
and
266
healthy
participant) revealed that, (57.7% and
50.4%) of clients with osteoporosis and
healthy clients respectively were from
rural areas. Kahsay study concluded
that, it was expected that sedentary
lifestyle which is more common in the
urban population than is in the rural
contributes to the development of
osteoporosis, but, in this study rural
residents were 1.93 times more likely to
develop osteoporosis, which might be
related to the high prevalence of
malnutrition in rural areas. The
difference between the two studies might
be related to the higher number of study
subjects from urban area.
Regarding study subject's education, it
was found that, less than half of them
can read and write, a statiscally
significant negative correlation was
found between client‘s education and
osteoprosis. In accordance with the study
results, the study done by Biino et al.,
(2011 ) in Italy revealed that,
osteoporosis was associated with poor
education. Also Alqahtani, (2014 ) in
Tabuk found that, (58.7%) of women
who had osteoporosis were illiterate. As
for the current study subject‘s
occupation, three quarters were not
working (retired, housewives). On the
same line, Alqahtani, (2014 ) found
Results revealed that, more than
three quarters of the study subjects had
osteoporosis, more than three quarers of
them were famales. Slightly less than
half of them had the disease from one to
5 years, more than one third had the
disease for more than 5 years and only
less than one quarter suffered from
osteoporosis for less than one year. On
the same line, the study done by Prasad
et al., (2010 ) on 264 males and females
in India, revealed that, the overall
prevalence of osteoporosis was 28.03%
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with females showing a higher
prevalence (34.21% ) as compared to
males (23.33% ). A smaller percentage
was found in the study done by
Londono et al., (2013 ) in Colombia
found that the prevalence of osteoporosis
was 4.8%. The difference between the
two study‘s results could be related to
the sample selection.
of women, one of its benefits is that it
protects women‘s bones and helps keep
them strong and healthy, but when
estrogen levels drop, many women lose
bone density. As a result, bones may not
be as strong. For midlife women, the
drop in estrogen that happens with
menopause can lead to rapid bone loss
causing osteoporosis.
Results revealed that, two third
of the study subjects who have
osteoporosis had family history of
osteoporosis
with
a
statistically
significant correlation. On the same line,
the study done by Prasad et al., (2010 )
in India revealed a significant
association between family history and
the prevalence of osteoporosis. This
finding was similar to the study done by
Pérez et al., (2011 ) on Spanish women
where osteoporosis was significantly
associated with family history that
increases the probability of developing
osteoporosis. Also Jakobsen et al.,
(2013 ) who studied the occurrence of
risk factors for osteoporosis among
populations in Greenland found that, the
risk factors for osteoporosis as reported
by the respondents were family history.
Opposite to the study results, Hossien,
Tork & EL-Sabeely, (2014 ) in ElMinia, Egypt revealed that, the highest
percentage of the studied sample
(90.2%) had no family history of the
disease. This difference could be
attributed to the sample selection.
Results revealed that, slightly
more than one third of clients without
osteoporosis and almost one quarter of
clients with osteoporosis were drinking
alcohol with a statistically significant
correlation. Almost the same results
were revealed by Jakobsen et al.,
(2013 ) in Greenland where all the
respondents were drinking alcohol.
Researches from Austria and Europe
showed that, chronic heavy alcohol use,
especially during adolescence and young
adult year‘s interfere with calcium
absorption, can dramatically affect bone
health and increase the risk of
osteoporosis later in life (Malik et al.,
2009 ). In contrast to the study results,
Kahsay et al., (2014 ) in Ethiopia
revealed that, alcohol intake ≤ 2 drinks
per day was observed in 87 (66.9%) of
the cases and in the majority (72.2%) of
the controls but it had no significant
association with the development of
osteoporosis; this may be attributed to
the fact that many people hesitate to tell
the truth about the frequency and amount
of alcohol intake due to high religiosity
in the study area. Furthermore, it may be
due to lack of statistical power of the
study. However, the study done by
Jahanbin, Aflaki & Ghaem, (2014 )
revealed a positive relationship between
vertebral osteoporosis and consumption
of alcohol.
Results revealed that, around one
quarter of clients without osteoporosis
and those with osteoporosis were taking
hormonal therapy with a statistically
significant correlation. According to the
National Osteoporosis Foundation,
(2009 ) Estrogen is a female hormone
that plays an important role in the health
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Results revealed that, slightly
less than one quarter and slightly more
than half of clients with and without
osteoporosis were drinking tea and
coffee respectively. A statistically
significant correlation was found
between osteoporosis among the study
subjects and drinking tea and coffee. The
study done by Kahsay et al., (2014 ) in
Ethiopia revealed that, (77.7%) of the
cases and (76.7%) controls consume
coffee ≤ 2 cups a day but no significant
association was found between caffeine
intake and osteoporosis. Yet caffeine
intake increases urinary calcium output
and it is among the risk for osteoporosis
that lead to fractures.
Kahsay et al., (2014 ). Also, the study
done by Prasad, et al., (2010 ) in India
revealed a significant association
between the estimated risk factors like
alcohol consumption/cigarette smoking
with the prevalence of osteoporosis.
Results revealed that, 86.7% of
females having osteoporosis had their
menopause between the ages of 45-55
years.
A
statistically
significant
correlation
was
found
between
osteoporosis and age at menopause
among females with and without
osteoporosis (p=0.001 ). The same was
reported by Alexandraki et al., (2008 )
where osteoporosis was more common
in women after the menopause. The
study done by Alqahtani, (2014 ) in
Tabuk showed that, 66.1% were
postmenopausal. In the same context, a
study done by Jakobsen et al., (2013 )
in Greenland, revealed that age at
menopause was among the risk factors
for osteoporosis. This finding is similar
to the study done by Pérez et al., (2011 )
in Spanish women where osteoporosis
was significantly associated with age at
onset of menopause. The present study
agrees with the previous explanation.
About one quarter of clients with
osteoporosis and more than one third of
those without osteoporosis were smokers
with
a
statistically
significant
correlation. A study by Jakobsen et al.,
(2013 ) on the occurrence of risk factors
for osteoporosis among populations in
Greenland, found smoking habits to be
one of the risk factors for osteoporosis.
Almost the same results was found by
Kahsay et al., (2014 ) in Ethiopia and
found that, smokers were few in both the
cases and the controls. Literatures from
UK, Australia, USA and Europe also
indicated that, cigarette smoking is a risk
factor for the development of
osteoporosis; the reason is that nicotine
and toxins in cigarettes affect bone
health from many angles. Cigarette
smoke generates huge amounts of free
radicals molecules that attack and
overwhelm the body's natural defenses.
The result is a chain-reaction of damage
throughout the body, including cells,
organs, and hormones involved in
keeping bones healthy (Law &
Hackshaw; Nguyen et al.; Lunt et al.;
Daniel; Williams et al., cited in
Regarding practicing exercises,
slightly more than one third of clients
without osteoporosis and around ten
percent of those with osteoporosis were
practicing exercises. A statistically
significant correlation was found
between osteoporosis among the study
subjects and practicing exercises. These
results were supported by the study
conducted by Prasad et al., (2010 ) in
India, where a significant association
was seen between the estimated risk
factors like chronic diseases such as
diabetes, hypertension, and ischemic
heart disease etc, lack of exercise,
131
July 2015
Osteoporosis health guidelines.
enj@nursing.cu.edu.eg
alcohol consumption/cigarette smoking
and family history with the prevalence of
osteoporosis. Also, the study done by
Etemadifar et al., (2013 ) in Iran found
that, 95.9% of women did not exercise
regularly. Also, the study done by
Hossien, Tork & EL-Sabeely, (2014 )
in El-Minia, Egypt revealed that, 58%
were engaged in some sort of physical
activity but not on a regular basis. On the
same line, the study done by Gaur et al.,
(2015 ) on young Indian adults revealed
a higher prevalence of osteoporosis
amongst Indians as compared to the
individuals from more developed
countries and this prevalence was the
result of poor health awareness in early
growth years of life and lack of physical
training in youth is responsible for the
large share of this prevalence.
for both men and women; in contrast low
BMI less than 19 kg/m2 can lead to
osteoporosis (Barrera et al., 2004 ;
Kenny et al., 2000 ; Shin et al., 2004 ).
In approval with the study results, a
recent study by Asaoka et al., (2015 )
found that, low BMI were associated
with osteoporosis among the Japanese
patients. The explanation of Cao,
(2011 ) indicated that, excessive fat mass
may not protect humans from
osteoporosis and in fact, increased fat
mass is associated with low total bone
mineral density and total bone mineral
content and high-fat diet, often a cause
of obesity, has been reported to interfere
with intestinal calcium absorption and
therefore contributing to low calcium
absorption. The researchers of the
present study agree with Cao‘ s
explanation.
Overweight and obesity were
prevalent among the study subjects, and
slightly less than one third of clients
with osteoporosis were suffering from
appetite loss with a statistically
significant
correlation
between
osteoporosis and obesity and appetite
loss. On the same line, the study done by
Kahsay et al., (2014 ) in Ethiopia
revealed that, BMI of the cases and
controls was almost similar. In addition,
a significant difference was found in the
weight of the study participants with a pvalue of 0.004 . The study done by Pérez
et al., (2011 ) in Spanish women, found
that osteoporosis was significantly
associated with weight loss as it
increases the probability of developing
osteoporosis. Also, Londono et al.,
(2013 ) in Colombia found that, patients
with osteoporosis had a lower BMI and
lower body weight than healthy patients
(P = 0.02). Also, studies from the USA
and Korea confirm that a high BMI
(above 30 kg/m2) has a protective effect
Results revealed that, about two
third of those with osteoporosis have
been falling down during the previous
two years and slightly less than half of
those also had previous fractures two
years ago with a statistically significant
correlation. The same results were
reported by Gale et al.,(2012 ) in
Edinburgh, where women fracture
occurred more frequently in those with a
history of falling in the year prior to the
survey.
Results revealed that, less than
one quarter of those with osteoporosis
and slightly more than half of those
without osteoporosis were eating enough
proteins with a statistically significant
correlation. In the same context, a study
done by Jakobsen et al., (2013 ) in
Greenland found the risk factors for
osteoporosis as reported by the
respondents as lack of intake of dairy
products. Also, the study done by
132
July 2015
Osteoporosis health guidelines.
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Jahanbin, Aflaki & Ghaem, (2014 ) in
Iran, revealed a significant correlation
between the incidence of osteoporotic
vertebrae and dairy, white meat
consumption.
The current study revealed that
onlya
minority
of
those
with
osteoporosis were taking corticosteroid
treatment, but no statistically significant
correlation was found. According to
Walsh et al., (2002 ) corticosteroids
have several adverse effects on bone
metabolism;
direct
inhibition
of
osteoblast function, inhibition of
gastrointestinal calcium absorption,
increase in urinary calcium loss, and
inhibition of gonadal hormones mainly
affect the trabecular bone. Canalis et al.,
(2007 ) added that, glucocorticoidinduced osteoporosis is the most
common
form
of
secondary
osteoporosis. The central mechanism of
action of glucocorticoids is decreased
bone formation, secondary to impaired
osteoblastic differentiation and function.
The
National
Osteoporosis
Foundation,
(2010 )
―oral
corticosteroids used in a number of
different chronic diseases contribute to
an increased prevalence of osteoporosis
and an increased incidence of fracture‖.
Also, the study done by Jahanbin,
Aflaki & Ghaem, (2014 ) in Iran,
revealed a significant correlation
between the incidence of osteoporotic
vertebrae and thyroid disorders, and
drugs including corticosteroids.
may have direct inhibitory effects on
osteoblast differentiation, and valproate
and carbamazepine have anti-androgenic
effects (Petty, O’Brien & Wark,
2007 ).
Around two third of osteoporotic
study
subjects
were
taking
anticoagulants compared to about half of
those without osteoporosis with a
statistically significant correlation. Study
results were supported by Gage et al.,
(2006 ) who assessed the risk of
osteoporotic fracture in elderly patients
taking warfarin in the USA, and found
that, long-term use of warfarin was
associated with a 25% increased risk of
osteoporotic fracture. In contrast, use of
warfarin for less than one year had no
significant association with osteoporotic
fracture. Among those with long-term
use, warfarin was most strongly
associated with vertebral fractures. The
correlation between warfarin use and
fracture differed in men and women;
long-term warfarin use was significantly
associated with osteoporotic fractures in
men but not women. Researchers of the
present
study agree
with
this
explanation.
Oral anticoagulant effects on
bone metabolism are controversial.
Anticoagulants
are
vitamin
K
antagonists that interfere with gammacarboxyglutamate
formation,
and
consequently inhibit the accumulation of
osteocalcin in the extracellular matrix
(Mazziotti, Canalis
& Giustina,
(2010 ). Although there are potential
negative effects, evidence that these
drugs cause osteoporosis and fractures in
the general population is insufficient
(Woo, Chang, Ewing & Bauer, 2008 ).
Results revealed that, around half
of those with osteoporosis were taking
antiepileptic or anticonvulsants drugs
with
a
statistically
significant
correlation. These drugs may cause bone
loss, but the mechanisms are unclear.
There is accelerated vitamin D
metabolism, but anticonvulsants also
Around five percent of study
subjects with osteoporosis were taking
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Osteoporosis health guidelines.
enj@nursing.cu.edu.eg
antidepressants with no statistically
significant correlation. Diem, Blackwell,
Stone, et al., (2007 ) revealed that, the
greater the severity of depression, the
lower the Bone Mineral Density (BMD).
These findings are further supported by a
meta-analysis of 20 studies on the
relationship between depression and
osteoporosis, which found that depressed
patients had lower BMD at all sites
versus controls (spine, femoral neck, and
total femur), which is likely to increase
fracture risk (Cizza, Primma, Coyle,
Gourgiotis & Csako, 2010 ). In the
same context, the study done by Rizzoli
et al., (2012 ) identified in their review
article that, antidepressant treatments
that act on serotonin pathways may
therefore be expected to have some
impact on bone, bone mass, and fracture
rates. The link between depression,
antidepressant use, and osteoporosis is
becoming more widely understood, and
there is mounting evidence for an effect
of depression and antidepressants on
fracture rates.
diseases but no statistically significant
correlation was found. This finding is
similar to the study done by Prasad et
al., (2010 ) in India where a significant
association was found between chronic
diseases such as diabetes, hypertension
ischemic heart disease and the
prevalence of osteoporosis. Also, Pérez
et al., (2011 ); Jakobsen et al., (2013 )
found
that,
osteoporosis
were
significantly associated with chronic
diseases that increase the probability of
developing
osteoporosis.
Also,
Alqahtani, (2014 ) in Tabuk showed
that, the most common medical problem
encountered were type two Diabetes
Mellitus followed by thyroid health
problems, rheumatoid and kidneys
diseases.
It was found that, about half of
study subjects without osteoporosis and
onlyabout thirteen percent of study
subjects
with
osteoporosis
were
exposing themselves regularly to
sunlight but no statistically significant
correlation was found. In the same
context, a study done by Jakobsen et al.,
(2013 ) in Greenland revealed that, sun
exposure was among the risk factors for
osteoporosis. Also, the study done by
Jahanbin, Aflaki & Ghaem, (2014 ) in
Iran revealed significant correlation
between the incidence of osteoporotic
vertebrae and exposure to sunlight.
Results revealed that around two
percent of the study subjects were taking
immune-suppressive drugs ,but no
statistically significant correlation was
found. Researches revealed that, posttransplantation , bone disease is a major
complication present in most of patients,
where low bone mineral density (BMD)
increases the risk of fractures and
consequently, reduces quality of life and
increases mortality (Stein, Ebeling &
Shane, 2007 ; Kulak et al., 2010 ;
Kulak et al., 2014 ).
Conclusion: the study concluded that,
the common risk factors identified were;
family history, lack of excersies,
irregular exposure to sun light, being a
female. Also, osteoporosis health
guidelines
were
needed
for
prevention/reduction of osteoporosis.
The study revealed that, two third
of those without osteoporosis and about
half of study subjects with osteoporosis
were having chronic diseases in the form
of hypertension, diabetes and heart
Recommendations:
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July 2015
Osteoporosis health guidelines.
enj@nursing.cu.edu.eg
Based on the findings of the present
research
the
following
recommendations are suggested:
- Better
programs
for
the
evaluation of osteoporosis are
needed.
- Dissiminate osteoporosis health
guidelines
in
orthopedic
outpatient clinics.
- Increase population‘s awareness
of risk factors and preventative
behaviors.
- Community
based
health
programs on osteoporosis that
targeted a wide audience should
be implemented.
- Further studies are needed to
evaluate the effect of osteorosis
health
guidelines
in
the
prevention of osteoporosis.
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Bauer D.C., (2008 ). Single-point
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Geriatric Homes Caregivers’ Knowledge and Practices Regarding Physical and
Social Needs of Elderly, Cairo Governorate
Mona Sadek Shenoda*, Gehan Mostafa Ismail ** Naglaa Mahmoud Abdel Hamid ***
*Prof. Dr. / Community Health Nursing Department, Faculty of Nursing, Cairo
University, Cairo, Egypt
** Assist. Prof. Dr. /Community Health Nursing Department, Faculty of Nursing, Cairo
University, Cairo, Egypt
***B.Sc. Nursing, Cairo University
Abstract
Background: Elderly population face a broad range of medical, physical and social needs that require assistance
on a temporary or full-time basis, depending on their needs. The aim of this study was to assess knowledge and
practices of caregivers regarding physical and social needs of elderly in geriatric homes. A descriptive exploratory
research design was utilized in this study. Setting: the study was conducted at six geriatric homes located in Cairo
Governorate. A convenient sample of 100 caregivers was included in the study. Tools: two tools were used. IElderly caregivers' questionnaire composed of two parts: a) structured interviewing questionnaire as: age, education,
experience years etc...b) Elderly caregivers knowledge questionnaire as: nutrition, hygiene, sleeping, social
interaction, etc…II) Elderly caregivers' practice questionnaire composed of two parts: a) observational checklist
included nutrition for independent elderly, exercises for dependent elderly, social interactions with elderly, etc…b)
Items related to caregivers‘ self reported practices as administration of medication, mobilization, social problems,
etc... Results: the majority (91.0%) of the caregivers had unsatisfactory total knowledge scores and more than two
third of them gained partially satisfactory total self reported practice scores and 52.0% of them had partially
satisfactory total practice scores during observational checklist. A statistically significant positive correlation was
found between total knowledge and total practice scores of caregivers. Also, a statistically significant positive
correlation was found between total knowledge scores & total practice scores and caregiver‘s education, income,
training program. This study concluded that, the majority of caregivers had less than satisfactory knowledge and
practices regarding needs of elderly. Recommendation: based on the study results it is recommended to develop a
health education program for caregivers working in geriatric homes to raise their awareness regarding needs of the
elderly.
Keywords: Elderly, Physical needs, Social needs, Caregivers, Knowledge, Practice.
The number of elderly people
worldwide (aged sixty years or more) is
800 million, and experts expect increase
this percentage to reach 1.2 billion
elderly by the year 2025 and 2 billion
elderly by 2050 , although this number is
alarming, and large. The proportion of
elderly in developing countries is now
50% of the world population and this
percentage will increase to 75% of
elderly of the world by the year 2025
[WHO, 2012 ].
Caregiver refers to the provision
of assistance to another person who is
ill, disabled, or needs help with daily
activities. It often requires attention to
the physical, mental, social, and
psychological needs and well-being for
Introduction
Aging is a natural process that
every human being must go through.
The physical and social needs address
the importance of caring for the whole
elderly and not just treating symptoms.
Throughout a lifetime a lot of challenges
and adjustments are facing elderly
people in response to life experiences
such as coping with losses and change,
establishing
meaningful
roles,
exercising independence and control,
and finding meaning in life. However,
if these tasks are not successfully met,
the result is unhappiness, bitterness, and
a fear of the future [Aubrey & Grey,
2012].
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the elderly person requiring care [Lin &
Rowe, 2010]. Caregivers need certain
knowledge and skills to provide the best
possible care and to protect their own
well-being. The basic knowledge that
caregivers use to make decisions and
solve problems provides the foundation
for developing and improving skills
[Boehmer & Clark, 2011 ]. Due to
inadequate knowledge and skills,
caregivers may be unfamiliar with the
type of care they must provide or the
amount of care needed.
Significance of the study
Central Agency for Public Mobilization
and Statistics, (2012 ) stated that, the
elderly people were about 600 million
in 2011 which accounted for 11% of the
total population in the world and it is
expected by 2030 to rise to 11.6% and
they will reach to about 22% by 2050 of
the total population in Egypt. This
increase in the elderly people presents a
burden on their health care providers,
their families as well as the community
due to many problems and challenges
which are attached to this age category
[Shepard, 2012 )].
From the investigator's experience at
geriatric homes, it was observed that,
many caregivers were lacking the
necessary skills and knowledge that
provide sustained care for the elderly.
Caregivers deal with physical condition
only such as feeding, administration of
medication and completely ignoring the
social interaction with elderly. This
study gave a basic data about caregivers
social needs and knowledge and its
application.
Operational Definition
Caregivers:
Caregivers refers to workers who
are providing physical and social needs
for the elderly in geriatric homes (non
professionals).
Research Questions
1. What are the knowledge and
practices of caregivers regarding
physical needs of the elderly?
2.
Material and Methods
Research design
A descriptive exploratory research
design was utilized in this study
Setting
The study was conducted at six
geriatric homes; El Safa home,
Mosineen Al Khairea Al Eslamia,
Foundak Takreem Al Ensan, Hedia
Barakat, Lifer Green and El Habaib
home, Cairo Governorate.
Sample selection
There are 600geriatric homes in
Cairo Governorate, ten percent of those
homes were selected by using simple
random sample which were six geriatric
home as follow: Foundak Takreem Al
Ensan, Hedia Barakat, Lifer Green and
El Habaib home, Cairo Governorate.
Convenient sample for all participant
present at data collection were selected
was to the study from the six geriatric
homes. Data was collected within six
months (from November 2012 till April
2013). The total numbers of the sample
after 6 month were 100 caregivers.
Tools
Two tools were used in this study:I- Questionnaire composed of two
parts:
Therefore, the aim of this study
was to assess knowledge and practices of
caregivers regarding physical and social
needs of elderly in geriatric homes.
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What are the knowledge and
practices of caregivers regarding
social needs of the elderly?
Geriatric Homes Caregivers‘ Knowledge.
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aStructured
interviewing
questionnaire: was used to collect data
about personal characteristics of the
caregivers
as:
age,
education,
occupation, marital status, monthly
income, place of residence, experience
years and training programs.
(6 steps) and social interactions with
elderly (17 steps).
Scoring system:For practice scores, complete
correct answer was giving two scores,
incomplete correct answer was giving
one score and incorrect answer was
giving zero. The total practice questions
were 72 with 144 scores: unsatisfactory
level of practice from (0 >86), partially
satisfactory level of practice from (86 >
108) and satisfactory level of practice
from (108-144 ) scores.
b- Elderly caregivers' knowledge
questionnaire: included items related to
the caregiver's knowledge regarding
physical needs for elderly such as
nutrition (5 questions), personal
hygiene (3 questions), sleeping (3
questions), mobilization (3 questions),
and social needs (6 questions) such as
social
interaction,
participation,
loneliness and recreational activities.
bItems related to the
caregivers‘ self reported practices during
elderly care; hygiene (6 questions),
administration
of
medication
(2
questions), mobilizing (2 questions) and
social problems (1question).
Scoring system:The total knowledge questions
were 36 with 131 scores, (some
questions of the 36 questions had more
than one answer), knowledge scores
were;
unsatisfactory
level
of
knowledge < 60% from (0-79),
partially
satisfactory
level
of
knowledge 60-75% from (80-97 ) and
satisfactory level of knowledge >75%
from (98-131 ) scores.
Scoring system:The total practice questions were
12 with 30 scores, (some questions of
the 12 questions had more than one
answer),
practice
scores
were;
unsatisfactory level of practice from
(0>19), partially satisfactory level of
practice from (19>24) and satisfactory
level of practices from (24:30 ) scores.
II- Elderly caregivers' practice
questionnaire composed of two parts:
Procedure
All the research tools for data
collection were revised by panel of 5
professors for content validity and
proposal were submitted to the ethical
committee in the Faculty of Nursing and
initial approval was obtained on 17-72012 for data collection. An official
permission was obtained from the
director of the Ministry of Social Affairs
and Health Insurance, the director of the
Family and Childhood Unit. The
investigator explained the aim of the
study to each caregiver to gain their
a- Observational Checklist: during
physical needs for dependent and
independent elderly; physical needs for
dependent and independent elderly;
nutrition for independent elderly (4
steps), exercising for independent elderly
(5 steps), oral hygiene for dependent
elderly (10 steps), complete bed bathing
for dependent elderly (14 questions),
nutrition for dependent elderly (9 steps),
exercises for dependent elderly (7 steps),
changing positions for dependent elderly
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cooperation to share in the study.
Written consent was obtained from
caregivers who accept to participate in
the study. The interviewing sheet took
around 25-40 minutes to be completed.
Data was collected within 6 month from
November 2012 till April 2013 (3
days/week).
76.0% of caregivers are living in rural
areas. 80.0% of caregivers cannot read
& write, (10.0%) can read & write,
(7.0%) are having university education.
As revealed in figure 1, 91.0% of
the caregivers get unsatisfactory total
knowledge scores, while (9.0%) of them
gained partially satisfactory total
knowledge scores. As revealed in figure
2, more than two third (66.0%) of the
caregivers gained partially satisfactory
total self reported practice scores, 28.0%
got satisfactory total self reported
practice scores. Figure (3) shows that,
52.0% of the caregivers have partially
satisfactory total practice scores during
observational checklist and 43.0% have
unsatisfactory total practice scores
during observational checklist (Research
questions answered).
Table (1) indicates a highly
statistically
significant
positive
correlation between the total knowledge
scores and total practice scores of the
caregivers
(p=0.000 ).
A
highly
statistically
significant
positive
correlation is found between the
caregiver's education and their total
knowledge and total practice scores
(p=0.002 & p=0.000 ) respectively. Also,
a highly statistically significant negative
correlation is found between caregiver's
working hours and their total practice
scores (p=0.001 ). A highly statistically
significant positive correlation is found
between the caregiver's monthly income
and their total knowledge scores and
their
total
practice
scores
(p=0.001 &p=0.002 ) respectively. A
highly statistically significant positive
correlation is found between training
programs and their total knowledge and
their total practice scores (p=0.013 &
p=0.016 ) respectively (table 2).
Pilot study
A pilot study was carried out on 10%
of the total sample to check clarity of
items and determine the feasibility of the
study.
Ethical consideration
•
Human subject approval was taken
from the board of the faculty of nursing,
Cairo University as well as the director
of the Ministry of Social Affairs and
Health Insurance.
•The
investigator emphasized that,
participation in the study is entirely
voluntary; and their rights were secured;
anonymity and confidentiality was
assured through coding the data.
Statistical Analysis
Collected data were coded, scored,
and tabulated using personal computer.
Statistical Package for Social Science
(SPSS windows) version 22 was used.
Descriptive as well as inferential
statistics were used to answer research
question. Statistical significance was
considered at (p-value) less than 0.05.
Results
Regarding personal characteristics
of the caregiver's age, 41.0% of them
aged from 40 to 49 years old with a
mean age of 51.05±13.53 years.
Regarding marital status of the
caregivers, 61.0% are married. 73.0% of
the caregivers have a monthly income
from 601- 900 pounds; with a mean
income equal 514.0±138.7 pounds.
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Figure (1): Distributions of the caregiver's total knowledge scores (n=100 ).
Figure (2): Distributions of the caregiver's total self reported practice scores (n=100 ).
Figure (3): Distributions of the caregiver's total practice scores during observational
checklist (n=100 ).
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Table (1) Correlation between the caregiver's total knowledge scores and their total practice
scores.
Total practice
Study variable
Total knowledge
r
P
0.352
0.000**
**P= 0.001
Table (2) Correlation between total knowledge scores and total practice scores of the
caregivers in relation to their education, working hours, income and training programs.
knowledge
Personal characteristics
Practices
r
p
r
Education
0.310
0.002**
0.419
0.000**
Working hours
- 0.27
0.788
- 0.324
0.001**
Income
0.032
0.001**
0.242
0.002**
Training programs
0.249
0.013**
0.240
0.016**
**p≤ 0.01 , **p=0.001
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college or graduate school. This could be
related to the difference among cultures
and that most of the females in Egypt are
less educated than males and this is more
among rural females than urban females
as reported by Unicef, (2008)12. From
the investigator's point of view, early
marriage of Egyptian females may be an
obstacle for them to join higher
education and also, more than three
quarters of the caregivers were from
rural areas where education is not the
main concern of people.
Regarding marital status of the
caregivers, almost two third of the
caregivers were married, while about
one quarter were widow. This result was
consistent with Haggstrom & Bruhn,
(2011 )13 who conducted a study on 92
caregivers at nursing home centers
situated in the Swedish countryside and
revealed that, the majority of the
caregivers
were
married.
Also,
Jakobsson, Hallberg & Westergreen,
(2010 )14 who conducted a study on 110
caregivers taking care of elderly in
Jordan and found the majority of the
caregivers were married and have
another children and responsible about
their whole family.
Regarding the caregiver's working hours,
results of the study revealed that, the
majority of the caregivers were working
from 11 to 12 hours per day, this result
were supported by Al Hamidan, (2011)15
who studied 100 caregivers in three
geriatric homes at El Bahrain and found
that more than half of the caregivers
were working ten hours and more. In
contrary to the study results Daly,
Brennan & Flatley, (2009 )16 who studied
160 caregivers at New York reported
that, more than half of the caregivers
were employed and working eight hours
while caring for their relatives. From the
investigator's point of view, the
Discussion
Caregivers are in a unique position to
provide care for the physical, social,
mental and spiritual needs for the elderly
and other loved ones. They provide
companionship and support to those in
need. Caregivers provide assistance to
someone who is, in some degree,
incapacitated and needs help [National
Alliance for Caregiving, 2012]
Personal
characteristics
of
the
caregivers:
Regarding the personal characteristics of
the caregiver's age, results of the current
study indicated that, less than half of
them aged from 40 to 49 years and this
result was consistent with National
Alliance for Caregiving, (2010)8 which
identified that, the average age of
caregivers to be 48 years and about
(43%) of caregivers in USA were
between the ages of 19 and 49 years.
Also the study done by Gilliss & Starke,
(2011 )9on 80 caregivers at National
Institute for Health and Disability
Insurance at Bankok, found that, the
majority of caregiver's age ranged from
25-35 years and 36-46 years. This age is
considered the capable age for providing
care for the elderly at homes.
Concerning the caregiver's education, the
current study indicated that, the majority
of the caregivers were unable to read and
write. This result was consistent with the
study done by Atef, (2008 )10 who
studied 60 caregivers at four geriatric
homes in Alexandria and found that,
more than half of the caregivers were
illiterate. In contrast to the study results,
Ruehlman, Turner & Findlay, (2010 )11
who conducted a study on 300
caregivers at Community Health Survey
in Canada and found that most of the
caregivers completed their high school
and approximately one third completed
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difference between the studies could be
related to sample selection and cultural
difference and their working hours.
Concerning the place of residence, the
current study showed that, more than
three quarters of the caregivers were
from rural areas. This result was in
agreement with the study done by AlJauissy, (2011 )17 who found that, most
of the caregivers were coming from rural
areas. But this result contradicted the
study done by the National Alliance for
Caregiving, (2010 ) who studied
caregivers in USA and indicated that,
caregivers were equally distributed
among urban and rural areas.
Results of the current study revealed
that, more than two third of the
caregivers gained partially satisfactory
total self reported practice scores, while
the minority of them had satisfactory
total self reported practice scores. These
results were almost the same as Torvik,
Polit, Kaasa & Rustoen, (2011 )19 who
conducted a study on 123 caregivers in
Nursing Homes to study Quality of Life
among their residents at Norwegian and
found the majority of caregivers gained
partially satisfactory total self practice
scores while the minority of them had
satisfactory total self reported practice
scores.
The findings of the current study
showed that, the majority of the
caregivers had unsatisfactory total
knowledge scores, while the minority of
them had partially satisfactory total
knowledge scores. These studies
contradicted the study done by Rautio &
Heikkinen, (2009 )18 who conducted a
study survey on caregiver's to assess
knowledge regarding caring of the
seniors in Philippines and found the
majority of them had satisfactory total
knowledge scores. On the other hand
Gilliss & Starke, (2011 ) found that, most
of the caregivers had good level of
knowledge and minority of them gained
unsatisfactory total knowledge scores.
From the investigator's point of view, the
difference could be related to lacking
awareness of the caregivers regarding
needs of the elderly, and also this
knowledge deficit may be due to lower
educational level of the caregivers and
lack of proper health education or
training programs about needs and
caring of elderly from the health care
team.
A highly statistically significant
positive correlation was found between
the total knowledge scores and total
practice scores of the caregivers, where
the more knowledge they have, and the
better practices they provide. This result
was supported by Ozel et al., (2011)20
who conducted a study on 85 caregivers
to assess biopsychosocial needs of
elderly in Brazil and found that,
caregiver's knowledge had an impact on
their practices. From the investigator's
point of view, when caregivers were
provided with basic knowledge about
physical,
social,
emotional
and
psychological needs of the elderly this
could assist them in practicing healthy
behaviors regarding their elderly.
The findings of the current study showed
a highly statistically significant positive
correlation between the caregiver's
educational level and their total
knowledge and total practice scores.
These results were in agreement with
Reinhard, Barbara, Huhtala, Petlick &
Bemis, (2010 )21who conducted a study
on the relationship between caregiver's
burden and caring for the elderly in
Northeastern US and found that,
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caregiver's knowledge scores increased
with the caregiver's educational levels
which may improve the care for the
elderly while caregiver's illiteracy was a
negative factor on practice compliance.
total knowledge and total practice
scores, which means that, the longer the
period of caring for their elderly and
interacting with them, the more they
become knowledgeable about their needs
and the better their practices at home.
A highly statistically significant
negative correlation was found between
caregiver's working hours and their total
practice scores, the more the work
responsibilities of the caregivers, the less
knowledge and practices for the needs of
the elderly they will exhibit. In contrast
to the study results done by Kim & Lee,
(2012 )22 who found no statistically
significant correlation between the
caregiver's working hours and their total
knowledge and total practice scores.
From the investigator point of view, the
difference between the two studies could
be related to the number of the
caregivers selected in the studies where
the majority was unemployed and only
23 caregivers were employed and
worked females.
A highly statistically significant positive
correlation was found between the
caregiver's monthly income and their
total knowledge and total practice
scores. These results was supported by
Al Naser, (2009 )23 who conducted a
study on 70 caregivers in Social
Department Center at El Kuwait and
found that, most of the caregivers living
in low socioeconomic status and facing
financial difficulties this directly
influence their total knowledge and
practice scores
A highly statistically significant positive
correlation was found between social
interactions of elderly and caregiver's
total knowledge and total practice
scores. This result was supported by Al
Naser, (2009 ) who found a statistically
significant correlation between social
interactions for elderly and caregiver's
Conclusion, the present study concluded
that, the majority of the caregivers got
unsatisfactory total knowledge scores
and more than two third of the caregivers
got partially satisfactory scores in their
total self reported practice scores and
more than half of the caregivers have
partially satisfactory total practice scores
during observation. There was a highly
statistically
significant
positive
correlation between caregiver's total
knowledge scores and their total practice
scores. There was a lack of caregiver's
knowledge and practices regarding
physical and social needs of the elderly.
Recommendations, based on the study
results, the following recommendations
are suggested:1A specific training program is
needed for caregivers to provide them
with the needed skills regarding the care
of the elderly (physical ,social and
psychological).
2Conduct
written
guidelines
booklet for caregivers containing
information about aging, normal
changes, physical needs of the elderly,
importance of social interactions for
them and specific practices for elderly as
maintaining their body posture when
rising and lifting elderly.
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at:
www.springerlink.com/.03W468425717
210.pdf.
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Community Based Early Detection and Prevention of Visual Problems among
School Children, Cairo Governorate
Dr. Gehan M. Ismail*; Dr. Eman M. Seif El-Nasr**
*Assistant Prof. of Community Health Nursing; **Lecturer of Community Health
Nursing, Faculty of Nursing, Cairo University,
Abstract
Background, Ocular morbidity in children affects learning ability, adjustment in school and personality.
Empowerment is a key concept for communities aiming to achieve a better quality of life. Aim; To detect
visual problems among school age students at governmental primary schools, to identify strengths and
weaknesses regarding visual problems among school children and suggest guidelines for early detection
and prevention regarding visual problems based on community empowerment approach. Design; A
descriptive correlational design was used. Setting; this study was conducted at two primary schools in
Cairo governorate. Sample; Multistage random sample technique was used to select the schools. All
available students at the time of data collection were included in the study. Tools for data collection, 1)
Structured interviewing child visual questionnaire: this question has two parts; a) demographic
characteristics of the students as age, sex, academic year, parent‘s occupation and education & income. B)
Eye hygiene & medical history: eye cleanliness, previous eye examination, consanguinity between parents,
and visual acuity (weaknesses & strengths). 2) Snellen chart: used to measure visual acuity of the students.
Results; it was found that, 55.5% of them aged 8 years to less than 10 years, 54% of them were females,
79.5% of them never had previous eye examination. Only 5% of the students were having eye
inflammation and/or discharges. It was found that, 39% of them were suffering from hyperopia and 1.5%
was having myopia. A statistically significant negative correlation find between student‘s age and eye
diseases. Conclusion: Primary school children represents high risk group for refractive errors. Periodic
screening in schools should be carried out. School teachers, children and their parents should be educated
about signs and symptoms of refractive errors and for the risk factors involved in their development.
Recommendations; empower periodic screening for school students to detect visual problems, disseminate
the suggested guidelines to parents, school teachers and nurses for early detection of student‘s vision
problems and connected to referred system for correction which is integrated in school insurance program.
Keywords: school students, visual problems, early detection & community empowerment.
problems (He, et al., 2007 ). Ocular
morbidity in children affects learning
ability, adjustment in school, and
personality. About 30% of blind
populations of India lose their eyesight
before the age of 20 years and many of
them are under 5 when they become
blind (Biswas et al., 2012 ). Research
demonstrates that up to 20 percent of
children have vision problems in China
(Pi et al., 2012 ).
Introduction
School children are considered
one of the most important sectors of
population due to their continuous
growth and development at all levels.
They are a vulnerable group and great
attention should be paid for them (ElMoselhy et al., 2011 ). Vision has an
essential role in a child‘s scholastic
achievement, and visual deficit is a risk
factor not only for altered visio-sensory
development, but also for overall
socioeconomic status throughout life
(Okoye, Umeh & Ezepue, 2013 ). A
series of World Health Organizationsupported
studies
suggest
that
approximately 10 to 15 percent of
school-aged children in the developing
world are having common vision
In most settings, about ninety
percent of these vision problems are
caused by refractive error (largely
myopia, but also hyperopia and
astigmatism). In most cases children‘s
vision problems can be easily detected
by simple vision tests (such as visual
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acuity screenings) and corrected by
timely and proper fitting of quality
eyeglasses
(World
Health
Organization, 2006 ). Unfortunately,
studies in a variety of developing
countries document that, 35 to 85
percent of individuals with refractive
error do not have eye glasses and that
many of them have never been screened
or examined (Ramke et al., 2007 ;
Fotouhi et al., 2006 ). Almost 1.4
million blind children exist in the world
(Rahi, Cited in Arif & Mehboob,
2014 ). Non-correction of the refractive
strain over eyes, with or without redness
or watering and headache. Moreover,
due to lack of awareness, to these
complaints remained unnoticed the
parents leading to ocular complications.
Effective methods of vision screening in
school children are useful in detecting
correctable causes of decreased vision,
especially refractive errors. It is an
alarming thing and the only solution is
the early diagnosis and treatment for
these problems (Danish Assistance to
the National Program for control of
Blindness cited in Arif & Mehboob,
2014 ).
errors may result in visual impairment;
according to some studies, refractive errors
cause visual impairment in children in about
80% of the cases (Yekta et al., 2010 ). A
refractive error is not considered as a
disease, unless it is the magnification of a
structural abnormality, as in some cases of
high myopia and astigmatism (Kassa &
Alene, 2011 ).
Current
health
promotion
policies and practices value community
developmental projects that empower
communities as a vehicle to achieve
agreed upon health and social outcomes
(Minkler, 2005 ; Wallerstein, 2006 ).
Empowerment is a key concept for
communities aiming to achieve a better
quality of life (Labonte, 2010 ). The
Ottawa Charter identifies community
empowerment as the core concept of
health promotion discourse (World
Health Organization, 2010 ). Indeed, a
body of evidence exists in support of
empowerment initiatives that lead to
improved health outcomes and that
represent viable health promotion
strategies (Van Uden-Kraan et al.,
2008 ).
All over the world, school health
remains an important aspect of every
community health program. It is a
formative period for a child not only
physically but mentally also. Poor
vision has a negative impact to the
child‘s performance. Refractive errors
and vitamin A deficiency are the most
common visual disorders diagnosed
which are treatable and preventable
causes of childhood blindness and visual
disturbances identified by the World
Health Organization under Vision 2020
programme (Rahi, Cited in Arif &
Mehboob, 2014 ).
Empowerment approaches have
been used for the prevention of noncommunicable diseases in India
(Mohan et al., 2006 ) in suicide
prevention among citizens of six towns
in Japan (Motohashi et al., 2007 ) for
prevention of malaria in Thailand
(Geounuppakul et al., 2007 ) and in
many other initiatives. Empowerment is
a complex issue, according to
Mostly, the children do not
complain of visual problems and may
not even notice the condition. They try
to adjust these problems themselves by
sitting very close to the board,
squeezing their eyes, holding the books
closely. In early stages, they may feel
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Zimmerman, (2000 ) empowerment
may be viewed on different levels:
individual,
organizational
or
community. These levels are closely
linked. In empowered communities,
empowered organizations exist, and an
empowered organization is reliant on
the empowerment levels of its members.
Laverack & Wallerstein, (2001 )
revealed
that,
the
community
empowerment process promotes the
participation of people, organizations
and
communities
for
increased
individual and community control,
political efficacy, improved quality of
life and social justice. The primary
concept
is
to
mobilize
local
communities to address their health and
social needs and to work inter-sectorally
to solve local problems.
national or municipal health problems
(top to bottom approach) or by
combined approaches. The evidencebased research has demonstrated that the
most effective strategies are those that
expand empowerment of local people
and communities (Wallerstein, 2006 ).
According to the Center of
Disease Control (CDC), to achieve the
goals of reducing vision impairment and
promoting visual health, population
awareness about visual health need to be
increased through community-based
approach and community partners.
Activities include; increasing awareness
of issues surrounding the maintenance
of vision health, exercising appropriate
self-care and adopting healthy behaviors
(CDC, 2008 ). To ensure early detection
of visual defects, students should be
examined early in the primary school.
Primary care clinicians can play a vital
role in preserving vision by ensuring
that
students
undergo
periodic
evaluations by eye care professionals
and receive needed eye care (Rowe et
al., 2004 ). Early intervention can
reduce the burden of this problem, and it
is possible only if the parents perceive
their child‘s vision problem and seek
eye care. Hence, knowing parents‘
perceptions and behavior regarding eyerelated problems of their wards is
crucial in understanding why some
parents show concern and seek early
care for their children whereas others do
not (Hugenholtz, Broer & van Daalen,
2009 ).
Community school partners may
vary by community but they share a
common purpose: to involve all
stakeholders interested in improving
academic achievement and social
outcomes
for
children
(Blank,
Jacobson & Melaville, 2012 ). Thus,
approaches that foster community
empowerment suggest that community
members should direct the course of
intervention and action through
participatory activities that involve
decision-making (Jagosh et al., 2012 )
and communication of research findings
(Cornwall & Jewkes cited in Nield,
Quarrell & Myers, 2013 ). Community
empowerment is said to offer the most
promising approach for reducing health
problems in communities [Wallerstein,
2006 ; Robinson, Elliott, cited in
Kasmel
&
Andersen,
2011 ).
Community health programs are
initiated by local people in response to
local needs (bottom up approach), by
government requirements to solve
Significance of the study:
Childhood blindness has been
given a high priority by the World
Health Organization in it‘s ‗‗VISION
2020: Right to Sight‘‘ program not only
because it contributes to 4 to 5% of the
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world‘s blindness but also because
many of the causes of childhood
blindness are preventable or treatable
(Gilbert & Foster, 2001 ). A study
done by El-Bayoumy, Saad &
Choudhury, (2007 ) on school children
at Cairo governorate revealed that, 1292
out of 5839 students (22.1%) had
refractive error and 728 (12.5%) had
low vision. Strabismus was found in
only 42 students (0.7%). Of the children
with refractive error, 55.7% were
myopic, 27.3% hypermetropic and
17.0% astigmatic.
visual problems based on community
empowerment approach.
Research questions
 What are the types of visual
problems among primary school
children?
 What are the weaknesses and
strengths regarding visual problems
among school children?
 What are the relation between
weakness aspect and visual health
problems?
Operational definition:
―Community empowerment is a process
where people work together in order to
make changes in their communities. In
this research community members were;
parents of the students, school teachers
& director and school nurse as well as
school children.
Researchers during clinical area
observed that some students were
unable to read from the board
although they were sitting at the
front, teachers were not aware that
some students might be suffering
from eye problems. So this study
aimed
at
detecting
visual
abnormalities among school age
students at governmental primary
schools through community based
assessment of weaknesses and
strengths through the participation of
community
partners
(children‘s
parents, school director, teachers and
school nurse) to empower them
regarding visual problems and
suggest guidelines for early detection
and prevention of visual problems
among school children.
Material and methods:
Research design
A
descriptive
correlational
design was used in this study.
Research setting
Cairo governorate is divided into
four directions; North, South, East and
West, by using simple random sample
technique, one direction was selected
from these four directions. This
direction was the ―South‖. There are
thirty two (32) educational directorates at
Cairo Governorate; one directorate from the
South of Cairo was selected randomly. This
Aim
- To detect visual problems among
school age students at governmental
primary schools.
- To identify strengths and weaknesses
regarding visual problems among
school children.
- To suggest guidelines for early
detection and prevention regarding
directorate was EL-Sayeda Zeinab
educational directorate. Two schools
were selected randomly from this
directorate (Kasr El-Nil and Taha
Hussien governmental primary schools).
They are mixed governmental school,
located at Kasr El Eine and EL Mounira
district respectively. These two schools
serve EL Sayeda Zeinab district which
has four neighborhoods (Abden,
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Khalifa, Masr El-Kadema and Kasr ElNil). This district is an old one with
large number of population about
149661 , people in this area are
considered as having an average
socioeconomic standard (The Ministry
of Administrative Development, 2014).
Ethical consideration
An approval was obtained from
the school director, students and their
parents, teachers and school nurse. Each
student was informed about the purpose
of the study and its importance.
Researchers
emphasized
that,
participation in the study was entirely
voluntary.
Anonymity
and
confidentiality were also assured
through coding the data. An informed
verbal consent was obtained from
parents of the students. All students
were informed that they can withdraw at
any time.
Research sample
Multistage
random
sample
technique was used to select the schools.
All available students at the time of data
collection from first to the six grades at
Kasr El-Nile and Taha Hussien primary
schools were included in the study. In
both schools, each grade had 2 classes,
each class had from 25 to 30 students.
So the total sample after 6 months was
600 students.
Pilot Study
A total of 10% of the students
were included in the pilot study in order
to assess the feasibility and clarity of the
tools and determine the needed time to
answer the questions. Based on its result
minor changes were carried out. Pilot
study revealed that the average length of
time needed to complete the structured
interview schedule was approximately
30-45 minutes with each student. The
pilot study was included in the study
since only very limited minor changes
were done on the tools.
Tools for data collection:
After extensive reviewing of
related literature, the researchers
developed one tool to be used in
collection of data pertinent to the study.
1. Structured interviewing child visual
questionnaire: this question has two
parts; a) demographic characteristics of
the students as age, sex, academic year,
parent‘s occupation and education &
income. B) Eye hygiene & medical
history: eye cleanliness, previous eye
examination, consanguinity between
parents, and visual acuity (weaknesses &
strengths).
Procedure
Permission was obtained from
the school‘s director, teachers, school
nurse, student‘s parents and students
who agreed to participate in the study.
Data collected through a period of 6
months from October 2013 to the end of
March 2014 , two days/week from 9.00
a.m. to 12.00 p.m. Data was collected
from the students through interviewing
questionnaires. Parents, students, school
teachers and director and school nurse
were consulted for the proposed
guidelines that will be followed by them
2. Snellen chart: used to measure visual
acuity of the students.
Tool validity
Tools were submitted to a panel of
five experts in the field of community
health
nursing,
medicine
and
ophthalmologist to test the content
validity. Modifications were carried out
according to the panel judgment on
clarity of sentences and appropriateness
of the content.
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for early detection of visual problems
among school children.
- The school nurse wrote a report for the
parents asking them to come to the
school.
- Researchers announced a day for the
parents to come to the school
according to the student‘s academic
year through the school director.
- Invite the school nurse, teachers and
school director to be available during
certain day.
- Use of posters on school walls and
library.
- Environmental changes included seats
changing of students having visual
problems.
Each student and his/her parent
was interviewed to collect data about
demographic characteristics of the
students as age, sex, academic year,
parent‘s occupation and education &
income, eye hygiene & medical history:
eye
cleanliness,
previous
eye
examination, visual acuity, wearing eye
glasses, previous eye history & diseases.
Eye examination was initiated in the
presence of the class teacher and school
nurse.
Eye examination: eye examination
was performed using Snellen Chart to
measure eye acuity through the
following steps:
1. Ensure good natural light or
illumination on the chart.
2. Explain the procedure to the
student.
3. Position the student standing,
at a distance of 6 meters
from the chart.
4. Ask the student to use a
hand/opaque paper to cover
one eye at a time.
5. Test each eye separately.
6. Start asking the student to
read from the top of the
chart.
7. Record the result for each
eye.
8. Repeat the whole procedure
for the second eye.
9. Refer detected cases to
school nurse.
Suggested guidelines emphasizing
community partner empowerment:
These
guidelines
were
developed by the researchers based on
the study results and extensive review of
related literature. Guidelines were
distributed to the students and their
parents, school director and teachers,
school nurse and a copy was left in the
school library after conduction of the
study for ethical consideration. The
objective of these guidelines was to help
parents and school teachers and school
nurse to recognize symptoms of visual
problems for early detection and
prevention of complications. These
guidelines cover four main parts:
First: Student’s guidelines
 Keep your hand clean and
avoid touching your eyes while
playing.
 Wash your eyes frequently.
 Never rub your eyes in case
of itching.
 Protect your eyes as you
would protect your skin by
wearing sunglasses.
After conducting eye examination the
following community activities were
done:
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



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Suitable distance/hours for
watching T.V, computer.
Electronic games……etc.
Continuous wearing of eye
glasses.
Give your eyes a rest. If you
spend a lot of time at the
computer or focusing on any
one thing, you sometimes
forget to blink and your eyes
can get fatigued. Try the 2020-20 rule: Every 20
minutes, look away about 20
feet in front of you for 20
seconds. This can help
reduce eyestrain.
Give your eyes a break from
digital device use.
Eat for good vision: eat leafy
greens,
green,
leafy
vegetables such as spinach,
salmon, tuna, and other oily
fish
-
-
Third: Teacher’s guidelines
 Ensuring that children who have
glasses wear them.
 Students with visual problems
should be placed in the front.
 Early identification of students
with visual problems.
 Refer detected cases to school
health nurse for further
interventions.
 Observe student‘s eyes for the
presence of discharges or
redness and refer them to the
school nurse.
 Observe for inability to see
things at a distance.
 Inability to read from the board
and/or difficulty in reading
from books.
Second: Parent’s guidelines
 Observe the following:
- Red eyes.
- Eye discharges.
- Excessive tears.
- Eye squint.
- Inability to concentrate.
- Extreme sensitivity to
light.
- Sitting too close to the
T.V.
- Severe eye stress after
reading.
 Outdoor
activities
are
needed to help taking
vitamin "D" to alleviate eye
problems.
 Give the children healthy
diet:
- Emphasizes
fruits,
vegetables, whole grains
Fourth: Nurse’s guidelines
 Regular
student‘s
examination each year.
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and fat-free and milk
products, includes lean
meats, poultry, fish,
beans, eggs and nuts,
cantaloupe,
carrots,
orange, yellow pepper,
and eggs.
Vitamin C lowers the
risk
of
developing
cataracts, and when taken
in combination with
other essential nutrients,
can slow the progression
of age-related macular
degeneration and visual
acuity loss.
Vitamin D is important
and it is found in nuts,
fortified cereals and
sweet potatoes. It is
thought to protect cells of
the eyes from damage.
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
year, 27% are in 2nd and 3rd year, 24%
are in the 5th year, 13.5% are in the 4th
year and only 8.5% are at the 1st
primary year. Regarding parent's
education, 33%, 29% of fathers and
mothers respectively have preparatory
education, while 28%, 23.5% of fathers
and
mothers
respectively
have
university education, 6%, 11.5% of
fathers and mothers respectively are
unable to read and write, 12.5%, 11% of
fathers and mothers respectively have
secondary school education and only
18%, 21.5% of fathers and mothers
respectively are able to read and write.
Referral of students with visual
problems to the ophthalmologist.
 Collaborate with teachers and
parents in the early detection of
students with visual problems.
 Identifies children at high risk
for visual problems or in need
for professional examination
through risk assessment and
vision screening.
 Provides parents and teachers
with valuable information and
education about eye care.
 Diagnoses eye disorders and
diseases by detecting signs and
symptoms.
 Notification of results to parents.
 Follow-up of referral outcomes
 Children whose eyes are red or
draining should not be screened
but referred immediately to their
primary care provider.
 Ensuring that children who need
glasses received them.
 Ensure that children with these
visual
problems
receive
appropriate treatment in a timely
way.
 Continuous follow up.
Results
The study results will be presented in
three parts: part 1: Demographic
characteristics of the students, part 2:
Eye hygiene & medical history of the
students, part 3: Correlation between
variables
Part 1: Demographic characteristics of
the students
Regarding student‘s age, 55.5% of them
age 8 years to less than 10 years, while
27.5% age from 5 to less than 8 years
and only 17% of the student‘s age from
10 to 11 years with a mean age of
8.81+1.66 years. Regarding student‘s
sex, 54% of them are females and 46%
are males. As for the student‘s academic
Regarding father‘s occupation,
56% are working in private work, 41%
are working in governmental work and
only 3% are retired. As for mother‘s
occupation, 52% are housewives, 36%
are working in governmental work and
only 11.5% are in private work. More
than three quarters (79%) of the students
have a monthly family income from
1000 to less than 2000 Egyptian
pounds, 13% have from 2000 to 3000
Egyptian pounds monthly and only 8%
have from 500 to less than 1000
Egyptian pounds monthly. Results
revealed that 22% of the student‘s
parents are relatives.
Part 2: Eye hygiene, family & medical
history of the students (strengths and
weaknesses)
Results revealed that, 79.5% of
the students never have previous eye
examination and only 4% are wearing
eye glasses. Regarding eye cleanliness,
99% of the students have clean eyes. It
is found that, 27% & 13.5% of the
fathers and mothers respectively wear
glasses and 11% of the student‘s
siblings wear eye glasses. Results
revealed that 12% of the male and 4.6%
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of the female students respectively have
history of eye diseases and only 5% of
the students have eye inflammation
and/or discharges. Only 1% of the
studied sample is suffering from eye
squint, and 5% have eye irritation.
Table (1) reveals that, 39% of the
students suffer from hyperopia and
1.5% has myopia. Figure (1) reveals
that, 59.5% of the studied sample has
6\6 on Snellen chart examination, only
0.5% of the students have -6\6, while
25% have 6\9, 8% of them has 6\12,
and 3.5% have 6\18 and only 1.5% &
1% have 6\24 & 6\36 respectively.
Part 3: Correlation between variables:
Table (2 & 3) reveal a statistically
significant negative correlation between
students age and eye diseases
(p=0.001 ). On the other hand, a
statistically
significant
positive
correlation find between students‘
academic year and eye diseases
(p=0.000 ). While no statistically
significant correlation find between
students‘ sex, monthly income, father &
mother‘s education, father‘s & mother‘s
occupation, eye examination, vision
acuity, wearing eye glasses and parents
consanguinity.
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Table (1): Distribution of the students as regards their vision acuity (n=600 )
Vision acuity
No
%
9
1.5
234
39.0
357
59.5
Myopia (short-sightedness)
Hyperopia (Far-sighted)
Normal
Figure (1): Distribution of the students in relation to vision acuity (n=600 ).
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Table (2): Correlation between age, sex, academic year, monthly income, father and
mother’s education and eye diseases among the students (n=600 )
Eye diseases
Study variables
r
P
Age
-.237
0.001*
Sex
-.124
0.081
Academic year
.310
0.000**
Monthly income
.097
0.170
Father‘s education
-0.044
0.538
Mother‘s education
-0.049
0.491
Table (3): Correlation between father and mother’s occupation, eye examination,
vision acuity, wearing eye glasses, parents consanguinity and eye diseases among the
students (n=600 )
Eye diseases
Study variables
r
P
Father‘s occupation
0.129
0.069
Mother‘s occupation
Eye examination
Vision acuity
Wearing eye glasses
Parents consanguinity
0.026
-.066
.115
-.102
-.055
0.715
0.354
0.104
0.150
0.437
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12±1.6 years (range: 8-15 years).
Opposite to the study results, ElMoselhy et al., (2011 ) who studied eye
diseases among school children in Egypt
found that, the rates for vision problems
increase as children age. An opposite
results was found also by Kamath et
al., (2012 ) in India where refractive
error increased with age and this was
statistically significant. The difference
between the present study and the two
studies in India and Gabon could be
related to the criteria chosen in selection
of the sample and the sample sizes.
Discussion:
Vision health is a fundamental
part of early child development and of
overall health and wellbeing (Proser &
Shin, 2008 ). Vision conditions in early
childhood can lead to vision loss, visual
impairment, or blindness (Marshall,
Meetz & Harmon, 2010 ) and may
impact
an
individual‘s
health,
educational achievements, employment
options and social functioning across the
lifespan (Davidson & Quinn, 2011 ;
Chua & Mitchell, 2004 ). Communitybased
research
(CBR)
engages
communities and researchers in a shared
partnership where each actor plays an
equitable role in every phase of the
research with the ultimate goal of
societal transformation (Wallerstein &
Duran cited in Nield, Quarrell &
Myers, 2013 ).
Regarding student‘s sex, slightly
more than half of them were females but
no statistically significant correlation
was found between student‘s sex and the
presence of eye problems. The same
results was revealed from the study done
by Kamath et al., (2012 ) who studied
school children in South India and
found males and females number to be
(60.77% & 39.23%) respectively. The
study done by Al Wadaani et al.,
(2013 ) in Saudi Arabia revealed that,
48.3% females & 51.7% male. The
study
done
in
Iran
by
Ostadimoghaddam,
Heravian
&
Norouzirad, (2013 ) to examine the
prevalence of uncorrected refractive
errors found that, 7.1% of girls and
4.8% in boys were affected with a
statistically
significant
different
(p=0.068 ). The difference might be
related to the study sample selection and
its number in both studied.
Part 1: Demographic characteristics of
the students
Mean age of the students was
8.81+1.66
years.
A statistically
significant negative correlation was
found between student‘s age and eye
diseases. Almost the same result was
found by Al Wadaani, Amin, Ali &
Khan, (2013 ) who studied eye
problems among school students in
Saudi Arabia and revealed that, the age
of the included school children ranged
from 6 to 15 years with a mean of 9.4
years+2.3 years. In the same line, Arif
& Mehboob, (2014 ) who studied
60,402 children aged 5 to16 years from
governments, private and community
schools in Pakistan to detect visual
problems and revealed that, the mean
age of the students was 8.46±2.3 years.
The study done Ategbo et al., (2014 )
on school children in Gabon to assess
visual problems contradicted the study
results where the average age was
As for the student‘s academic
year, slightly more than one quarter was
in 2 nd and 3rd year and almost one
quarter was in the 5 th year. A
statistically
significant
positive
correlation was found between student‘s
academic year and eye diseases. Almost
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it is true that, parent‘s high education
can be effective in lowering student‘s
eye problems because of their increased
awareness about importance of eye
cleanliness
and
continuous
eye
examination.
the same result was revealed from the
study done by Al Wadaani et al.,
(2013 ) in Saudi Arabia where 13.8% of
the students were from grade one,
17.9% were grade two, 19.9% were
grade three, 17.6% were grade four,
18.1% were grade five and 12.7% were
grade six. From the researchers‘ point of
view, eye problems appear as the
students get older in age and in their
academic year because they become
aware of their inability to see from the
board and can express it to their parents,
teachers and school nurse.
Regarding father‘s occupation,
slightly more than half were working in
private places and more than one third
were working in governmental places.
As for mother‘s occupation, more than
half were housewives, but no
statistically significant correlation was
found between fathers & mother‘s
occupation and student‘s eye diseases.
The same result was found by Prajapati
et al., (2010 ) in India where no
association was found between parent‘s
working status and student‘s ocular
morbidity. Also, the study done by
Ostadimoghaddam et al., (2013 ) in
Iran found that employment of the
mothers did not correlate with
uncorrected refractive errors of the
students significantly (p=0.961).
Regarding parent's education,
one third and slightly more than one
quarter of fathers and mothers
respectively had preparatory education,
while almost one quarter of fathers and
mothers had university education, with
no statistically significant correlation
found between fathers & mother‘s
education and student‘s eye diseases.
Opposite to the study results, the study
done by Prajapati et al., (2010 ) in
India where, only 5% of fathers and
17.5% of mothers were illiterate and
education of parents affects the
occurrence of ocular morbidity, either
illiterate or lower education (only up to
primary level) of father (p=0.00) and
mother (p=0.00) was significantly
associated with occurrence of ocular
morbidity. In contrast to the study
results El-Moselhy et al., (2011 ) in
Egypt found that, low level of parental
education (illiterate or primary) were
significant risk factors for eye diseases,
while the high level of parental
education (university) were significant
protective factors for eye diseases. The
difference between the present results
and the two researches could be related
to
the
sample
selection
and
socioeconomic level of the students but
More than three quarters of the
students had a monthly family income
from 1000 to less than 2000 Egyptian
pounds. No statistically significant
correlation was found between family
monthly income and student‘s eye
diseases. Opposite results was found by
Prajapati et al., (2010 ) in India where
a statistically significant difference was
found between ocular morbidity and
lower
socio-economic
adolescents
(p=0.01). The study explained that,
monthly income could affect the
nutritional status of the students which
in turn will affect their eyes. Also, low
income could prevent the parents from
taking
their
children
for
eye
examination. This difference could be
related to the number of the sample. The
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researchers of the present study agree
with this explanation.
& Zhao, (2011 ) who conducted a study
on school children in China where high
prevalence of poor vision was revealed,
the rates of eyeglasses use appeared to
be quite low where only four percent of
the sample reported having eyeglasses
and only three percent actually brought
their eyeglasses to school. The study
explained that, it might be possible that
children (or their parents or teachers)
either do not know that they have a
vision problem, do not know what to do
about it or do not believe it is an
important consideration or some
combination of these factors. Not
wearing eye glasses may lead to a
greater deterioration in the vision of the
affected children. Thus, awareness about
the importance of visual correction may
play a significant role in proper
management.
Results revealed that, slightly
less than one quarter of the students
were having consanguinity between
their parents but no statistically
significant correlation was found
between parent‘s consanguinity and
student‘s eye diseases. In contrast to the
study results, Prajapati et al., (2010 ) in
India found a positive family history of
refractive error reported in half of the
students
with
moderate
visual
impairment. Also, El-Moselhy et al.,
(2011 ) in Egypt found that, positive
consanguinity of the parents was among
the important significant personal
characteristic predisposing to eye
problems. From the researchers‘ point of
view, a lot of diseases in Egypt are
related to consanguinity between parents
so eye problems are not an exception.
Results revealed that, twelve
percent of the male and only four point
six percent of the female students were
having history of eye diseases
respectively and only five percent of the
students were suffering from eye
inflammation and/or discharges. A
bigger percent was found by ElMoselhy et al., (2011 ) where 28.2% of
the Egyptian students were having eye
diseases also, previous eye diseases
represented a significant risk factor for
present eye diseases among students.
The same results was revealed from the
study done by Misra & Baxi, (2012 ) in
India where the most important eye
problems identified were watering,
dimness of vision, redness of eye,
swelling of eye and far and near vision
difficulty.
Part 2: Eye hygiene, family & medical
history of the students
Results revealed that, slightly
more than three quarters of the studied
sample never had previous eye
examination and only four percent were
wearing eye glasses. According to ElMoselhy et al., (2011 ) lack of early
consultation for eye diseases and never
received eye examination were among
the most important significant health
care behavioral risk factors for eye
problems among Egyptian school
students. Almost the same result was
found by Ategbo et al., (2014 ) who
revealed that, among the 156 children
with visual problems, (80.8%) of them
never went to an ophthalmologist, also a
significant association was found
between visual problems and visits to
see the ophthalmologist (p< 0.01). The
same result was found by Glewee, Park
Only one percent of the students
were suffering from eye squint. The
same results were revealed from Datta
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et al., (2009 ) who Studied disorders of
visual acuity among adolescent school
children in India and found that 1.3%
suffered from squint. Also Arif &
Mehboob, (2014 ) in Pakistan showed
that, the prevalence rate for squint was
0.06%.
conjunctivitis (6.3%). Also, the study
done by Shrestha et al., (2013 ) on
children in Nepal to examine ocular
morbidity revealed that Myopia
accounted for (1.9%), Hypermetropia
(0.5%) among the children.
Study results revealed that, more
than half of the studied sample had 6\6
on Snellen chart examination, only point
five of the students had (-6\6) while one
quarter had visual acuity (6\9), eight
percent had (6\12), and three point five
percent had (6\18) and only one point
five and one percent had (6\24 & 6\36)
respectively. Almost the same results
was found by El-Bayoumy et al.,
(2007 ) where the prevalence of
refractive error (≤ 6/12) was high in
(22.1%) Egyptian school students aged
7-14 years and (12.5%) of them had low
vision (≤ 6/18).
Slightly more than one third of
the students were suffering from
hyperopia and only one point five
percent was having myopia. Within the
same line, Nassar, cited in ElBayoumy et al., (2007 ) who studied
school children in Cairo found that,
21.8% of all examined children had
refractive error (myopia, hyperopia &
astigmatism). Also in Menofiya
governorate, it was reported that 17.5%
of
primary-school
children
had
refractive errors (El-Sayed et al., cited
in El-Bayoumy et al., 2007 ). Another
study done by Abou-El Ela MA et al.,
cited in El-Bayoumy et al., (2007 )
detected a higher prevalence of
refractive error (36.8%) among primaryschool children in Giza governorate.
A higher result was found by
Biswas et al., (2012 ) who studied
ocular morbidity among children in
Indian, where the overall myopia was
the most frequent type of refractive error
affecting (54.44% ) students followed by
hypermetropia (24.85% ). Among 169
children with refractive error only 9
(5.33%) had uncorrected vision less
than 6/60 while majority (62.72% ) had
uncorrected visual acuity between 6/9
and 6/18. Also, the study done by
Mehari & Yimer, (2013 ) on
prevalence of refractive errors among
school children in rural central Ethiopia
revealed that, the prevalence of visual
impairment (6/12 or worse) was 9.6%,
63.6% had presenting vision of (6/9 or
better) in at least one eye. The overall
rates of myopia and hyperopia in
students 7-18 years were 6.0% &
0.33%. Uncorrected vision showed a
Opposite to the study results, ElBayoumy et al., (2007 ) in Cairo found
that, 55.7% were myopic, 27.3%
hypermetropic. The difference between
the two studied could be related to the
sample size. On the same line, the study
done in Saudi Arabia by Al Wadaani et
al., (2013 ) on 2002 school children
found that, the overall prevalence of
refractive errors was 13.7%. Myopia
was the most commonly encountered
refractive error among both genders. A
study done by El-Moselhy et al.,
(2011 ) at east district of Cairo showed
that, 28.2% of the students had eye
diseases; the most common eye diseases
were trachoma (9.3%), errors of
refraction
(7.1%)
and
allergic
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statistically
significant
difference
between genders (p<0.001 ).
children
among
community.
Conclusion:
Results revealed that, mean age
of the students was 8.81+1.66 years,
more than half of them were females,
twelve percent of the male and only four
point six percent of the female students
were having history of eye diseases.
Slightly more than one third of the
studied sample was suffering from
hyperopia and only one point five
percent was having myopia. Guidelines
were developed by the researchers based
on the study results and was distributed
to the students and their parents, school
director and teachers, school nurse and a
copy was left in the school library after
conduction of the study for ethical
consideration.
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July 2015
Effect of Postoperative Immobility.
enj@nursing.cu.edu.eg
Effect of Postoperative Immobility on Children with Musculoskeletal Disorders
By
*Samar Sobhi Abd Alkhair,** Afkar Ragab Mohammed,*** Sanaa Ahmed
Mahmoud*** Amr Said Arafa
* Clinical Instructor of Pediatric Nursing, Faculty of Nursing, Cairo University** Professor of Pediatric Nursing, Faculty of Nursing, Cairo University
*** Lecturer of Pediatric Nursing, Faculty of Nursing, Cairo University
****Lecturer of Orthopedics, Faculty of Medicine, Cairo University
Abstract
Musculoskeletal Disorders or MSDs are injuries and disorders that affect the human body’s
movement or musculoskeletal system. Immobility is a state in which the individual experiences or is at
risk of experiencing limitation of physical movement,purposeful physical movement of the body or of one
or more extremities. Immobility has serious consequences on children; physically, socially and
psychologically. The aim of the current study was to assess the effects of post operative immobility on
children with musculoskeletal disorders. A descriptive exploratory research design was utilized to fit the
aim of the study. The study was conducted at pediatric orthopedic surgical specialty ward and orthopedic
surgical outpatient clinic at Cairo University Specialized Pediatric Hospital. A convenient sample of 100
children with MSDs and their caregiver participated in the study. Tools of data collection were structured
interview schedule. Tools included socio- demographic data about child, his /her parents, observational
checklist to evaluate the effects of postoperative immobility on children with musculoskeletal disorders
physically and psychosocially. The study results revealed that, more than two fifth of children' age ranged
from 3- <6 years, and more than half of children were males. More than two fifth of the children with
MSDs stayed in cast for 2 months. More than half of children had impaired coping abilities and hostility
postoperatively. There was highly statistical significant difference that the postoperative immobility
affected the child physically can be noted in the most of body systems and psychosocially and the
immobilized child impacted on his/her family. There was statically significant correlation between surgical
treatment and presence of complications. The study concluded that, based on the results the effects of
postoperative immobility increased than preoperative physically (each system can affected as a result of
immobility) psychosocially on children and his/her family. The study recommended that, Comprehensive
nursing care program for children with immobilization is very important in both pre and postoperative
periods to minimize the effects of immobility on children and their families physically and psychosocially.
Keywords: Children, Musculoskeletal Disorders, Postoperative, Immobility.
of Orthopedic Surgeons (AAOS),
(2015 )
considers
childhood
musculoskeletal injuries and conditions
a major problem around the world.
Many thousands of children and
adolescents nationwide suffer from
musculoskeletal conditions each year. In
fact, for children younger than age 19,
abnormal musculoskeletal conditions
accounted for 427,000 hospitalizations
and more than 9.5 million physician
visits in 2008 alone.
Surgeries serve an important role
in the treatment of musculoskeletal
conditions and are used to heal injuries,
improve function and ease pain.
Orthopedic surgeons turn to surgical
Introduction
Musculoskeletal
Disorders
(MSDs) are injuries and disorders
that affect the human body’s
movement or musculoskeletal system
(i.e. bones, muscles, tendons, ligaments,
nerves, discs, blood vessels, etc.). In
children, a wide variety of disorders
affect the muscles, joints, and bones.
These disorders may be caused by
heredity, injury, inflammation, or
infection. MSDs can be classified to
traumatic injury, congenital defects, and
acquired defects, infections of bones and
joints, bone and soft tissue tumors and
disorders of joints (Hockenberry &
Wilson, 2012 ). The American Academy
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solutions for approximately half of their
patients (Hill, 2012 ). The most frequent
reason of immobility is due to
congenital defects, or acquired MSDs
itself and/or the therapies such as
traction, casts (Hockenberry &Wilson,
2013)
Impaired physical mobility is
defined as the state in which an
individual has a limitation in
independency, purposeful physical
movement of the body or of one or more
extremities (Beevi, 2012 ). One of the
most difficult aspects of illness is the
immobility, it often imposes on child.
Children's natural tendency to be mobile
influences all elements of growth and
development
physical,
social,
psychological,
and
emotional.
Immobility restricts expression and
causes anxiety and frustration. The most
frequent reasons of immobility are
either
from
the
disorders
in
musculoskeletal itself or from treatment
such as cast are responsible for
prolonged
immobilization
(Hockenberry, Wilson, 2013 ).
Physiological
effects
of
immobilization,
functional
and
metabolic responses to restricted
movement can be noted in the most of
body systems, all of which have a direct
influence on the child's growth and
development. Most of pathologic
changes that take place during
immobilization arise from decreased
muscle strength and mass, decreased
metabolism, and bone demineralization
which
are
closely
interrelated.
Immobility are related directly or
indirectly to decreased muscle activity,
which produces
numerous primary
changes in both muscular and bone
structure with secondary alternation in
the
cardiovascular,
respiratory,
metabolic, Integumentary,
nervous,
and renal systems (Ricci &Kyle,2012 ).
Throughout childhood, physical
activity helps the children to deal with a
variety of feeling and impulses and
provide a mechanism by which they can
exert control over inner tensions.
Activity serves children as an
instrument
for
communication,
expression, learning and understanding
of
world.
When
children
are
immobilized they experience diminished
environmental stimuli with loss of
tactile input and altered perceptions of
themselves and their environment.
Sensory deprivation frequently leads to
feelings of isolation, boredom and
restlessness. Children with MSDs suffer
from regression e.g., bed-wetting, fear
of darkness, depression and inability to
discharge anger (Mercer, 2013)
Living with a disabled child can
have profound effects on the entire
family–parents, siblings, and extended
family members. It is a unique shared
experience for families and can affect all
aspects of family functioning. On the
positive side, it can broaden horizons,
increase family members' awareness of
their inner strength, enhance family
cohesion, and encourage connections to
community
groups
or
religious
institutions. On the negative side, the
time and financial costs, physical and
emotional demands, and logistical
complexities associated with raising a
disabled child can have far-reaching
effects. Family needs must be met by
services of a multidisciplinary team
(Jones, 2014).
Nurses‘ responsibility is to
identify the impact of physical
immobility on children and their
families either physically, socially and
psychologically.
Assessment should
focus on not only the injured part (e.g.
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fracture) but also the functioning of
other systems that may be affected
secondarily the circulatory, renal,
respiratory,
muscular
and
gastrointestinal systems. With long-term
immobility some neurologic impairment
and
electrolytes
disturbances,
psychological impact of immobilization
should be assessed and the impact of
child‘s immobilization on family
(Hockenberry, Wilson, 2013 ).
Orthopedic postoperative nurse is
responsible for the majority of child care
following any orthopedic surgical
procedure. Specific responsibilities
include close supervision and care
immediately following surgery, daily
routine, and monitoring and care plan
management. Care of wound, cast,
fixation and traction care according to
the treatment. Pain management is
depending upon the severity of the
surgical procedure. Frequent positions
changes, nutritional support & adequate
hydration is needed (Media & Reid,
2013).
Significance of the study
In Egypt, there are scarce
researches about the effect of
postoperative
immobility
among
children with MSDs at Cairo University
Specialized
Pediatric
Hospital
(CUSPH). Moreover, it has been
observed during the researcher clinical
experience that postoperative children
with MSDs are suffering from
immobility. This immobility has its
effects physically on the child wellbeing
and can be noted in the most of the body
systems and each has a direct influence
on child growth and development. Also
psychosocial wellbeing of child will be
affected by immobility. When the child
is immobilized by the disease or as a
part of treatment regimen, Sudden or
gradual immobilization narrows the
amount and the variety of environmental
stimuli of children by means of all their
senses, this sensory deprivation
frequently leads to feel feeling of
isolation,
boredom,
helplessness
,unwanted
and
being
forgotten
especially by beers. Effect of
immobilized child on families is a
unique shared experience for families
and can affect all aspects of family
functioning, the time and financial costs,
physical and emotional demands, and
logistical complexities associated with
raising a disabled child can have farreaching effects. The impact of
immobilized child will likely depend on
the type of condition and severity.
According to the medical records in
CUSPH the incidences of children with
MSDs in (2011) was 1040 child and in
(2012 ) was 1284 child. So the current
study aimed to assess the effects of
immobility on children and their
families to be able to provide a
comprehensive nursing care program for
children and their families based on the
current study findings.
Aim of the study
The aim of the current study was to
assess the effects of post operative
immobility
on
children
with
musculoskeletal disorders.
Subjects &Methods
Research Design
A descriptive exploratory research
design was utilized to study the effect of
post operative immobility on children
with musculoskeletal disorders.
Research Questions
To fulfill the aim of this the
study, the following research questions
were formulated:
Q1: What are the effects of post
operative immobility on children with
MSDs on physical wellbeing?
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Q2: What are the effects of post
operative immobility on children with
MSDs on psychosocial wellbeing?
Setting
The study was conducted at
pediatric orthopedic surgical specialty
ward (4 th floor) bed capacity (12 beds)
and orthopedic surgical outpatient clinic
(2nd floor) at Cairo University
Specialized
Pediatric
Hospital
(CUSPH).
Sample
A convenient sample of 100
children with MSDs and their caregivers
were participated in the study. Children
with post operative MSDs regardless the
causes. Children aged from 2 to10 years
of both genders.
The study excluded children who have
other congenital anomalies and/ or
chronic illness and children who had
other physical disabilities.
includes 8 questions to assess
musculoskeletal system, respiratory
system,
cardiovascular
system,
gastrointestinal system, genitourinary
system, integumentary system and
neurosensory system.
-Second Section: To evaluate the
preoperative immobility psychosocial
effects on children with MSDs it
contained 44 questions as an example
(diminished environmental stimuli,
inability to concentrate, depression,
regression,
egocentrism,
increased
anxiety/frustration/helplessness,
and
social isolation).
Third Section: Effects of immobilization
on the child and family preoperative. It
contained19 items included as an
example (wasted of the time and
financial costs of the family, altered
coping abilities of the family, and divert
attention from other aspects of family
functioning).
Part (3): Observational checklist to
assess the effects of postoperative
immobility
on
children
with
musculoskeletal disorders. It composed
of three sections:
-First Section: It includes postoperative
immobility physical effects on children
with MSDs on system affected; it is
composed contained 8 questions to
assess
musculoskeletal
system,
respiratory
system,
cardiovascular
system,
gastrointestinal
system,
genitourinary system, integumentary
system and neurosensory system.
-Second
Section:
To
evaluate
postoperative immobility psychosocial
effects on children with MSDs it
contained 44 questions as an example
(Diminished environmental stimuli,
inability to concentrate, depression,
regression,
egocentrism,
increased
anxiety/frustration/helplessness,
and
social isolation).
Data Collection Tools
The tool was developed by the
researcher on Arabic language based on
extensive review of related literature
and after testing its validity and
reliability.
The required data was collected through
the following tools:
Part (1). Structured interview schedule
which include social and personal data
about the child‘s and his/her family, the
past medical history of the child, history
of the disease, signs and symptom
experienced by the child and treatment.
Part (2). Observational checklist to
assess the effects of preoperative
immobility
on
children
with
musculoskeletal disorders. It composed
of three sections:
-First Section: It was composed of the
effects of preoperative immobility
physically effects on children with
MSDs on each system affected; it
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-Third
Section:
Effects
of
immobilization on child and his family
postoperatively. It contained 19 items
include for example (wasted of the time
and financial costs of the family, altered
in coping abilities of the family, and
alteration of the family process and
functioning).
Data Collection Procedure
An official permission to conduct
the study was obtained from the
directors of CUSPH as well as
permission from the heads of pediatric
surgery department and outpatient clinic
of surgery. The consent was obtained
from the caregivers of children with
MSDs. Complete description of the
purpose, nature of the study, tool,
duration of the study, confidentiality,
and the right to withdraw from the study
was explained to each caregiver. The
research investigator was filling the
questionnaire sheet from the caregivers
who had children fulfilling study criteria
through interview schedule. The time
spent to fill the questionnaire ranged
between 15 to 20 minutes for each
caregiver. Data was collected using
retrospective method by asking the
caregivers about past and current
medical
history.
The
research
investigators observed the effect of the
immobility preoperatively and check on
the checklist. The time spent to fill the
observational checklist ranged from 15
to 20 minutes for each caregiver in the
orthopedic surgery ward and surgery
outpatient clinic. Another observational
checklist was done postoperatively
about the effect of immobility on
children with MSDs and monitoring the
effect of immobility postoperatively
until removing of cast and healing. The
data collection procedure took six
months (three days per week) from
February to July 2014 .
Pilot study
The pilot study was carried out on
10 children with MSDs and their
caregivers who attended in the pediatric
surgical unit and outpatient clinic in
CUSPH to test the study tools in terms
of its applicability and clarity of
questions, time required to fulfill it and
to add or omit questions were done.
Some modifications for questions were
done.
Tool Validity
Tools of data collection were
submitted to five experts in pediatric
surgery, pediatric orthopedic specialist
and pediatric nursing to test the content
and face validity of tools. Modifications
of the tool were done according to the
panel judgment on clarity of the
sentences, appropriateness of the
content and sequence of items.
Tool Reliability
The internal consistency was
measured to identify the extent to which
the items of tools measure the concept
and correlate with each other. Internal
consistency estimates reliability by
grouping questions in questionnaire that
measure the concept. Reliability of tools
was performed to confirm its reliability
of tools accepted coefficient alpha
between questions to be accepted at
0.79.by using Test- Retest reliability.
Ethical consideration
Final ethical approval was
obtained from the research ethical
committee in the Faculty of Nursing,
Cairo-University, to approve the
research. A written formal consent was
obtained from the mothers/ caregiver of
children after explaining to them the aim
of the study, its benefits and risks,
duration of the study and the data
collection
tools.
The
researcher
informed the parents that all data
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gathered during the study is considered
confidential. The researcher informed
the parents about their rights to
withdraw from the study at any time
without giving any reason and without
any effect on the care of their children.
than sixty percent of children (61%) did
not do orthopedic surgery before while
38% did orthopedic surgery at different
stages. More than two fifth (46%) of
children with MSDs stayed in cast for 2
months. Most of children (98%) with
MSDs had post operative complications.
As regards the effects of preoperative
and postoperative immobility in
children with MSDs table (3) showed
that; there was statistically significant
difference between the effect pre and
postoperative in reducing strength and
coordination of the muscles (X² =
5.553, p =0.018). There was highly
statistically
significant
difference
between the effect pre and postoperative
in loss of joint mobility and contracture
formation(X² =75.000 , p =0.000 ). There
was no statistical significant relation
between the effect pre and postoperative
in decreasing exercises intolerance. (X²
=1.541 , p =0.214 ). On gastrointestinal
tract (GIT), there was statistically
significant difference between the effect
of pre and postoperative in underweight
related to poor appetite (X² =4.110, p
=0.043 ).There was highly statistically
significant relations between the effect
of pre and postoperative regarding
inadequate hydration and nutritional
status and distention caused by poor
abdominal muscle tone (p =0.000 ).
Regarding urinary system, there was
highly statistical significant difference
between the effect of pre and
postoperative in urinary retention
(bladder doesn't empty completely,
decreased muscle tone) and urinary tract
infection (p =0.000 ). For integumentary
system there was highly statistical
significant difference between the effect
of pre and postoperative in reducing
skin turgor, ulcers or necrosis and
edema on the effected site (p<0.005).
Statistical analysis
The collected data was tabulated
and analyzed by personal computer
using statistical package for the social
science (SPSS) program version
20.Descriptive statistics will be utilized
as frequency, mean and standard
deviation. Inferential statistics will
include T test and chi squire. A
compatible personal computer (PC) was
used to store and analyze data, and to
produce graphic presentation for some
important results. Data were coded and
summarized using mean and standard
deviation for quantitative variables and
percent for qualitative variables,
Pearson correlation coefficient, The pvalue < 0.05 and p-value<0.001 was
considered statistically significant.
Results
Table (1) showed that, the studied
sample consisted of 100 children who
diagnosed as MSDs. As regards age less
than half of children' (46%) age ranged
from 3- <6 years and the mean age of
the children was7.39±4.97 years.
Regarding to sex more than half of
children (56%) were males. With
reference to residence less than half of
children (48%) came from urban areas.
In relation to presence of consanguinity
more than half the children' parents
(54%) had negative consanguinity
between parents and 46%of them had
positive consanguinity.
Table (2) represented that, nearly two
thirds of children (65%) had congenital
disorders as a cause of MSDs. More
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Table (4) illustrated that there was a
highly statistically significant difference
between pre and post operative feeling
depression, suffering from regression,
feeling egocentrism and sluggish
intellectual and psychomotor responses.
There was statistically significant
difference between pre and post
operative feeling of frustration and
helplessness,
mood
swings
and
listlessness and diminished ability to
perform self-care (p<0.05).
Table
(5)
demonstrated
highly
statistical significant difference between
pre and post operative as regard to
social isolation, and altered perceptions
of themselves and their environment
(p=0.000 ). There were no statistical
significant difference between pre and
post operative regarding experience
diminished
environmental
stimuli,
alteration in level of activity and passive
and aggressive verbal and nonverbal
communication (p>0.05).
Table (6) showed a highly statistically
significant difference between pre and
post operative in encouraging family
connections to community groups or
religious institutions, wasted of the time
and financial costs of the family,
difficult to find appropriate and
affordable child care, affect decisions
about work, education/training, having
additional children, feeling of confusion,
support from their families and feeling
guilt, blame, or reduced self-esteem (p
<0.001 ). There were statistically
significant differences between pre and
post operative in increased family
members' awareness of their inner
strength and enhance family cohesion,
altered coping abilities of the family,
increase stress in the family, fear of the
unknown more than they fear the known
(p<0.05).
Discussion
The aim of the current study was to
assess the effects of post operative
immobility
on
children
with
musculoskeletal disorders. The first part
of the current study dealt with data
related to analysis of sociodemographic
characteristics of children and their
families, it was shown that, more than
fifth of children age ranged from 3- <6
years while more than one third had 610 years old. These results were
supported by Ricci and Kyle (2012 )
who found that, musculoskeletal
disorders in children may occur as a
congenital malformation or a genetic
disorder that present from birth but may
not be identified until later in childhood
and adolescence.
Regarding the child's gender, the
study‘s results showed that, nearly more
than half of children were males. These
findings in accordance with the study
carried out by Gunz, Canizares,
MacKay and Badley(2012) who found
that, overall more boys than girls
presented to physicians with MSD
complaints (girl/boy ratio 0.9). It is
evident from the current study that, less
than half of children came from urban
areas which have increased risk for
congenital MSDs. These results were
supported
by
Padula,
Tager,
Carmichael, Hammond, Lurmann and
Shaw (2013) who concluded that, their
results extend the limited body of
evidence regarding air pollution
exposure and adverse birth outcomes.
The results of the current study
indicated that, more than two fifth of
parents had positive consanguinity
which was increased incidence of
musculoskeletal congenital anomalies.
This finding was in accordance with the
study carried out by Marwah, Sharma,
Kaur, Gupta, Goraya (2014) who
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evaluated the incidence of congenital
malformations in their population was
4.44%: frequently associated with
consanguineous marriage and these
finding also supported by WHO (2014 )
that indicated, there are some known
causes or risk factors one of them
consanguinity (relationship by blood)
which increases the prevalence of
congenital anomalies.
who concluded that, children older than
2 years may require an "open surgery"
to realign the hip, followed by spica
cast. The spica cast is worn for
approximately three to six months. The
cast is changed from time to time to
accommodate the baby's growth and to
ensure the cast's rigidity. On the other
hand, the current study‘s results showed
that, number of orthopedic surgery was
fifteen percentof children did orthopedic
surgery before once and eleven percent
had more than three times. In the same
field Jacobs, King, Klippel, Berven,
Burr, Caskey, Elderkin, Esposito and
etal (2013 ) mentioned that, Limb
deficiency,
either
acquired
or
congenital, requires lifelong medical
attention and frequent surgical services.
The results of the current study
indicated that, most of children with
MSDs had complications. In this respect
Halanski and Noonan (2014) stated that,
internal
fixation
has
become
increasingly popular for fracture
management and limb reconstruction.
Casting is not without risks and
complications (eg, stiffness, pressure
sores, compartment syndrome).
The results of the current study
indicated that, each system in the body
affected by immobility postoperatively.
The finding goes on the same line with
Brooker and Waugh (2013) who found
that, body systems that can be affected
by immobility are integumentary,
respiratory, cardiovascular, metabolic,
elimination,
musculoskeletal
and
neurological systems. The previous
results are in accordance with those of
other studies carried out by Manière
(2012 ) who studied complications of
immobility and bed rest (Prevention and
Management) and stated that, according
to prolonged immobilization affects
almost every organ system. Anorexia,
The results of the current study
revealed that, less than two thirds of the
studied
children
had
congenital
disorders, more than twenty percent of
children the cause of the MSDs were
traumatic disorder, more than ten
percent of children the cause of MSDs
were acquired. These results supported
by AAOS (2015) who concluded that,
abnormal musculoskeletal conditions
which require orthopedic care can range
from congenital conditions and include
other musculoskeletal infections and
diseases.
In addition, approximately five million
children younger than age 19 sustained
musculoskeletal injuries in 2008 .
Regarding to the line of
management utilized with children, the
results of the current study revealed that,
the highest percentage of children had
surgical treatment, these results
supported by Gunz, Canizares, MacKay
and Badley(2012 ) who reported that, the
majority of children presented to
surgical specialists (22.3% saw surgical
specialists, mainly orthopedic surgeons.
The current study proved that, more
than two fifth of children stayed in cast
for 2 months; which is stressful for
children and limits their activity and
decrease their energy level. These
finding was in accordance with the
study carried out by Mannheim (2014 )
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constipation, decreased basal metabolic
rate, increased genitourinary problems
include renal stones and more frequent
urinary tract infections. Herman,
Martinek and Abzug (2014 ) supported
this finding as they mentioned that,
diminished range of motion is identified
in 60% of patients who are treated for
tibial eminence fractures. The most
important risk factors for significant
knee stiffness include prolonged
immobilization. Rachel, Judith, David,
Timothy and Travis (2011 ) who
concluded that, spica cast treatment are
associated
with
numerous
skin
complications.
Regarding
the
effect
of
postoperative
immobility
in
psychological wellbeing of the studied
children the current study revealed that,
most of children had reduced
independence and felt frustration and
helplessness. Almost of children of
children increased tension, acting out,
felt guilt, protest and anger. The vast
majority of children altered self image.
Children had magical thinking might
make them felt that it was their fault
they got hurt and created a sense of loss.
Children decreased self esteem and
increased anxiety. The effect of
immobility on studied children on social
wellbeing that, almost of children
altered in level of activity. Most of
studied
children
diminished
environmental stimuli. The majority of
studied children had frightened facial
expressions and excessive clinging with
caregivers and fear of being separated
from parents, crying and screaming and
others effects of immobility appeared on
children psychosocially in the current
study. On the same line Benaroch and
Nolet (2011 ) who concluded that,
psychosocial impacts of immobility
alters self-image, feeling helpless,
interrupts social development and
interrupts education process. Child had
difficult return today care/school and
decreases socialization with others.
Child wants to decreases socialization
with others. Child wants to maintain
autonomy and mobility maintain
autonomy and mobility.
Regarding to the effects of
postoperative on immobilized child with
MSDs on the family in the current study
revealed that, the majority of families
the immobilized child affected them as
majority of the studied children diverted
attention from other aspects of family
functioning. The majority of the studied
children felt guilt, blame, or reduced
self-esteem and felt disappointment and
powerlessness. Most of families of
families fear of the unknown more than
they fear the known. The majority of
families felt confusion. These results are
supported by Benaroch and Nolet
(2011 ) who showed that, burden of care
to family and community and affects
parents work schedule. The treatment
also interrupted family routine and work
routine.
Conclusion
Based on the results of the current
study, it can be concluded that:
According to the result of the
current study, it was concluded that, the
main cause of MSDs was congenital
disorders. Children aged from 3-6 years
and did a series of surgical treatment.
Children stayed in cast for at least one
month. So the effects of postoperative
immobility had negative effects on
physical and psychosocial status of the
children and their families than
preoperative status.
Recommendation
Based on the findings of the current
study, the following recommendations
are suggested:
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- Comprehensive nursing care
-A multidisciplinary team consisting
program
for
children
with
of pediatric orthopedist, play
immobilization is very important in
therapist, pediatric nurses and social
both pre and postoperative periods
workers should be involved in
to minimize the effects of
teaching and helping the mothers
immobility on children and their
and their children to prevent the
families
physically
and
effects of immobility.
psychosocially.
- Further researches are needed to
-Designing
a
simple
Arabic
evaluate the effect of immobility on
illustrated booklet about care of cast
children using large scale sample
and immobilized child at home
study should be assess children and
-Educational programs for families
their
parents
(physical,
about the effects of immobility and
psychological,
emotional
and
how to prevent it. Health care
informational
providers including nurses to ensure
comprehensive care for parent and
children.
Tables
Table (1) Percentage Distribution of Child socio-demographic Characteristics
(n=100 )
Items
No
Percent (%)
Ages(years):
2-<3
16
16
3-<6
46
46
6-10
38
38
Mean±SD
7.39±4.97
Sex:
Male
Female
Child education:
Did not go to school
Reasons for didn't go to school:
Age of the child
Impact of the disease on the child
56
44
56
44
55
55
16
39
29
71
Child's place of resistance
Urban
Rural
Suburban
48
41
11
48
41
11
Presence of Consanguinity
Positive
Negative
54
46
54
46
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Table (2) Percentage Distribution of Past Medical History (n=100 )
Causes of MSDs
Congenital
65
65
Trauma
21
21
Acquired
14
14
No. of orthopedic surgery:
none
first
second
third
more than third
Period of cast
1month
2month
3months
More than 3months
61
15
8
4
11
61
15
8
4
11
27
46
19
8
27
46
19
8
98
2
98
2
Presence of Complications
Yes
No
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Table (3) Percentage Distribution of the effects of preoperative and
immobility on physical wellbeing in children with MSDs:
Postoperative
Effects of preoperative and Preoperative
postoperative immobility on
X²
Musculoskeletal system: No
%
No.
%
.
-Reduced strength and 30
30
89
89
5.553
coordination of the muscles.
-Loss of joint mobility and 20
20
25
25
75.000
contracture formation.
-Decreased exercises 27
27
96
96
1.541
intolerance.
Gastrointestinal (GIT)
system:
73
73
-Underweight related to 10
10
4.110
poor appetite.
50
50
-Inadequate hydration and 13
13
14.943
nutritional status.
15
15
-Distention caused by poor 13
13
84.674
abdominal muscle tone.
Urinary system
-Urinary Retention (bladder
doesn't empty completely,
decreased muscle tone).
-Urinary tract Infection.
Integumentary system
-Reduced skin turgor
-Ulcers or necrosis.
-Edema on the effected site
p-value
0.018 *
0.000 **
0.214
0.043 *
0.000 **
0.000 **
8
8
26
26
24.749
0.000 **
5
5
17
17
25.697
0.000 **
10
10
8
10
10
8
50
50
20
50
50
20
11.111
11.111
34.783
0.001 **
0.001 **
0.000 **
**Highly significant at p <0.001
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Effect of Postoperative Immobility.
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Table (4) Percentage Distribution of the Effects of Preoperative and Postoperative
immobility on Psychological Wellbeing in Children with MSDs:
Effects of preoperative and
postoperative immobility on
Preoperative
Postoperative
X²
p-value
Psychological wellbeing:
No.
%
No.
%
-Feeling depression.
13
13
23
23
50.025 0.000**
-Suffering from regression
6
6
14
14
39.210 0.000**
-Feeling egocentrism.
8
8
24
24
27.536 0.000**
-Feeling
frustration
and
30
30
92
92
3.727
0.045*
helplessness.
-Sluggish intellectual and
15
15
30
30
41.176 0.000**
psychomotor responses.
-Mood swings and listlessness.
10
10
73
73
4.110
0.043*
-Diminished ability to perform
20
20
84
84
4.762
0.029*
self-care
**Highly significant at p <0.001
Table (5) Percentage Distribution of the effects of preoperative and postoperative
immobility on social wellbeing in children with MSDs:
Effects of preoperative and
postoperative immobility on
Social wellbeing
-Social isolation.
-Altered
perceptions
of
themselves and their environment.
-Being forgotten especially by
peers
and
Distorted
peer
relationships.
-Experience
diminished
environmental stimuli.
-Alteration in level of activity.
-Passive and aggressive verbal and
nonverbal communication.
Preoperative
No.
%
12
12
22
22
X²
P-value
26.471
46.019
0.000**
0.000**
6
6
34
34
12.390
0.000**
13
13
92
92
1.299
0.254
19
2
19
2
97
54
97
54
0.725
1.738
0.394
0.187
**Highly significant at p <0.001
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Postoperative
No.
%
34
34
38
38
Effect of Postoperative Immobility.
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Table (6) Percentage Distribution of the effects of preoperative and postoperative
immobilized child with MSDs on the family wellbeing:
Effects of preoperative and
postoperative immobilized child with
Preoperative
Postoperative
MSDs
X²
P-value
On family wellbeing
No.
%
No.
%
-Increased family members' awareness
40
40
94
94
4.255
0.039 *
of their inner strength and enhance
family cohesion.
-Encouraged
connections
to
10
10
26
26
31.624 0.000 **
community groups or religious
institutions.
36
36
83
83
11.521 0.001 **
-Wasted of the time and financial costs
of the family.
35
35
89
89
6.655
0.010 *
-Altered in coping abilities of the
family.
49
49
96
96
4.003
0.045 *
-Increase stress in the family.
26
26
61
61
22.463 0.000 **
-Difficult to find appropriate and
affordable child care.
18
18
31
31
48.859 0.000 **
-Affect decisions about work,
education/training, having additional
children.
36
36
92
92
4.891
0.027 *
-Fear of the unknown more than they
fear the known.
30
30
85
85
7.563 0.006 **
-Feeling of Confusion.
31
31
82
82
9.862 0.002 **
-Support from their families
41
41
87
87
10.384 0.001 **
-Feeling guilt, blame, or reduced selfesteem.
**Highly significant at p <0.001
184
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Hill.L. (2012 ): Pediatric Orthopedic
Surgery.
Available
at:
www.lenoxhillhospital.org , accessed
at2/5/2013 .
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Nursing.9ed. Mosby Co .Canda. PP
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Mobility and Immobility. Available at:
www.atitesting.com.(pdf) , accessed
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Beyond the decade: strategic priorities
to reduce the burden of musculoskeletal
disease.
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Gunz,A.C., Canizares.M., & MacKay.C.
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(population-based
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Jones,L.(2014).The immobilized child.
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Cast
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immobilization:
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Manière, D.1. (2012 ). Complications of
immobility and bed rest, Prevention and
management. (Rainfray ,M., Dehail,
P.,& Salles, N., 2007 ). Available at:
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accessed at25/5/2015 .
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Dysplasia of the Hip. Available at:
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,
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Herman,M.J.,
Martinek,M.A.
and
Abzug,J.M. (2014 ). Complications of
Tibial Eminence and Diaphyseal
Fractures in Children: Prevention and
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at 12/5/2015 .
Marwah,S.,
Gupta,M.,&
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Kaur,H.
Goraya,S.(2014 ).
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malformations and their possible risk
factors in a teaching hospital in Punjab.
Volume 4, Issue 1( pp. 1-291 ).
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at:
www.scopemed.org,accessed
at8/3/2015 .
Media.D&
Reid.S,(2013 ):
Responsibilities of an Orthopedic PostOp Nurse available at: www.
work.chron.edu, accessed at 13/4/2013 .
Mercer.D, (2013 ).
Dysfunction.
at:www.bhslr.edu,
25/3/2014
Musculoskeletal
Available
accessed
at
Padula, A. M., Tager I.B., Carmichael,
S.L., Hammond, S.K., Lurmann, F.,
Shaw, G.M.(2013 ). The association of
ambient air pollution and traffic
exposures with selected congenital
anomalies in the San Joaquin Valley of
California.
Available
at:
www.ncbi.nlm.nih.gov.,accessed
at
20/2/2013 .
Rachel,D.
Judith,V.,
David,Z.,
Timothy,M., and Travis,M. (2011 ).
Incidence of Skin Complications and
Associated Charges in Children
Treated With Hip Spica Casts for
Femur Fractures. (Journal of Pediatric
Orthopaedics)
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Ricci.T& Kyle.S. (2012). Maternity and
Pediatric Nursing. 2nd
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Lippincott Williams & Wilkins Co. PP
(1453-1490 ).
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(2014 ).
Congenital
anomalies.
Available at: www.who.int, accessed
at1/3/2015 .
186
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Burn patients’ Knowledge Regarding Rehabilitation
*Shimaa M. Farghaly, **Dr. Manal M. Mostafa, ***Dr. Yasmin A.El Fouly.
*Clinical Instructor, Medical Surgical Nursing, Faculty of Nursing Cairo
University, Egypt. **Professor of Medical Surgical Nursing, vice dean of community
affairs and environmental services, Faculty of Nursing Cairo University, Egypt.***
Professor Medical Surgical Nursing, Faculty of Nursing Cairo University, Egypt.
Abstract
Burn is a serious health problem globally. Every year more than 300 000 people die from fires
only. More are killed by burns caused by hot liquids, electricity and chemicals. In addition, millions of
people are disabled and disfigured by severe burns. Survivors of burns often lead to a life complicated not
only by the physical consequences of the burns, but also by stigma and discrimination related to the
disability and disfigurement. This large burden of death and suffering is all that much more tragic as it is so
preventable (WHO, 2008).
The aim of the current study is to assess burn patients' knowledge regarding rehabilitation and
formulate the proposed guidelines for rehabilitation. A descriptive/exploratory research design was utilized
to achieve the purpose of this study. It is used to observe, describe, and document the frequency of
occurrence of behavioral aspects for burn patients‘ knowledge regarding rehabilitation (Polit & Beck,
2004). A convenience sample of 176fully conscious adult male and female burn patients diagnosed with ≥
25% TBSA admitted to the burn unit was recruited in the current study .The current study was conducted in
the burn unit at El Kasr El Ainy hospital one of the governmental university hospitals. Tool used to collect
the pertaining data are Socio demographic data sheet and Burn Patients' knowledge questionnaire Sheet
through face to face interview with patients. The main results were the majority (56.8%) of the sample who
had satisfactory total knowledge about burns. The majority of the sample had high level of knowledge
regarding causes of burns, avoiding complications, prevention, and treatment (77.%, 80.1%, 84%, and
76.6% respectively). A significant correlation between educational level, burn area and age and knowledge
score was found at p˂0.05. The study concluded that most of the studied sample had satisfied knowledge
about burn rehabilitation. The study recommended that developing a comprehensive treatment and
rehabilitation program, nurses who work at burn units should effectively utilize their role as educators and
counselors to contribute in the prevention burns complications.
Key words: Burn, Rehabilitation.
consequences of the burns, but also by
stigma and discrimination related to the
disability and disfigurement. This large
burden of death and suffering is all that
much more tragic as it is so preventable
(WHO, 2008 ).
Burn is a type of injury to flesh
or skin caused by heat, electricity,
chemicals, or radiation (Herndon,
2012). Disruption of the skin can lead to
increased
fluid
loss,
infection,
hypothermia, scarring, compromised
immunity, and changes in function,
appearance, and body image. Burn that
does not exceed 25% total body surface
area (TBSA) produces a primarily local
response. Burn that exceeds 25% TBSA
may produce both a local and a systemic
Introduction
An estimated 195 000 deaths
every year are caused by burns. Nonfatal burn injuries are a leading cause of
morbidity. In Bangladesh, Colombia,
Egypt and Pakistan, 17% of patients
with burns have a temporary disability
and 18% have a permanent disability
(WHO, 2012 ). Burn is a serious health
problem globally. Every year more than
300 000 people die from fires only.
More are killed by burns caused by hot
liquids, electricity and chemicals. In
addition, millions of people are disabled
and disfigured by severe burns.
Survivors of burns often lead to a life
complicated not only by the physical
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response and are considered major burn
injuries (Smeltzer, et al., 2011).
Significant of the study:
It has been observed over the last
5 years, an increasing in the incidence
of burn, as the number of patients
admission was increased to several burn
units among one of Egyptian
universities and governmental hospitals.
A mean length of hospital stay was 36
days ranging between 11-61 days
among 340 to 543 burned patients,
yearly, from 2008 to 2012 (statistical
and medical records department at ElManial University Hospital, 2013 ).
Moreover, the statistical records at
Central Agency for Public Mobilization
and Statistics in Egypt (2013) revealed
that up to 11697 burn patients in
governmental Egyptian hospitals were
increasing over the last few years, 2008
to 2011. It was observed from clinical
experience
that
burn
patients'
knowledge about rehabilitation was not
efficient .This may lead to increased
incidence of complications which is
interfering with patient's ability to
perform activities of daily living.
The Aim of the study:
The aim of the current study is to
assess burn patients' knowledge
regarding rehabilitation and formulate
proposed guidelines for rehabilitation.
Research Question: What is the level
of knowledge regarding rehabilitation
among burn patients?
MATERIALS AND METHODS
Study design: A descriptive/exploratory
research design was utilized in this
study.
Sample:
A convenience sample of
176fully conscious adult male and
female burn patients diagnosed with ≥
25% TBSA admitted to the burn unit
(total body surface area).
Inclusion criteria: Age of patients is
more than 18 years old and the
Diagnosis was Burn injuries>25%
TBSA.
Setting of the study:
The current study was conducted
in the burn unit at El Kasr El Ainy
hospital one of the governmental
university hospitals.
Tools
After reviewing the literature
and related scientific researches, the
investigator developed the tools of the
present study. Data of this study were
collected through scheduled interview
questionnaire sheets. It‘s divided into
two main tools:
Tool 1- Socio-demographic and medical
questionnaire sheet:
 Socio-demographic
questionnaire sheet: Data
covered variables related
to code number, ward
number, age, gender,
level
of
education,
occupation,
marital
status……etc.
 Medical
questionnaire
sheet:
Data covered variables
related
to
patient's
diagnosis,
medical
history, past surgical
history, smoking history,
family history,..….etc.
Tool 2 -Burn Patients' knowledge
questionnaire Sheet:
This sheet was used to evaluate
patient‘s knowledge about : (1) General
information about burn injuries e.g.;
definition, cause of injury, symptoms,
causes that lead to complications,…..etc.
(2) Importance of compliance to
treatment approaches and hospital
follow up. (3) Knowledge about
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rehabilitation including: aims of
rehabilitation, duration of each phase of
the rehabilitation, follow up ….etc.
Scoring system Knowledge was
assessed by scoring system through
marks distribution as follows: 1- general
information about burn injuries, as one
mark for each truly answered sub
statement (27 marks). 2- Importance of
compliance to treatment approaches and
hospital follow up, one mark for each
truly answered sub statement (9 marks).
3- Knowledge about rehabilitation, one
mark for each truly answered sub
statement (16 marks), Hence, the total
sum of all marks was 52. The scoring of
knowledge categorized as:
 < 26 = poor
 ≥ 26- 34 = fair
 ≥34 = good
 ≥39- 52 = very good
Validity and Reliability:
Content Validity was reviewed
and determined by panel of five experts
in the field of Medical Surgical Nursing
specialty, Faculty of Nursing Cairo
University.
Internal
consistency
reliability was assessed in the present
study and evaluated whether all items on
an instrument measure the same variable
and internal consistency reliability
tested and retested via Cronbach's Alpha
to indicate how well the items in an
instrument fit together conceptually.
Internal consistency reliability for the
revised tool 1 (24 items) using
Cronbach‘s alpha was 0.55 and revised
tool 2 (30 items) with Cronbach's Alpha
was 0.65.
and its importance. The investigator
emphasized that participation in the
study was entirely voluntary; anonymity
and confidentiality were assured through
coding the data. Written consent was
taken from patients who accept to be
included in the study.
Procedure:
Once official Permission was
granted to proceed with the proposed
study, the study sample of burn patients
who were diagnosed with burn injuries
25% TBSA or more was interviewed
individually face to face to explain the
nature and purpose of the current study.
The
investigator
confirmed
confidentiality of data which was
collected from patients, and to be used
only for scientific research. The
researcher collected data over three
consecutive days per week. Before that
the investigator obtained a written
consent from the patients or relatives of
patients with burned hands that were
willing to participate in the study,
questionnaires were distributed over
patients who met criteria of the present
study. Time taken to fill out each
questionnaire was around 15-25
minutes. As regard illiterate patients, the
questions were read by the investigator,
and then exact patients‘ responses were
recorded on the questionnaire sheet.
Time taken to fill out questionnaire
sheet for illiterate patients was 20-30
minutes starting by Socio demographic
data followed by Burn Patients'
knowledge questionnaire Sheet.
Statistical Design:
Obtained data were tabulated
and analyzed using statistical package
for social sciences (SPSS) program
version 20. Relevant statistical analysis
was done to test the obtained data.
Descriptive and inferential statistics
were performed such as mean and
Ethical consideration:
Initial permission to conduct the
study was obtained from research ethics
committee of Faculty of Nursing Cairo
University. Also, each patient was
informed about the purpose of the study
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standard
deviation;
frequency;
percentage and correlation coefficient.
The level of significance was considered
at the 5% level (P = 0.05).
high level of knowledge regarding
causes of burns, avoiding complications,
prevention, and treatment (77.3%,
80.1%,
84.1%,
and
76.6%,
respectively). As regards knowledge
related to burn grades and first aid of
burns almost half of the sample had fair
level of knowledge (61.4%, and 58.0%,
respectively).Less than half of sample
with satisfactory knowledge about burn
complications
and
rehabilitation
(30.1%, and 40.9 %).
Figure (14 - 15) Management
and complications of burn injury
showed that (93.2%) of the study
sample had no concomitant problems.
Figure 13 showed that half of the study
sample (50%) had complications, while
more than half of them (72.7%) had
graft in thighs. A mean duration of
hospital stay (3.8 ± 4.2) represented
more than half of the sample (54.0%)
ranging between 2 - 6 days.
Figure 16 showed that more than
half of the sample (79.0%) was
dependent to perform daily life activities
(DLA),
while
(43.8%)
were
independent practicing walking activity.
and only less than quarter of the sample
were able to perform clothing, religious
tasks, feeding, and toilet activities (2.8%
, 10.8%, 17.6%, and 29.5%,
respectively) .
Table 1 showed that more than
half of the study sample (58%) had
second degree of burns. a mean burn
area of (34.9 ± 1.1). More than half of
study sample (58.5%) had burn area
more than 25% TBSA falling between
25.5 – 98.0 TBSA (Total body surface
area).
Table 2 showed that more than
half (56.8%) of the sample had
satisfactory total knowledge about
burns. The majority of the sample had
high level of knowledge regarding
Results
Figures (1 - 7) showed that
(59.1%) of the sample was male falling
between the age of 18.0 – 80.0 years
old, living in urban area (56.3 %), they
were married (55.7%), living with
family (90.3%). As regards educational
level of the sample, the percentage was
among diploma level, then illiterate and
preparatory (23.3%, 21.6% and 21.0%,
respectively). Regarding job status,
(50.6%) of the sample was unemployed.
Figures (8 - 10) showed that
more than half of the sample (76.1%)
has no chronic diseases; they were
nonsmokers (62.5%). More than three
quarters of the sample (97.7%) had care
givers, more than of study sample
(62.2%) the siblings were the care
givers. Less than half of the study
sample (22.2%) had history of previous
surgery. Less than half of the study
sample (2.3%) had previous burns and
history of allergy was (3.4%) of the
study sample.
Figures (11 - 12) showed more
than three quarters of the sample
(91.5%) had incidence of burn
accidently. Flame was the most cause of
burn (67.6%) of the study sample. More
than half of the study sample (58%) had
second degree of burns with a mean
burn area of (34.9 ± 1.1). More than
half of study sample (58.5%) had burn
area more than 25% TBSA falling
between 25.5 – 98.0 TBSA (Total body
surface area).
Figures13 showed that more
than half (56.8%) of the sample had
satisfactory total knowledge about
burns. The majority of the sample had
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causes of burns, avoiding complications,
prevention, and treatment (77.3%,
80.1%,
84.1%,
and
76.6%,
respectively). As regards knowledge
related to burn grades and first aid of
burns almost half of the sample had fair
level of knowledge (61.4%, and 58.0%,
respectively).Less than half of sample
with satisfactory knowledge about burn
complications
and
rehabilitation
(30.1%, and 40.9 %).
Table 3 showed that there was
highly significant statistical relationship
between age and knowledge of general
information
about
burn
and
rehabilitation after burn injuries. While
highly significant statistical relationship
between level of education and
knowledge about burns and there was
highly significant statistical relationship
between
residence
and
patient
knowledge about burns as p≤ 0.05.
There is no significant statistical
correlation between performance of
daily living and knowledge score. Qui
square test showed that relationship
between age, educational level and
residence at (p ≤0.03, p ≤ 0.001 and p
≤0.003 respectively).
DISCUSSION
The present study aimed to
assess burn patients‘ knowledge
regarding rehabilitation. Ddiscussion
will focus upon findings the level of
burn patients‘ knowledge regarding
rehabilitation.
Regarding
sociodemographic data, In agreement with
Mohamed (2010 ) who found that the
majority of ages ranged between (1830) years old and minority was found in
age between (18 to 30) years old, as
well as Mohamed (2014 ) reported that
more than one third of her study sample
had age less than thirty years old which
constituted the highest percentage of
total sample. The findings of the current
study were also accepted by Abd ElMonaem (2002 ) who reported that the
highest percent of burn victims were
found among adults‘ patients. Therefore,
Timby (2011) recommended that,
because
many
adults
become
complacent about safety hazards, should
be raise awareness in schools, mosques,
and other work places to teach people
how to prevent burn and how to do first
aid. Mean age of the present study was
33.9± 13.0 ranging from 18-80 years
old. Most of burn patients were less than
30 years old, which were in the most
productive period of their life. This
result may be explained by the fact that
adults are generally active and therefore
they are exposed to hazardous situations
at both work and home. While
congruent with Chien, et al. (2008) who
indicated that age of patients was
ranging between 32 - 40years old.
In agreement with Hassan
(2008 ) who stated that the majority of
patients were male exposed to
occupational hazards. Also, Black,
(2009 ) agreed that adults with burn
injuries are more likely to be male and
in the 20to 40 age group. The study
results revealed that the more than half
of the study sample was male. This
could be due to as an Egyptian culture
male are responsible for earning life.
Therefore they are more exposed to
hazards.
On the other hand, this finding
disagrees with Ahmed (2011 ) who
stated that higher ratio of female burn
patients was more than male. Results in
this study indicated that women were at
high risk of burn injury. This could be
explained in the light of their primary
responsibility of caring for all family
members. In addition, Attia et al.,
(2001 ) explained that female do most of
domestic activities. On the same line,
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Mazezewa et al, (2010 ) explained that
women lead traditionally to cooking as
they were burn during the usual times of
preparing meals.
The study results show that more
than half of the studied sample was
married, and the majority of them have
low level of education, these findings
agreed with Abd El-Monaem (2002 )
findings who reported that the highest
percent of burn victims were married
and the majority of them were illiterate
and Chien et al, (2003 ) mentioned that
most of the patients, married and had
low level of education. This may
indicate that marriage problems may
lead to burn injury either by suicide
ideas or loss of concentration when
contacting with dangerous items as a
result of increasing workload. While the
results contradicted with Mohamed
(2010 ) results who found that the most
of the sample were single, with
agreement that the highest percent of
burn victims‘ level of education were
secondary school. This could be
attributed to the fact that lack of
education and safety precautions‘
knowledge can make people at more
risk to be exposed to burn injuries.
The study results showed that
majority of studied group was living in
urban areas this because nowadays
patients of rural areas were admitted to
new hospitals near their residence. In
congruent with Mohamed (2010),
Ahmed (2011 ), and Abd El-Monaem
(2002 ) they reported that the majority of
patients were living in rural areas. In
agreement with Mohamed (2010 ), Ying
(2010 ) and Abd El-Monaem (2002)
who reported that the highest percentage
of burn victims was not working. The
majority of the present study sample
was unemployed and living with
families because of lack of job
opportunities and high level of job
requirements. This later findings came
to similar results reported by Hemeda,
Maher, and Mabrouk (2003 ). On other
hand, Ebrahim (2009 ), and Elsherbiny
(2010 ), disagreed with the previous
findings whose patients in their studies
indicated that they were employed.
These results were supported by Abd ElHamid (2009 ), who found that the
majority of patients with burn injury
were workers.
Regarding
burn
associated
injuries and chronic diseases. These
results were confirmed with Mohamed
(2010 ) and Abd El- Moneam (2002),
who reported that minor percent of their
studied sample had associated injury,
whereas 1.6% had fractures. Although
Brandt, et al. (2002 ) commented that
fractures are the most frequent
associated injury with burn, the study
also showed that the highest percentage
of the studied sample had no associated
chronic diseases. Results of current
study were congruent with Mabrouk
(2003 ) in one reason as he reported that
most of the patients who were present
with burns suffering from chronic
illness
(diabetes
mellitus
and
cardiovascular disorders) that had long
been neglected.
The study results revealed that
the highest percentage of burn
complication, mainly infection, among
studied sample was half of the study
sample with concerning non-invasive
and invasive signs of infection mainly
local and systemic signs, as hotness,
tenderness, swelling, purulent exudates
and conservation of the wound from
partial- thickness to full- thickness. This
could be explained by auto infection and
from environment contamination which
include linen, bed, other patients or
visitors and also from hospital staff
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during dealing with patients, could not
use the aseptic techniques observed by
researcher during collection of the data.
This result is in agreement with
Mohamed (2010), Attia (2002) and
Mohamed (2004 ) in their research
findings who indicated that the presence
of infection is common in burn injury.
This consistent with Smelter et al,
(2011 ) who‘s emphasized that the
incidence of nosocomial infection in
burn injuries is higher than most other
patients. Also, agree with Hassan
(2008 ) who found that infection is
circulating in the burn unit and this was
consistent with Phipps (2003 ) who
mentioned that recently most invasive
burn wound infection are gram negative
organisms.
Mabrouk (2003) stated that
according to treatment policy at our
burn unit, early excision and grafting
performed on patients who were not
suffering from chronic diseases. As
noted, there were very few such cases
(10.3%) similarly to present study
grafting less than quarter of the study
sample had grafting. Thus, concurrent
with Kim and Luce (1998), that
although the standard early excision and
grafting protocol is successful for
managing patients with extensive burns.
On the other hand, the results congruent
with results of Mohamed (2010), Abd
El- Moneam (2002 ) and Attia etal,
(2002 ) mentioned that the majority of
their studied sample had wound
infection, and need for skin grafting.
Anyway, it was postulated that one of
the important roles of nursing
management of burn patient after
grafting is daily inspection. Daily
inspection is essential to detect early
signs of infection, while shortage of
nurses stand an obstacle for grafting.
Considering the types of burn
injury in the present study the most
common source is flame followed by
scald (boiled water). This can be
justified as the majority of patients were
burned by gas explosion and gasoline
flame. This may be due to unsupervised
and carless handling of gas pipes
without
safety
features
and
malfunctioning kerosene pressure stove
during cooking. Results were in
agreement with Mohamed (2012) who
reported that the majority of study
sample had direct fire flame. On the
same line, many researchers‘ findings
for Afify (2012 ), Fathy (2010 ),
Mohamed (2010 ) and Aherns (2007 )
reported that thermal burn was the most
common cause of burn injury. On the
contrary, their studies revealed that
chemical was the common cause of burn
as the majority of their patients who
were employed in chemical industry.
Hence it could be deduced that subject
cause and type of burn were very much
influenced
by
the
surrounding
environments.
The current study revealed that
the majority of the study sample
reported that their burn injury was
accidental. On the same line, Mohamed
(2014 ), Mohamed (2010) and Ahmed
(2011 ) reported that the major causative
agent of burn injuries in her studied
sample was flame and majority of
pattern of burn injury was accidental
burn. In addition, Kypri, et al. (2011)
found that culture supports these results
and socioeconomic factors, such as
housing, heating and cooking traditions
influence the pattern of burn injury.
According to American burn association
(2008 ), more than2.5 million people in
United States experience accidental,
thermal injury each year. Lemone; and
Burke (2008), Smeltzer, etal. (2011 )
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found that the major causative agent of
burn injuries in studied sample was
flame and the majority of pattern of
burn injury was accidental burn. In
addition Black, and Hawks (2009)
reported that the contact with fire
(flame) occurs in more than 60%
accidental injuries. Structural fires
account approximately 5% of burnrelated admissions. This also accepted
by Mohamed (2010 ) who mentioned
that the high percentage of mode of
injuries were accidental in both sexes.
The results of the current study
reported that more than half of the study
sample had satisfactory level of total
knowledge about burns as the majority
of the patients were familiar with the
prevention, causes and avoiding
complications of burns, as well as more
than half of the patients were acquainted
with burn grades,
first aid , and
treatment of burn. While less than half
of the patient were not aware of
rehabilitation and burn complication,
from the researcher point of view, this
could return to the patient‘s specific
knowledge about the treatment that
would prevent complication of burns
like infection but they didn‘t know the
specific complications got from burn
injuries on body systems . This result in
agreement with Mohamed (2014) who
found high significant relation in
knowledge scores among burn patients
regarding infection control. Pavoni et al.
(2010 ) mentioned that malnutrition, and
decreased protein intake, altered fluid
and electrolytes, and immobility that
affect contractures occur and delay of
wound healing process. In the present
findings there was no significant
relation between the degree of burn and
patients‘ knowledge about burn .patients
with less severe burn may suffer an
equally serious negative physical and
psychological impact because they
didn‘t experience a near loss of life. In
addition patients with second –degree
burns more quickly discharged from
burn unit with plan for daily visits to the
outpatient‘s burn clinic to receive
dressing changes, physical therapy, and
an evaluation of the burn wound and
pain control. Patients with third degree
burns who reported higher functioning
at the time of first orientation may have
had little pain present, a situation that
could even support denial of injury
(Mohamed 2010,; Remond, et al. 2008 ).
The majority of the study sample
was dependent in performance of daily
life activities and they had caregiver, as
indicated from the result most of them
were the patients‘ siblings. However
this could be due to two reasons, the
first one in our culture in Egypt people
always need for psychological support
when injuries happened and only few
percentage of the study sample had
experience of hospitalization for having
history of previous surgery or previous
burn injuries, from my observation the
other reason was the pain and anxiety of
burned patients thus required relatives to
assist the patients in performing daily
life. The results of the present study was
in agreement with Pavoni, et al. (2010 )
who found that in severe burn patients,
the injury mostly had difficulties
carrying out every day activities and
suffered from pain and anxiety.
In the present findings there was
no significant relation between the
degree of burn and patients‘ knowledge
about burns .patients with less severe
burn may suffer an equally serious
negative physical and psychological
impact because they did not experience
a near loss of life. In addition, patients
with second –degree burns more quickly
discharged from burn unit with plan for
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daily visits to the outpatient‘s burn
clinic to receive dressing changes,
physical therapy, and an evaluation of
the burn wound and pain control.
Patients with third degree burns who
reported higher functioning at the time
of first orientation may have had little
pain present, a situation that could even
support denial of injury. (Mohamed
2010, Remond, et al. 2008 and Abd El
–Moneam,( 2002 ).
The present study showed no
significant relation between types of
burn and patients‘ knowledge. However,
the patient with fire burn had the lowest
physical function. This result was in
agreement with Mohamed (2010) and
Hojat (2008 ) whereas no significant
relation appeared between the types of
burn and physical, psychological and
social functioning. They commented
that flame burn causes the most severe
burns as it leads to more extent and
depth, while scald burns may be
superficial or deep in a limited area. On
the other hand, the current study showed
that there is significant relation between
TBSA and patients‘ knowledge about
burns.
Current study found that
significant relation between age, level of
education and residence with patients‘
knowledge about burn this could explain
the nature and culture of Egyptian
people where the urban areas has raising
level of awareness. These results
confirmed with Dauber et al (2009),
who confirmed that there was
significant relation between patients‘
knowledge with level of education. This
result showed disagreement with
Watson, et al. (2005 ), that there was no
significant relation between residence
and patients‘ knowledge about first aid
of burns. There was no significant
relation between gender and marital
status of patients in the studied group
and their knowledge about burns. This
result confirmed with Mohamed (2010),
who reported that there was no
significant relation between patient
gender and marital status with patients‘
physical
and
psychological
rehabilitation after burn injuries.
Conclusion:
Based on results of the present
study, it was concluded that most of the
studied sample had satisfied knowledge
about burn.
Recommendations
The study recommended that
developing a comprehensive treatment
and rehabilitation program, nurses who
work at burn units should effectively
utilize their role as educators and
counselors to contribute in the
prevention of burns complications.
More studies need to be conducted to
assess and compare between the impact
of injuries and different types of illness
or different handicap.
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Figure (1)
Figure (2)
Gender
Age
32%
41%
43%
59%
25%
Male
Female
less than 30
Figure (3)
30- 40
more than 40
Figure (4)
Educational level
marital status
3% 7%
27%
25%
34%
4%
12%
56%
single
married
divorced
widow
Figure (5)
job
2% 1%
6%
8%
illirrate
read and write
primary
preperatory
secondary
diploma
Figure (6)
live
24%
Figure (7)
residence
8%
44%
41
%
91%
alone
with family
with relatives
with friends
56%
unemployed
worker
employed
196
July 2015
51
%
urban
rural
Burn patients‘ Knowledge.
Figure (8)
care giver
2%
enj@nursing.cu.edu.eg
Figure (9)
Figure (10 )
smoking
3%
chronic
illenss
34%
98
%
yes
24%
76%
63%
current
none
Figure (11 )
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July 2015
yes
no
Burn patients‘ Knowledge.
enj@nursing.cu.edu.eg
Figure (12 )
Figure (13 )
Figure (14 )
Total satisfactory
knowlegde about
burn
concomitant
problems
Figure (15 )
graft sites
7%
34%
43%
57%
93%
satisfactory
yes
198
July 2015
no
66%
arms
thight
Burn patients‘ Knowledge.
enj@nursing.cu.edu.eg
Figure 16
Table 1 burn injuries characteristics of patients in the study sample (N=176 )
Characteristics
Burn grade
2
3
Burn area (%):
25
>25
Range
Mean ±SD
Median
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July 2015
frequency
Percentage
102
74
58.0
42.0
73
103
25.0-98.0
34.9±1.1
30.0
41.5
58.5
Burn patients‘ Knowledge.
enj@nursing.cu.edu.eg
Table 2: knowledge about burns among patients in the study sample (N=176 )
Satisfactory knowledge (50%+) of:
Burn grades
Causes of burn
Complication of burns
Avoiding complications
Prevention
First aid
Treatment
Rehabilitation
Total knowledge
Satisfactory
Un satisfactory
frequency
108
106
53
141
148
102
135
72
Percent
61.4
77.3
30.1
80.1
84.1
58.0
76.7
40.9
100
76
56.8
43.2
Table 3 Correlation between patients’ knowledge score and their personal and burn
characteristics
Knowledge score
Sperman‘s rank
p-value
correlation coeffiecient
-.188*
0.012
.350**
0.000
0.01
0.912
-.165*
0.029
0.08
0.278
0.09
0.243
Age
Education level
Burn degree
Burn area
Hospital stay
Score of daily life activities
4- Association of Rehabilitation Nurses
(2008 ).
Rehabilitation
Nursing
Criteria for Determination and
Documentation of Medical Necessity
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5- Ahrens T.S., Prentic D. and kleinpell
R.M.(2007): Critical care nursing
certification. Burns, 5 th edition,
Megraw-hill, New York, p: 617.
6- Abd El Hamid A. (2009 ):
conventional occlusive dressing
versus polythene gloving on second
degree burned hands. Unpublished
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Effect of Phototherapy on Accuracy.
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Effect of Phototherapy on Accuracy of Measuring Transcutaneous Bilirubin (Tcb)
Level in the Neonates with Hyperbilirubinemia
By
*Samar Mahmoud El-Hadary, ** SoheirAbdelhamidDabash, *** ShadiaRiadElGendy.
* Clinical Instructor of Pediatric Nursing, Faculty of Nursing, Cairo
University.
** Assistant Professor of Pediatric Nursing, Faculty of Nursing, Cairo University.
*** Assistant Professor of Pediatric Nursing, Faculty of Nursing, Cairo University.
Abstract
Hyperbilirubinemia is an important problem in the neonatal period. It is a cause of concern for nurses and
physician and a source of anxiety for the parents. High bilirubin level may be toxic to the developing
central nervous system and may cause neurological impairment even in term neonates. The gold standard
for bilirubin measurement is total serum bilirubin (TSB). Transcutaneous bilirubinometry (TcB) is an
alternative to TSB that has been validated for clinical use through extensive study. TcB provides many
advantages over TSB including instantaneous measurements without requiring a painful lab draw. TcB can
reliably identify neonates at risk for severe hyperbilirubinemia and can decrease the number of TSB
measurements obtained. However, pediatric care providers should be aware of limitations in clinical use of
TcB such as limited research regarding its use during phototherapy.The aim of the current study was to
assess the effects of phototherapy on accuracy of measuring transcutaneous bilirubin level in the neonates
with hyperbilirubinemia.Descriptive exploratory design was used in the study.The current study was
conducted at the neonatal intensive care unit (NICU) in Elmonira pediatric hospital of Cairo University.A
purposeful sample of 100 neonates, who admitted to (NICU), diagnosed with hyperbilirubinemia, data
were collected using the neonatal medical records and transcutaneous bilirubin measurement were done for
twosuccessful times for every neonate in subsequent two days during the routine times of measuring TSB
according to the unit's policy. The study results revealed that, more than half of neonates (sixty percent)
were males. The majority of neonates‘ age (eighty two percent) ranged from one to seven days. Most of
neonates (ninety seven percent) had unconjugated hyperbilirubinemia. There was no statistically significant
difference between TcB and TSB measurements before starting phototherapy as well there was no
statistically significant difference between TcB and TSB measurements after phototherapy but there was
statistically significant difference between TcB and TSB measurements during phototherapy.The study
recommended that, using a transcutaneous bilirubin measurements as an accurate estimation for serum
bilirubin levels before and after phototherapy but don‘t use it during phototherapy and apply the research
for larger sample size to generalize the results using photo opaque patches during phototherapy.
Key words: Hyperbilirubinemia, Transcutaneous, phototherapy, Neonates.
enough to get rid of bilirubin in the
bloodstream. In some cases, an
underlying disease may cause NHB.
Most hospitals have a policy of checking
a newborn for hyperbilirubinemia before
discharge. Neonatal jaundice, caused by
hyperbilirubinemia, is frequently seen in
healthy newborns (Wong et al, 2011 ).
Introduction
Hyperbilirubinemia
is
an
abnormally elevated serum bilirubin
level characterized by yellowing of the
skin and other tissues of a newborn
infant
(Hokenberry&Lowdermilk,
2014). It is the most common condition
that requires medical attention in
newborns. It affects 60% of term and
80% of preterm infants in the 1st week
of life (janet&giles 2013).Neonatal
hyperbilirubinemia
usually
occurs
because a baby's liver is not mature
Although Neonatal Jaundice is a
benign self-limiting and fairly common
condition,
severe
neonatal
hyperbilirubinemia
can
lead
to
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Kernicterus and irreversible brain
damage. While the incidence of severe
hyperbilirubinemia has decreased in
developed countries, this is not reflected
in resource limited countries (Leroux&
Rivas, 2013 ). Excessive amounts of
bilirubin build up in the blood stream
and cause brain damage and can result in
death or lifelong illnesses, problems with
vision, hearing difficulties and mental
retardation. This is a very serious
medical condition; it can easily be
prevented with proper medical and
nursing management. When jaundice left
untreated, kernicterus begins to develop,
so the key to prevention is early
diagnosis and quick treatment to control
the level of bilirubin (Anderson, 2012).
led to search for a non-invasive, reliable
technique for estimation of TSB. A large
number of studies have demonstrated the
possibility of prediction of serum
bilirubin in neonates by measuring the
yellowness of the skin in the jaundiced
neonate using transcutaneous bilirubin
(Nagar,
Vandermeer,
Campbell&
Kumar, 2013).
Assessment of the degree of
jaundice is usually done visually, and
if necessary serum bilirubin is
investigated in a blood sample. The
visual assessment is subjective and can
alternatively
be
replaced
by
transcutaneous measurement. The
clinical utility of the TcB is limited to
a
screening
method
for
hyperbilirubinemia, rather than a
replacement for invasive blood
sampling and little is known about the
effect of the actual use of a TcB on the
quality of care. Further evidence is
needed
to
evaluate
whether
transcutaneous bilirubin measurements
improve clinical outcome, shorten
length of stay and reduce costs
(Isala&Jolita, 2012 ).
Most
neonates
with
hyperbilirubinemia are treated with
phototherapy when it is believed that
bilirubin levels could enter the toxic
range (Gomella, 2013). Prophylactic
phototherapy may be indicated in special
circumstances, such as with ELBW
infants or which severely bruised infants,
when TSB is anticipated to increase
rapidly. In hemolytic disease of
newborn, phototherapy is started
immediately while the rise in the
bilirubin level is plotted and during the
wait for exchange transfusion (Cloherty,
Eichenwald, Hansen& Stark, 2014).
Transcutaneous bilirubin offers
several advantages over laboratory
measurements in that it is painless, noninvasive, reduces the risk of skin injury
and infection in the newborn, reduces the
risk of sharps injury to the health care
employee, and is faster than laboratory
measurement (Karon&Wickremasinghe,
2010). TcB are providing instantaneous
information as well as reducing the
likelihood that a clinically significant
TSB will be missed (Maisels, 2010 ).
TcB measurements can significantly
reduce
the
number
of
TSB
measurements needed both in the term
nursery and the NICU; they help to
Management
of
jaundiced
neonates often requires measurement of
total serum bilirubin (TSB) is commonly
determined by spectro-photometric
methods by analyzing plasma or serum
sample. Such techniques require drawing
of blood causing pain and trauma to the
neonate. In addition, there is a wide
range of intra- and inter-laboratory
variability in the performance of the
bilirubin analyzers. These problems have
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estimate the risk of subsequent
hyperbilirubinemia and they are
invaluable in the outpatient setting and
TcB reduces the health care costs
(Cloherty, Eichenwald, Hansen& Stark,
2014).
Transcutaneous
bilirubin
especially through forehead can be used
for screening of icteric neonates and
their follow-up during phototherapy
(Movahedian
2013 ).Although TcB
measurements have been shown to
correlate well with TSB, TcB can be
affected by variety of factors, such as
phototherapy and exposure to sunlight
(Tanja, 2009 ). Its use in Egypt is quite
restricted because it is not available to
most Egyptian pediatricians outside the
capital and is relatively costly to use
(Iskander, 2012).
(National association of neonatal nurse
(NANN), 2010 ).
Significance of the study
Neonatal hyperbilirubinemia
(NHB) is a common disorder
worldwide and one of the important
contributors to the high neonatal
morbidity and mortality in Africa (
Egube, Ofili, Isla&Onakewhor 2013).
Poor access to clinical laboratory
resources and screening programs to
measure plasma bilirubin levels is a
major contributor to delayed treatment
in developing countries, and the cost of
existing
point-of-care
screening
instruments
precludes
their
dissemination (Coda, et al, 2013).
The gold standard to assess
NHB remains the serum bilirubin
measurement. Unfortunately, this is
invasive and painful procedure and
may lead to infection and other
complications with improper technique
(Tanja, Hans& Jean-claude 2009).
TcB measuring can be achieved using
a simple, noninvasive and painless
technique while applying the TcB; so,
the researcher would like to identify
the factors affecting accuracy of
measuring TcB level in the neonates
with hyperbilirubinemia.
Nurses must be vigilant when
caring
for
babies
with
hyperbilirubinemia
by
monitoring
bilirubin levels, identifying infants at
risk
for
developing
severe
hyperbilirubinemia, and implementing
prescribed treatment effectively when
indicated (Watson, 2012 )
Neonatal nurses must be
proactive in the assessment and
management of hyperbilirubinemia in
the newborn, and screening is a key
intervention in the prevention of
neonatal ABE and kernicterus. A top
priority for neonatal nurses is to
provide written and verbal information
about neonatal jaundice so that all
families are educated about this
condition. Neonatal nurses must
continue to take steps to increase
awareness and identify strategies
within their institutions and practices
to enhance the processes of diagnosing
and managing hyperbilirubinemia
Through clinical observation at
NICU in one Pediatric Hospital in
Cairo University, the researcher
observed that neonates with neonatal
hyperbilirubinemia
exposed
to
frequent measuring of serum bilirubin
which may expose them to many
complications. In Egypt the statistics
of
admitted
cases
with
hyperbilirubinemia
in
pediatric
university hospital at the year (2012)
were 1000 cases. For this reason and
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based on the previous disadvantages of
blood sampling the researcher would
like to identify the factors affecting
accuracy of measuring TcB level in the
neonates with hyperbilirubinemia
Description:
n=required sample size
t=confidence level at 95 %( standard
value of 1.96)
p=estimated prevalence of neonates
with hyperbilirubinemia
m=margin of error at 5 % standard
value of (0.050 ).
Aim of the study
The aim of the study was to identify the
factors affecting accuracy of measuring
TcB level in the neonates with
hyperbilirubinemia.
Inclusion criteria:
Neonates
were
selected
according the following criteria:
1. Both genders.
2. Neonates
diagnosed
with
hyperbilirubinemia.
Research question
To fulfill the aim of this study,
the following research question was
formulated:
What is the effect of phototherapy on the
accuracy of TcB results?
Subject and Methods
Research Design
Descriptive exploratory design
was conducted to carry out the current
study.
Setting
The current study was conducted
at the neonatal intensive care unit
(NICU) in Elmonira pediatric hospital of
Cairo University.
Sample
A purposeful sample of 100
neonates with hyperbilirubinemia who
were admitted to (NICU) was included
in the study according to inclusion
criteria.
Determination of sample size
based on the following formula:
T² x p (1-p)
n = -----------------------------------------(M) ²
(1.96)² x 0.01000 (1-0.01000 )
n= ----------------------------------------- = 100
(0.05)²
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July 2015
Exclusion criteria:
1. Neonate with skin diseases or skin
lesions.
Tools of Data Collection
After reviewing the related
literature, data were collected through a
tool designed by the researcher and
revised by five experts to confirm its
validity.
1. Structured interview questionnaire
sheet consisted of two parts:
Part I: It included questions
about characteristics of the newborn
such as gender, gestational age, age in
days at start the study, birth weight,
body weight, and date of admission,
initial diagnosis &personal data and
past obstetric history of mother such as
age, mode of delivery, level of
education, parity, and health status,
TPAL and previous sibling with
hyperbilirubinemia.
Part II: it included questions
about newborn health condition such
as
previous
illness,
previous
admission, reason for admission,
duration of hospitalization.
2. Patients record designed by the
researcher which included: signs
and
symptoms
of
Effect of Phototherapy on Accuracy.
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hyperbilirubinemia, method of
management, site of measuring
TcB level and readings of bilirubin
level
from
measuring
by
transcutaneous
bilirubinometer,
results of total serum bilirubin.
3. Transcutaneous bilirubinmeter: was
used for measuring bilirubin level for
newborn infants.
4. Medical record chart including
readings of serum bilirubin level &
other maternal and Neonatal
laboratory investigations which
include: Rh and blood group for
neonates and their mothers,
neonate‘s hemoglobin, coomb‘s
test and BIND score.
emergency unit in the same hospital after
permission from the hospital assistance
director. Bilirubin level was checked by
TcB from newborn fore head A single
device was used for all measurements in
each
participating
neonate.
All
measurements were performed by the
researcher according to the instructions
of the manufacturer and using the
standard technique at the same time of
taken blood sample for serum bilirubin
which was performed in the clinical
chemistry laboratory of the hospital and
this was done for 2 successive times for
every neonate in subsequent 2 days
during the routine times of measuring
TSB according to the unit's policy and
the researcher recorded the results in
bilirubin result chart.
Data collection procedure
Before conducting the study an
approval was obtained from the
relevant research ethical committee in
the faculty of nursing, Cairo
University. The official permissions
were obtained from the Director of the
Pediatric Hospital and the Head of
Neonatology Unit, up on letters issued
from the Faculty of Nursing, Cairo
University and explaining the nature of
the study was performed. A formal
written consent was obtained from one
of the parents of the neonates who was
admitted to the unit and fulfilling the
inclusion criteria.
Data were collected about the
neonates who fulfill inclusion criteria
who were admitted to the NICU in
Elmonera pediatric hospital Cairo
University between December, 2013 and
Jun, 2014 and questionnaire sheet was
completed through an instructional
interview with one of parents and from
medical
record,
which
contains
demographic data about neonates and
their mothers. The researcher took
transcutaneous bilirubinometerfrom the
Pilot study
The pilot study was done on 10%
of sample size (10 neonates) at the
neonatal intensive care unit at Cairo
University, Pediatric Hospital (CUPH).
The pilot study was conducted to test the
feasibility of the study, applicability of
tools, clarify of sentences and estimate
the time required to collect required data,
ensure that the parent of neonate
understand and accept the items of the
sheets. Unnecessary items were omitted
and new variables needed modifications
were done. Subjects who shared in the
pilot were not included in the study
sample. The time required to fill out the
sheets was 15-20 minutes.
Validity:
The tools were submitted to a
panel of five experts in Pediatric
Nursing and Medicine neonatologist to
confirmtool validity. Modifications on
the tools were done according to the
panel judgment in relation to
appropriateness of the content, and
sequence accuracy of items.
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Reliability:
Reliability of the tools was performed to
confirm consistency of tool and was
calculated statistically. The internal
consistency was measured to identify the
extent to which the items of the tool
measure the same concept and correlate
with each other.Reliability of the study's
tools was done by alpha cronbach test.
two variables was done using student's ttest. Probability (P-value) is the degree
of significance, less than 0.05 was
considered significant. The smaller the
P-value obtained, the more significant is
the result (*), less than 0.001 was
considered highly significant (**).
Results:
Table (1): Showed that more than half of
neonates with hyperbilirubinemia (60%)
were males, while two fifth (40%) were
females. the majority of neonates (86%)
were full term (37 weeks) and the mean
of gestational age was (37.68 ±1.136 ).
The mean admission weight was
(2932.1 ±489.554 gms.), the highest
percentage of body weight (64%) ranged
between 2500 – 3500 gms. The mean
age of these neonates on admission was
(5.47±4.064 days), (82%) of them
ranged between 1 to 7 days. The highest
percentages (79%) were included in the
study between 2 days to 7 days of age. It
also revealed that the majority of
neonates (97%) were diagnosed as
unconjugated hyperbilirubinemia, while
a minority (3%) was diagnosed as
conjugated hyperbilirubinemia.
Table (2) showed that the
majority of neonates (84%) had no
previous illness or previous admission,
while another (16%) of neonates had
previous illness and previous admission.
(10%) of neonates admitted because of
neonatal hyperbilirubinemia, (3%) of
neonates admitted because of transient
tachypnea of newborn, (2%) admitted
because of neonatal convulsion and only
(1%) because of respiratory distress
syndrome.
Table (3): It presented method of
management received by neonates
during hospitalization in 1st and 2nd
transcutaneous measuring of the study, it
revealed
that
treatment
with
Ethical consideration
Acceptance of ethical committee
at faculty of nursing, Cairo University
was gained. All neonates' parents who
participated in the study were informed
about the aim, procedure, benefits, and
nature of the study and the written
consent was obtained by the researcher
from parents. The researcher was
emphasized that participation in the
study is voluntary, and participant can
refuse to participate in the study without
any reason and obtained data only used
for the research purpose. The
confidentiality of information was
assured and the parents had the right to
withdraw from the study at any time
during the study without any effect on
the care provided to their children.
Statistical analysis
Data
were
summarized,
tabulated,
and
presented
using
descriptive statistics in the form of
frequency distribution, percentages,
means and the standard deviations as a
measure of dispersion.
A statistical package for the
social science (SPSS), version (20) was
used for statistical analysis of the data,
as it contains the test of significance
given in standard statistical books.
Numerical data were expressed as mean
and SD. Qualitative data were expressed
as frequency and percentage. For
quantitative data, comparison between
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phototherapy was received in (76%) of
neonates during 1st TcB measuring;
(21%) of them were on single
phototherapy, (21%) were on double
phototherapy, and slightly more than one
third (34%) of neonates were on
intensive phototherapy. Less than one
quarter
(24%)
didn't
receive
st
phototherapy during 1 measuring. In
2nd measuring (35%) of neonates
received single phototherapy, (26%) of
neonates received double phototherapy,
and intensive phototherapy was used in
(8%) of neonates. (31%) of neonates
didn't receive phototherapy in 2nd
measuring.
Table (4), it was evident from
this table that there was no statistically
significant difference between TcB and
TSB measurements before starting
treatment (p = .632) as well there was no
statistically
significant
difference
between TcB and TSB measurements
after treatment (p = .632) but there was
statistically
significant
difference
between 1st and 2 nd TcB and 1st and 2nd
TSB measurements during single
phototherapy (p = .000* ; p= .000*),
during double phototherapy (p = .000* ;
p= .004*) and during intensive
phototherapy (p = .000* ; p= .000*).
(2014 ) in the same field as indicated that
the incidence of hyperbilirubinemia was
higher among males than females, and
also agreed with this finding the study
done by Iskander, Gamaleldin&Kabbani
(2012 ) at Cairo university pediatrics'
hospital (CUPH) which revealed that the
higher incidence was in males.
These findings disagree with
study done by Ragab, (2012) that
showed that there was an equal
incidence of hyperbilirubinemia in both
sexes, while in previous studies in the
CUPH a higher incidence of females was
found (fifty eight percent) compared to
males. (Seoud&Abd El-Latif, 2007 ),
another study done by Salah El-Din
(2012 ) in Ain shams university who
indicated that (fifty one percent) female
neonates and (forty nine percent) males.
Watchko (2010) described that
one of the clinical factors that may be
associated with increased risk of
developing
significant
hyperbilirubinemia; gestational age
ranging from 35-38 weeks. In the
current study the majority of neonates
(eighty six percent) were full term
delivered > thirty seven weeks of
gestation,
while
relatively small
percentages (fourteen percent) were
between thirty four to thirty six weeks.
This was same finding by the study done
at the same setting by Ragab, (2012). In
the study done by Sabry, (2013 )
gestational age of nearly all neonates
was ≥ thirty seven week. While
Elmazzahy (2013), study showed that
the mean gestational age of the
newborns was 37.8+- 0.6 weeks. Sarici
et al., 2004 studied a group of
sixtyjaundiced neonates, in which sixty
two percent for their cases were thirty
fife to thirty eight weeks old
The current study revealed that
mean
admission
weight
was
Discussion:
It is clearly stated by several
authors that male infants are more at risk
for developing severe jaundice than their
female counterparts (Zoubir at al.,
2011). This correlates well with our
findings where more than half of
neonates with hyperbilirubinemia (sixty
percent) were males, while (forty
percent) were females. This also
correlates well with other study done by
Elmazzahy (2013), at the same hospital
as founded that the male to female ratio
1.4 to 1. This also agreed with Sabry
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(2932.1 ±489.554 gms.), the highest
percentage of body weight (sixty four
percent) ranged between >2500 – 3500
gms. The mean body weights during
measuring were (3199.60±2580.360
gms.), in the previous study by Sabry
(2013 ), revealed that mean admission
weight of neonates was (2632.4 ± 822.2
gms. Elmazzahy (2013) reported that on
admission, the mean weight of the
studied neonates was 2.9 kg (± 0.4SD).
The mean age of neonates on
admission in this study was (5.47±4.064
days), eighty two percent of them ranged
between one to seven days. While the
mean age of neonates on admission in
the study by Ragab (2012) was 6.80+
3.17 days which is nearly similar to that
found by Seoud et al., (2007 ) who
reported a mean of age 6.1+ 3.5 days.
In the same fieldSabry (2013 )
revealed that mean age on admission
was (4.56 ± 1.59). Salah El-Din (2012)
revealed that postnatal age ranged from
24 hours to 50 days with a mean of 7.1±
6.3 days.
In our study the mean age of
starting jaundice manifestations was
(2.77±2.224 days) and this was nearly
similar to finding by Elmazzahy (2013)
as the mean age of onset of jaundice was
(2.9 ± 1.35). In a Turkish study by
Bulbul et al., (2011 ) studied neonates
>thirty fife weeks and documented that
the mean age family noticed jaundice
was (2.9 ±1.7). Late presentation of
jaundiced babies to medical care is one
of the main causes of severe
hyperbilirubinemia
in
developing
countries. This late presentation may
related to early discharge from maternity
units (<24h) often with no neonatal
clinic examination prior to discharge, no
evaluation for the risk of developing
jaundice, or any instructions for follow
up, lack of available or affordable
phototherapy and false sense of security
regarding the potential consequences of
severe jaundice by both physicians and
parents.
The current study found that one
tenth of neonates were readmitted
because
of
rebounding
of
hyperbilirubinemia and this may be due
to improper weaning from phototherapy
or early discharge after phototherapy
treatment without follow up.In a study of
Kaplan, Kaplan & Hammerman, 2006
(thirteen percent) neonates developed
significant
rebounding
hyperbilirubinemia. And he was
concluded
that
post‐phototherapy
neonatal bilirubin rebound to clinically
significant levels may occur and in the
study conducted by (Bansal, Jain,
Parmar&Chawla, 2010 ) to determine the
incidence and magnitude of post
phototherapy bilirubin rebound in
neonates. A total of (seven percent)
neonates developed SBR.
The current study revealed that
the majority of neonates (ninety seven
percent) were diagnosed as unconjugated
hyperbilirubinemia and (three percent)
of neonates were diagnosed as
conjugated hyperbilirubinemia, and this
finding was near similar to the study
done by Salah El-Din (2012) included
282 healthy neonates with unconjugated
hyperbilirubinemia (ninety four percent)
and seventeen sick neonates with
conjugated hyperbilirubinemia (fifty
point seven percent).In the study done to
evaluate neonatal jaundice in the Makah
region revealed that the type of jaundice
found at the highest frequency was
physiological jaundice (fifty four
percent) (Alkhotani,
NourEldin,
Zaghloul&Mujahid, 2014 ).
The current study revealed that
treatment with phototherapy was
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received in the majority (seventy six
percent) of neonates. Ragab (2012)
stated that double or triple phototherapy
was used for all neonates as an
emergency measure.
It was evident from this study
that there was no statistically significant
difference between TcB and TSB
measurements
before
starting
phototherapy and after phototherapy, but
there
was
statistical
significant
difference between TcB and TSB
measurements during phototherapy. And
this may be due to the effect of
phototherapy on skin color and there was
no photo opaque patches used on site of
measuring to cover and protect it from
the effect of phototherapylight.Our study
agrees with Cloherty, Eichenwald,
Hansen& Stark, (2014 ) study that stated;
TcB monitoring is unreliable after
phototherapy has begun due to bleaching
of the skin with treatment.After
phototherapy treatment a correlation was
also found between the TcB and TSB
values, but this correlation was less than
before phototherapy. And concluded that
transcutaneous bilirubinometry can be
used for evaluation of bilirubin levels in
both preterm and full-term neonates
receiving phototherapy by using the nonexposed skin of forehead.Initial studies
found no significant correlation between
TcB and TSB after the onset of
phototherapy. However, TcB is still less
reliable within 18 hours after cessation
of phototherapy, even if patches are
used, and the NICE guidelines do not
recommend use of TcB during or postphototherapy
(Zecca,
et
al.,
2009).Grabenhenrich, Grabenhenrich,
Bührer&Berns,(2014 ) stated that TcB
measurements remain a valuable tool
after phototherapy when time-dependent
underestimation of TcB is being
accounted for.Phototherapy, through its
bleaching effect on the skin, precludes
the use of TcB to monitor the progress of
treatment once phototherapy is in
progress
(Janet
&
Giles
2013).Panburana,Boonkasidach&Rearky
ai, (2010) stated that serum bilirubin
measurement to monitor a disease
progression and severity is essential to
perform at prior, during and post
treatment with phototherapy.
Conclusion

Transcutaneous bilirubin is a
useful easy non-invasive tool for
the early detection and close
follows up of neonatal jaundice.
 Transcutaneous bilirubin can be
measured before and after
phototherapy, but it is inaccurate
on babies who have already on
phototherapy. However, TcB
measurements may be accurate
when photo opaque patches are
applied to baby‘s skin.
Recommendations
Based on the findings and the foregoing
conclusion of the current study, the
following
recommendations
are
suggested:
 Initiating a program of bilirubin
screening in a multi-hospital
health system, coupled with
evaluating the results using a
percentile based nomogram.
 Parental education at the time of
birth hospitalization discharge
combined with timely follow-up
to reduce the risk of developing
hazardous hyperbilirubinemia.
 All
neonates
should
be
systematically assessed for risk
of
developing
severe
hyperbilirubinemia
prior
to
hospital discharge.
 All health staff should be
provided
with
basic
and
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

enj@nursing.cu.edu.eg
continuing
education
and
updating of information of TcB.
Measurement of TcB at birth is a
simple way to predict significant
hyperbilirubinemia before early
discharge of mothers from
maternity hospital.
Increase community awareness to
neonatal
jaundice
(causes,
prevention and management) and
introduction of transcutaneous
bilirubin meter device in all
hospitals and primary health care
units and screening of TcB at the
same time of thyroid test at MCH
centers during the first week of
neonate‘s life to detect early high
risk neonates.
Apply the research for larger
sample size to generalize the
results.
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Table (1) Characteristics of neonates involved in the study in percentage distribution
(n=100 )
Items
No.
%
Gender:
 Male
60
60
 Female
40
40
Gestational age
 34-36 weeks
14
14
86
86
 37-42 weeks
Mean ± SD
37.68±1.136
Weight on admission /gms
 1500 – 2500
23
23
 >2500 – 3500
64
64
 >3500
13
13
Mean ± SD
2932.1 ±489.554
Age on admission (days)
 1-7
82
82
 8-14
13
13
 >14
5
5
Mean ± SD
5.47±4.064
Age at starting jaundice manifestations (day):
 First
16
16
 2-7
79
79
 >7
5
5
Mean ± SD
2.77±2.224
Type of HB:
 Unconjugated
97
97
 Conjugated
3
3
Table (2): Neonatal health condition percentage distribution (n=100 ).
Items
No.
%
Previous illness:
 Yes
16
16
 No
84
84
Previous admission:
 Yes
16
16
 No
84
84
Reason for previous admission
(n:16):
10
10
 HB
3
3
 TTN
2
2
 Neonatal convulsion
1
1
 RDS
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Table (3): Types of phototherapy and other management types percentage distribution (n=100 ).








Item
Type of phototherapy during 1st measuring:
Single phototherapy
Double phototherapy
Intensive phototherapy
No
Type of phototherapy during the 2nd
measuring:
Single phototherapy
Double phototherapy
Intensive phototherapy
No
No.
%
21
21
34
24
21
21
34
24
35
26
8
31
35
26
8
31



Item
1st TcB measuring time:
Before treatment
During treatment
After treatment



2nd TcB measuring time:
Before treatment
During treatment
After treatment
No.
%
21
76
3
21
76
3
0
70
30
0
70
30
Table (4): Comparison between 1 st&2 nd TcB and 1 st& 2 nd TSB and timing of measurements
Before treatment
Mean ± SD
1 st TcB
21.829±9.5
1 st TSB
21.952±10.3
nd
2 TcB
2 nd TSB
t–
test
0.486
Single phototherapy
Mean ±
t – test
SD
P
.632
10.348±3.0
12.219±3.5
10.551±2.3
11.871±2.4
P
7.102
.000**
11.287
.000**
Double phototherapy
Mean ± SD
ttest
13.229±3.4
6.927
15.467±3.5
11.650±3.3
3.200
13.092±3.2
During treatment
Intensive phototherapy
Mean ± t – test
SD
P
.000**
.004*
11.218±4.5
21.368±5.8
9.250±5.5
24.000±9.1
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July 2015
After treatment
p
15.642
.000**
7.291
.000**
Mean ± SD
9.000±2.4
8.933±2.1
9.355±3.1
9.539±2.7
t - test
p
0.305
.789
1.464
.153
Effect of Phototherapy on Accuracy.
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Assessment Of Risk Factors.
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Assessment of Risk Factors Contributing To Accidental Poisoning Among Children
Less Than Six Years
Osama Mohamed Elsayed 1*, Gehan Ahmed Elsamman 2, Mahmoud Mohamed Amr 3,
Hewida Ahmed Hussein 4.
1. Demonstrator of Pediatric Nursing, Faculty of Nursing, Cairo University.
2. Professor of Pediatric Nursing, Faculty of Nursing, Cairo University.
3. Prof. of Occupational Medicine, Faculty of Medicine, Cairo University.
4. Assistant Professor of Pediatric Nursing, Faculty of Nursing, Cairo University.
Abstract
Background: Accidental poisoning is one of the important causes of emergency unit admissions
and it is a major cause of morbidity in the developing as well as the developed world. In spite of the
success of some interventions to prevent accidental poisoning in the pediatric population, accidental
poisoning continues to be a common occurrence. Aim of the study: to assess risk factors contributing to
accidental poisoning among children less than six years. Research design: A descriptive exploratory
design was conducted. Sample: convenient sample of 100 caregivers with children less than six years
diagnosed as accidental poisoning was included in the current study. Setting: This study was carried out at
National Center for Clinical and Environmental Toxicology. Tool of data collection: structured interview
questionnaire used for data collection which Includes: a- socio-demographic data about children and their
caregivers, b- Child‘s assessment complains on admission checklist to assess children health status and cpredisposing factors checklist for poisoning. Results: Less than two thirds of children were males and less
than one fourth of children their age ranged between 30<40 months. More than one third (35%) of children
were active and the minority (9%) were quiet, more than half of children (58%) exposed to poisoning even
in the presence of caregivers at home because caregivers were busy by home activities such as cooking in
kitchen and washing clothes in the bathroom (37.93%, 6.9%, respectively). Most of caregivers in the rural
and urban areas had kerosene at their houses (95.7% & 90.7% respectively). Less than half of caregivers
(47.8%) in rural areas storage medication in refrigerator. There was a positive correlation between
frequency of exposing children to poisoning and child age. Conclusion: The study concluded that these
risk factors of children, caregivers and environment factors interrelate together to produce poisoning.
Children highly exposed to accidental poisoning if they are younger, active male living in large family in
urban areas with working and secondary educated caregivers. The environment risk factors are the main
causative of poisoning among children as home contains a lot of toxic materials which stored improperly.
Recommendation: The current study recommended that mass media must be share in provide information
about poisoning material, prevention, first aid and immediate management.
Key Words: Accidental Poisoning, Children, Rural, Urban, kerosene, Risk factor.
Introduction
Healthy children are vital
resources to ensure the future well-being
of the nation. They are the parents,
workers; leaders, decision-makers of
tomorrow, their health and safety depend
on today‘s decisions and action.
Children future lies in the hands of those
people responsible for their well-being.
So well-being of children should be a
subject of great concern (Raed,
Mahmoud, Ramadan, Hoda& Amr,
2013). Poisoning of children is one of
the most common and an important
subject in the field of pediatric nursing.
Poisoning can be defined as taking, or
being exposed to a substance injurious to
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July 2015
health (Ahmed, Fatmi, Siddiqui &
Sheikh, 2011), Whereas Wong, Enberry,
Eaton,Wilson, Winkelstein, & Schwartz,
(2014 ) defined poisoning as a substance
which when introduced into the body
causes injures or destroys the tissues and
enzymes.
Ashgar,
Anees,
Mahmood,
(2012 ) stated that childhood poisoning is
a major cause of morbidity in the
developing as well as the developed
world. In spite of the success of some
interventions to prevent accidental
poisoning in the pediatric population,
toxic ingestions continue to be a
common occurrence and poisoning
remains a significant health concern,
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with most cases occurring in children
younger than 6 years of age (Wong,
Enberry, Eaton, Wilson, Winkelstein, &
Schwartz, 2014 ). The American
Association of Poison Control Centers
(2009 ) reported that children less than 6
years old made up 50.9% of cases and
2.4% of the total reported fatalities
(Jesslin, Adepu & Churi, 2010). An
estimated 86 000 childhood poisoning
incidents were treated in US hospital
emergency departments in 2008 ,
amounting to 429.4 poisonings per 100
000 children (Marchelet, & Leiller,
2009). While in Japan, the poison
centers received 31510 enquiries in
2010, about poisoning in children less
than 6 years of age, 20% enquiries
relating to children less than 1 year old
made up 35.7% of these cases (Dal
Santo, Goodman & Jackson, 2013).
In Egypt according to Read, et
al., (2013 ) there are 437 children less
than six year suffering from accidental
poisoning admitted at Alazhar poisoning
university hospital from July (2011) to
May (2012 ). According to Hassan and
Siam (2014) the total cases of acute
poisoning among children admitted at
Ain Shams University in Cairo (poison
control center) during the year 2008
were 8841 (Ain –Shams Poison Control
Center, 2008) while the total cases of
acute poisoning among children
admitted during the year 2004 were
12018 cases.
Poisoning in children is a
complex interaction between the child,
hazardous substances and environmental
factors (Ramos, Barros, Stein & Costa
2010).
Commonly
reported
environmental risk factors include
caregiver‘s lack of knowledge of a
poisoning risk, improper storage of toxic
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July 2015
substances, and improper or insufficient
supervision, (Hassan, et al 2014). Wong,
et al., (2014) revealed that many
accidental poisoning reflect the ready
accessibility of the product in the home,
where more than 90% of poisonings
occur, although a significant number
take place elsewhere, such as in
grandparent‘s or friends home , in
school, or in a health care facility.
Taft, Volkaner, Sarmerick, &
Freick (2013), stated two factors that
increase the risk of poisoning in children
less than six year are large families as
the mother is often too occupied with
household chores that she is not able to
supervise the child. Lack of supervision
increases the chances of poisoning.
Negligence of parents or caregivers can
cause accidents and poisoning in
children, which may be of fatal
consequences to the child (Chhetri,
Ansari, & Shrestha, 2013). Other risk
factors for unintentional poisoning have
been suggested, such as marital status of
parents as living apart, number of
siblings more than three, medicine users
at home (Schwartz, Eidelman, Zeidan &
Applebaun, 2010 ). Families living
together in one housing unit often leads
to unsafe storage of medicines and
chemicals due to lack of personal space.
In addition, with many people sharing
living quarters, it is difficult to control
the ways in which individuals store
dangerous products around children.
Crowded living conditions are often
major contributors to the risk of
poisonings and other injuries in the
home (Manzar, Saad & Fatima, 2010 ).
Commonly reported risk factors
include caregiver‘s lack of knowledge of
a poisoning risk, improper storage of
toxic substances, and improper or
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insufficient supervision (Whaley &
Wong, 2014 )).Toxic household products
were easily accessible and the
inadequate storage in homes often led to
the ingestion of those products, in many
instances the product was within the
reach of children or was stored in
beverage
bottles
and
caused
unintentional poisoning among children
less than six years (Andiran &
Sarikayalar, 2011 ). Sometimes, parents
and caregivers underestimate their
child‘s climbing ability. Plants or
mushrooms in the home garden may also
present a poisoning risk to your child
(Ghai, Paul, & Bagga, 2009 ).
The type of caregivers present at
the time of the poisoning episode may be
a risk factor for child poisoning. Almost
12% of child poisoning cases at the
Pittsburgh Poison Center occurred when
the caregiver was someone other than
the child‘s own parents and the
poisoning occurred away from the
child‘s home. There was an over
representation of cardiovascular drugs
poisoning when grandparents were
caregivers (12.3%) as opposed to parents
(0.7%), a finding in keeping with the
greater use of these drugs in the older
age group. A history of previous
poisoning episodes requiring medical
treatment was found to increase the risk
for subsequent child poisoning. Perhaps
due to continued inappropriate storage
and/or supervision by the parents, or the
child‘s familiarity with where the
product is kept. A tendency to re-ingest
similar types of substances was also
found to be significant (Wawrzyniak,
Hamulka & Skibinska, 2012 ).
There are multiple contributory
factors in household product poisoning
exposure among children rather than
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July 2015
mother's working status, and her
educational background. Lack of poison
control centers coupled with a negligent
attitude, explains why accidental
pediatric poisoning is still a major cause
of admission to pediatric emergencies
(Makaled, Emara, El-Maddah & El-Rafi
2012). Most accidental poisonings occur
within the home environment as the
children of working mothers were at a
lower risk of poisoning than those of
housewives this finding is in patan
hospital in Nepal (Chhetri et al., 2013 ).
Housewife mothers provide inadequate
supervision to their children and can
inadvertently create a hazardous home
environment due to unhealthy storage
habits. Contrary to that, working
mothers often leave their children in a
selected environment such as a nursery
with chosen supervisors (Whaley, et al
2014).
Osaghe & Sule (2013 ) revealed
that socio-economic status may be a key
factor associated with childhood
poisoning. Issues such as illiteracy may
affect the parent‘s ability to read
warning labels or directions for use. Also
Ahmed, et al (2011 ) revealed that
economic
status
of
a
child‘s
family/parents, household structure, and
ownership. Information about parental
education on the basis of number of
schooling years completed family type
as nuclear or extended were also risk
factors for accidental poisoning among
children less than six years. Studies from
developing countries have demonstrated
that unintentional pediatric injuries are
more closely related to maternal
education than any other socioeconomic
factor.
Poisoning can have long term
psychological
and
physical
Assessment Of Risk Factors.
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consequences for children and may
result in large societal costs. In low and
middle income countries, poisoning
accounts for 10% of the total burden of
unintentional injuries, and 6% of
disability adjusted life years (Taft, et al
2013). The admission rate of children
with poisoning (2012 ) around (1000
child / year) whom admitted to
emergency room and inpatient of
National Center for Clinical and
Environmental Toxicology at Cairo
University, so that the researcher wants
to intervene the risk factors contributing
to accidental poisoning among children
to overcome and prevent the occurrence
of such serious problems. Therefore The
nurse has a great role in poisoning
prevention through health teaching to
caregivers, moreover caregivers should
be educated regarding safe storage of
toxic substances and they have to be
advised about prevention (Petridou,
Kouri & Polychronopoulos, 2009 ).
Aim of the study
The aim of the current study was to
assess risk factors contributing to
accidental poisoning among children less
than six years.
Research questions
Q1. What are the risk factors
contributing to accidental poisoning
among children less than six years?
Q2. What are the most common risk
factors contributing to accidental
poisoning among children less than six
years?
Research design
Descriptive exploratory research
design was utilized to carry out the
current study .
Setting
The study was conducted in emergency
unit and inpatient ward of National
Center for Clinical and Environmental
Toxicology at Cairo University, this
221
July 2015
center provides care to all children of all
age groups for 24 hours a day, 7 days a
week.
Sample
A Convenient sample of 100 caregivers
of children diagnosed as accidental
poisoning who admitted to National
Center for Clinical and Environmental
Toxicology included in the study
Inclusion criteria:
Both sexes.
Children‘s age less than six years.
Children admitted in emergency unit
with suspicion of accidental poisoning.
Exclusion criteria:
Children with diseases like chronic
encephalopathy,
neuropathies
and
mentally retarded.
Children age more than six years.
Tools for Data Collection
Data collected through utilizing a
structured
interview
questionnaire
schedule which developed by the
researcher after reviewing the related
literature; this tool designed to collect
the following:Part A. Socio demographic data which
included
(a) Child's personal data such as
sex, age, birth order, nursery school,
recurrence of exposure to poisoning
….etc.
(b) Family caregivers data which
included: age, level of education,
occupation, number of children, family
size and family income……etc.
Part B. Child’s assessment complains
on admission which included
It includes 9 questions such as
vital signs, level of consciousness, the
time of arrival at the toxicology center
after exposure to poisoning, type of
poisoning, cause of poisoning, signs and
symptoms of poisoning such as
vomiting, fever, nausea, disorientation,
edema, and pain in stomach … etc.
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Part C. Predisposing factors for
poisoning:
It included 12 questions related to
caregivers, child and home environment
such as the storage site of poisoning
agent in kitchen or bathroom…etc, and
proper or improper storage of toxic
substance as storage in beverage bottles
…etc.
Validity and Reliability
Tool validity
The tool was given to a panel
of five expert in the field of pediatric
medicine and pediatric nursing to
examine content validity. Modification
of the content done according to the
panel judgment on the clarity of
sentences, appropriate of content and
sequence of items.
Tool reliability
One
common
way
of
computing correlation value among the
question instruments is by using
Cronbach‘s alpha. Regarding to the
reliability of this study tools coefficient
alpha of questionnaire sheet was 0.65
which indicates fair correlation between
items of the tool.
Procedure
An official permission had been
taken from the Faculty of Nursing, Cairo
University to the director of the National
Center for Clinical and Environmental
Toxicology to provide an official
permission to the researcher to collect
required data. After taking permission,
clear explanation about the aim and
nature of the study were explained by the
researcher for each caregiver of children
who fulfilled inclusion criteria. After
that, a formal written consent was
obtained from all caregivers to get their
acceptance and gain their cooperation.
After admission the researcher met each
caregiver individually to collect socio222
July 2015
demographic data by using socio
demographic data tool, then researcher
started to assess child‘s complains on
admission by using child‘s assessment
complain tool on admission and then
after that the researcher assessed
predisposing factors of poisoning by
using predisposing factors for poisoning
tool. The tool was filled by the
researcher in one session took about 3545 minutes. Each caregiver was met
individually in inpatient ward and
emergency unit of National Center for
Clinical and Environmental Toxicology.
This was done four days/ week on every
Saturday, Monday, Tuesday and
Wednesday. The data collection
procedure took about eleven months
from August 2013 to June 2014 .
Pilot study
A pilot study was carried out on
10% of the total sample of caregivers of
children under six years with accidental
poisoning in inpatient and emergency
room at National Center for Clinical and
Environmental Toxicology to test the
applicability and clarity of the questions
of the study tool, to estimate the time
needed to complete the structured
interview schedule and to add or omit
questions. Little modifications on the
questions were done. Pilot study sample
was included in the study sample.
Ethical Considerations
Ethical approval was obtained
from the research ethical committee in
the Faculty of Nursing, Cairo University,
to approve the research. A written
consent was obtained from the
caregivers of children after explaining
the aim and nature of the study. The
caregivers were informed that they have
the right to withdraw at any time from
the study without any effect on their
treatment and their were assured about
the confidentiality of their data
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Statistical Analysis
A
compatible
personal
computer (PC) was used to store and
analyze data. A statistical package for
the social studies (SPSS) version 20 was
used for statistical analysis of data. Data
were coded and summarized using
descriptive statistics such as frequency,
frequency distribution mean and
standard deviation for quantitative
variables, Qui Square was used to
compare qualitative variables and (r)
correlation coefficient was used to test
correlation
between
quantitative
variables. The p-value ≤ 0.05 was
considered a statistically significant.
Results
The present study found that less
than two thirds of children (63%) were
males whereas more than one third
(37%) was females. Less than one fourth
of children (24%) their age ranged
between 30<40 months, and the
minority of them (2%) ranged between
1< 10, with mean age of children was
37.31 ± 15.21 months.
Table (1) showed that characteristics of
children can play a role in exposing them
to poisoning, as more than one third
(35%) of children were active. More
than two fifths (42%) of children were
alone during occurring of poisoning,
because caregivers were outside home as
more than two fifth of them (42.85%)
were at work and less than one fourth
(21.43% ) of them were at market. On
the other hand poisoning occurred for
more than half of children (58%) even in
the presence of caregivers at home
because caregivers were busy by home
activities such as cooking in kitchen and
washing clothes in the bathroom
(37.93% , 6.9%, respectively).
Table (2) points up the distribution of
child's caregiver's characteristics, more
223
July 2015
than two thirds (70%) children
caregivers were the mother. Touching to
education of caregivers, more than one
fourth (26%) had secondary education
followed by less than one fourth (24%)
can read and write. With respect to
caregivers work, more than half of them
(54%) were employee. More than three
fifth (64%) of caregivers able to provide
care to their children and less than two
fifth (36%) cannot provide care for their
children for different reasons as more
than one fourth (30.56%) of caregivers
were pregnant and the minority of them
(11.11% ) have chronic diseases such as
diabetes and hypertensive.
Table (3) delineates the percentage
distribution of predisposing poisoning
factors related to family and caregivers.
In relation to family number less than
one third (31%) of families size consists
of five members. With respect to type of
family, more than three fifth (65%) of
children have nuclear family, while more
than one third (35%) have extended
family. Approaching the duration of
caregiver out of home, less than half
(47%) of caregivers out of home for
more than eight hours/day and the
minority of them (1%) out of home for
two hours. As regard to the person who
cares about the child when responsible
caregivers were out of home, more than
one third (37.93% ) of children received
care from grandfather or grandmother or
sisters or brothers and nearly one fourths
(24.14% ) of children received care from
relatives.
Table (4) clarifies the comparison
between studied poisoned children
according to kerosene and medication
poisoning in rural and urban. It is
evident from table (4) that most of
caregivers in the rural and urban areas
Assessment Of Risk Factors.
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had kerosene at their houses (95.7% &
90.7%
respectively).
Regarding
exposure of children previously to
poisoning by kerosene, less than two
third (65.2%) of children in rural areas
and the majority (85.2%) of children in
urban area didn‘t previously exposed to
poisoning. Three fourth (75%) of
caregivers in rural and more than three
fourth (77.6%) in urban store kerosene
in kitchen, while one fourth (25%) of
caregivers in rural areas and less than
one fourth (22.4%) of caregivers in rural
areas storage kerosene in bathroom.
Most of caregivers (97.7%) in rural
areas and all caregivers (100%) in urban
areas store kerosene in unclosed place.
All the caregivers in rural and urban
storage kerosene in any available bottle.
All of caregivers (100%) of children in
the urban and rural areas had
medications at their home, the majority
of children in rural and urban areas did
no previously exposed to poisoning
(82.6%, 85.2% respectively), while the
minority exposed to previous poisoning
(17.4%, 14.8% respectively). Less than
half of caregivers (47.8%) in rural areas
storage medication in refrigerator, while
more than one third (35.2%) in urban
areas storage medication in wardrobe.
More than half of caregivers (58.7%) in
rural areas and more than three fifth of
caregivers (61.1%) in urban areas
storage medications in unclosed place.
There were no statistical significant
differences between children whom live
in rural and urban areas regarding to
presence of medications at home,
previous exposing to poisoning by
medications, store of medications and
safety of medications storage.
The present study showed that there was
a statistically significant positive
correlation between frequency of
224
July 2015
exposing children to poisoning and child
age (r = 0.178, p = 0.038). Whereas
there were no correlations between
child's birth order (r = 0.675 , p = 1.66),
child‘s residence (r = 0.773 , p = 0.069 )
caregiver's works (r = 0.14, p=1.66),
caregivers health status (r = 0.04, p =
1.66) and frequency of exposing
children to poisoning.
Assessment Of Risk Factors.
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Table (1): Percentage distribution of predisposing poisoning factors related to child.
Items
N
%
Characteristics of child (N=100 ):
-Quiet
9
9
-Active
35
35
-Hyperactive
30
30
-Curious
26
26
The child was alone during poisoning (N=100 ):
-Yes
42
52
-No
58
48
The reason for being alone (N=42 ):
a- caregiver outside home :
-The caregiver was at work
18
42.85
-The caregiver was at neighbors
15
35.71
-The caregiver was at market
9
23.80
b- caregiver at home but child poisoned (N=58 ) :
-The caregiver was in the kitchen
22
37.93
-The caregiver was sleeping
13
22.41
-The caregiver was in the bathroom
9
15.51
-The caregiver was washing
4
6.89
-The caregiver was in another room
10
17.24
Table (2) Percentage distribution of child's caregiver's characteristics (N=100 )
Items
N
%
The caregiver is:
- Mother
70
70
- Parents
15
15
- Grandparents
13
13
- Brothers/Sisters
2
2
Education of caregiver :
- Illiterate
22
22
- Reading & Writing (not taught)
24
24
- Preparatory education
3
3
- Secondary education
26
26
- University education
21
21
Work of caregiver :
- House wives
29
29
- Employee
54
54
- Farmer
9
9
- Worker
8
8
Able to provide care for children :
-Yes
64
64
- No
36
36
Reason for inability to provide care for children (N=36 ) :
- Pregnancy
- Hypertension
- Diabetes
- Paralysis
- Hypertension + Diabetes
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July 2015
11
10
6
5
4
30.56
27.78
16.67
13.89
11.11
Assessment Of Risk Factors.
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Table (3) Percentage distribution of predisposing poisoning factors related to family and
caregivers
Items
Family number:
- Three
- Four
- Five
- Six
- Seven +
Number of children in family:
- One
- Two
- Three
- Four
- Five
Types of family :
- Nuclear family
- Extended family
- In case of extended family:
- Grandparents
- Grandparents + uncle‘s family
- Grandmother
- Grandfather
- Uncle‘s family
Duration of caregiver out of home (N=100 ):
- 2 hours
- 4 hours
- 6 hours
- 8 hours
- >8 hours
The time spent at home in case the caregiver doesn’t work (N=29 ):
- Most of the day
- Parts of the day
The person who cares about the child when responsible caregiver out of home
(N=29 ):
- Grandfather/Grandmother
- Sisters/Brothers
- Relatives
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July 2015
N
%
8
23
31
24
14
8
23
31
24
13
7
58
23
10
2
7
58
23
10
2
65
35
65
35
24
5
2
2
2
68.57
14.29
5.71
5.71
5.71
1
13
23
16
47
1
13
23
16
47
10
19
34.48
65.52
11
11
7
37.93
37.93
24.14
Assessment Of Risk Factors.
enj@nursing.cu.edu.eg
Table (4) Comparison between studied poisoned children regarding to Kerosene and Medication poisoning in rural and urban
Poisoning
substance
Rural
N
%
Kerosene
Urban
N
%
Rural
N
%
Medication
Urban
N
%
44
2
95.7
4.3
49
5
0.29
46
0
100
0
54
0
16
30
34.8
65.2
5.43
0.018*
8
38
17.4
82.6
33
11
0
0
0
77.6
22.4
0
0
0
0.084
0.481
0
0
11
13
22
1
43
0
100
1.126
19
27
x²
P
Value
90.7
9.3
0.92
8
46
14.8
85.2
75
25
0
0
0
38
11
0
0
0
2.3
97.7
0
49
x²
P
value
100
0
0
0
8
46
14.8
85.2
0.123
0.468
0
0
23.9
28.3
47.8
0
0
19
17
18
0
0
35.2
31.5
33.3
2.442
0.322
41.3
58.7
21
33
38.9
61.1
0.06
0.483
Items
Presence at home :
- Yes
- No
Previous exposure:
- Yes
- No
Storage site:
- Kitchen.
- Bathroom.
- Wardrobe.
- Home pharmacy.
- Refrigerator.
Safety of storage:
- Closed
- Unclosed
0.473
*p=0.01
227
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Assessment Of Risk Factors.
enj@nursing.cu.edu.eg
Discussion
The current study showed that
characteristics of children can play a role
in exposing them to poisoning, as more
than one third of children were active
and the minority were quiet. This finding
congruent with Read, et al (2013) who
found that all children who admitted to
hospital were active. Also this finding
supported by Wong, et al (2014 ) who
reported that the children activity and
curiosity plays a major role in accidental
poisoning. From the researcher point of
view, it is also observed that the
behavior of activity makes children
prone to the ingestion of harmful
substances. However such personality
characteristics
of
children
when
accompanied with poor storage practices
at home resulted in a greater risk of
ingestion of hazardous substances.
The finding of the current study revealed
that more than two fifths of children
were alone during occurring of
poisoning, because caregivers were
outside home as more than two fifth of
them were at work and the minority at
market. This finding supported by Dal
Santo, et al (2013 ) and Chatsantiprapa,
Chokkanapitak and Pinpradit (2010 )
whom studied host environment factors
for exposure to poisons: a case control
study preschool children in Thailand,
and they found that the vast majority of
poisoning occurs when the children were
alone because of work of caregivers.
in a home even caregivers present during
accident but there was no close
observation due to busy by house
working. This finding contradicted
Maklad, Emara, El-Maddah and ElRefai, (2012), who studied the
etiological
and
demographic
characteristics of acute household
accidental poisoning in children a
consecutive case series study from
Pakistan, who found that about twothirds of children accessed the poisoned
products were not supervised by their
parents when they were poisoned.
On the other hand poisoning occurred
for more than half of children even in the
presence of caregivers at home because
caregivers were busy by home activities
such as cooking in kitchen and washing
clothes in the bathroom. This result
matched with Osaghae, et al (2013) and
Baaker, et al (2010 ) who found that
more than half of children were poisoned
Touching to education of caregivers, the
present study showed that more than one
fourth had secondary education followed
by can read and write followed by had
preparatory education. This finding
congruent with Osaghae and Sule (2013)
who studied socio-demographic factors
in accidental poisoning in children, and
they found that the high percentage of
228
July 2015
Concerning the distribution of child's
caregiver's characteristics, the result of
current study showed that, more than
two thirds children caregivers were the
mother, while the minority was brothers
and sisters. This finding matched with
Read, et al (2013 ) and Baaker, et al
(2010 ), who found that the majority of
caregivers were mother. This finding
contradicted with many authors:
Osaghae and Sule (2013 ) who studied
socio-demographic factors in accidental
poisoning in children, and they found
that the high percentage of caregivers
during poisoning were parents followed
by older sibling then grandparents then
other relatives then neighbors. Also
Chhetri, Ansari & Shrestha (2013 ), who
found that the high percentages of
caregivers were father then mother then
parents then relatives.
Assessment Of Risk Factors.
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caregivers educational status of poisoned
children were secondary school. Also
this finding contradicted with many
authors: Dal Santo, Goodman, Gilk &
Jackson (2013) who found that the high
percentage of caregiver‘s educational
status was collage graduate. Also this
finding contradicted with Read, et al
(2012 ) who found that the majority of
caregivers
of
poisoned
children
educational status were illiterate. Also
Baaker, et al (2010 ) who found that the
majority of caregivers had primary
school and the minority were illiterate.
With respect to caregivers work, the
current study showed that more than half
of them were employee and the minority
were workers. These findings go with
Read, et al (2013 ) who found that the
majority of caregiver‘s employment
status was working while the minority of
them didn‘t working. This finding
contradicted with Ramos, Barros, Stein
and Costa (2010 ) and Baaker, et al
(2010 ) who found that the majority of
caregivers were housewives.
The current study found that more than
three fifths of caregivers able to provide
care to their children. This finding
matched with Hassan and Siam (2014)
who found that the majority of
caregivers who had children exposed to
poisoning they healthy. The current
study showed that less than two fifths of
caregivers cannot provide care for their
children for different reasons as more
than one fourth of caregivers were
pregnant, while the minority of
unhealthy caregivers have chronic
diseases such as diabetes and
hypertensive This finding matched with
Hassan and Siam (2014 ) who found that
the minority of caregivers were
unhealthy due to problems during
229
July 2015
pregnancy. Also this finding matched
with Andrian and Sarikayalar (2011 )
who studied pattern of acute poisoning
in childhood in Ankara, and they found
that more than half of caregivers were
unhealthy due to chronic disease. From
the researcher point of view this could be
attributed to the fact that healthy
caregivers are more able to provide care
and observe their children than
caregivers with chronic diseases.
In relation to family number, the current
study clarified that less than one third of
families‘ size consists of five members
and the minority consists of three
members. This finding goes with
Tshiamo (2011) who studied paraffin
(kerosene) poisoning in under five
children: a problem of developing
countries and who found that the
majority of family consists of five to
seven people. Whereas contradicted with
Ramos, et al (2013 ) who found that the
majority of family number is between
3to 4 numbers.
With respect to type of family, the
current study revealed that more than
three fifths of children had nuclear
family, while more than one third had
extended family. This finding congruent
with Read, et al (2013 ) who found that
the majority of children had nuclear
family, while the minority had extended
family. Whereas contradicted with
Osaghae, et al (2013 ) who found that
less than one third of children had
nuclear family, while more than two
third of children had extended family.
From the point view of the researcher,
because of more than three fifth of
children had nuclear family so there is
no body take care children with their
parents in case of absence or busy of
Assessment Of Risk Factors.
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parent with home duties thus increase
incidence of poisoning in nuclear family.
The current study revealed that the
majority of caregivers in the rural and
urban areas had kerosene at their houses.
This finding supported by many authors
Hassan, et al (2014 ), Abd Elhaleem, et
al (2014 ) and Tshiamo (2011), who
found that all caregivers had kerosene at
their home. Regarding exposure of
children previously to poisoning by
kerosene, the current study showed that
more than one third of children in rural
areas and the minority of children in
urban areas had previous poisoning. This
result contradicted with Ramos, et al
(2010 ) who found that the majority of
children exposed previously to poisoning
by kerosene.
The present study showed that about
three fourth of caregivers in rural and
urban store kerosene in kitchen, while
the others storage it in bathroom. The
vast majority of caregivers in rural and
urban areas store kerosene in unclosed
place. This finding agreed with Osaghae,
et al (2013) and Ahmed, et al (2011),
who found that the majority of
caregiver‘s storage kerosene in kitchen
in any empty bottle at unclosed place.
The current study showed that all the
caregivers of children in the urban and
rural areas had medications at their
home. From the point view of the
researcher this result may be due to the
caregivers use medication for treatment
or may be related to habits in Egypt to
keep all the remained medication after
complete treatment for future use of
medication. This finding contradicted
with Keka, et al (2014 ), Read, et al
(2013 ) and Baaker, et al (2010) who
found that less than one third of
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July 2015
caregivers had medications at their
houses. The majority of children in rural
and urban areas did no previously
expose to poisoning by medication. This
finding matched with Chhetri, Ansari, &
Shrestha, (2013) who found that the
majority of children had no previous
history form medication poisoning.
The present study clarified that less than
half of caregivers in rural areas storage
medication in refrigerator, more than
half of caregivers in rural areas and more
than three fifth of caregivers in urban
areas store medications in unclosed
place. This finding matched with Baaker
et al, (2010) who found that more than
three fourth of caregivers storage
medication in unclosed refrigerator. This
finding supported by Read, et al (2013 )
who found that the majority of
caregivers had no home pharmacy.
The present study highlighted that there
was a statistically significant positive
correlation between frequency of
exposing children to poisoning and child
age. From the researcher point of view
child age play a very important role in
induce poisoning frequency as the child
grow it increase his ability to move and
his curiosity to explore environment in
addition he had short memory span and
had satisfaction from putting objects in
his mouth. Kyle, (2010 ) revealed that
the normal developmental progression of
young children including exploration of
their environment, places them at risk for
poisoning. As children become mobile,
they are able to maneuver through the
home; they learn to open cabinets and to
examine the contents. As children begin
to walk, they may be able to grab items
that were previously out or reach. This
result goes in line with by Read, et al
(2013 ), Schmertman, et al (2013), who
that there was a statistical significant
Assessment Of Risk Factors.
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relation between child age and recurrent
of poisoning.
There were no correlations between
child's birth order, child‘s residence,
caregiver's works, caregivers health
status and frequency of exposing
children to poisoning, the result
contradicted with Keka, et al (2014 ) who
found there was correlation between
child‘s residence, caregiver's works,
caregivers health status and frequency of
exposing children to poisoning. This
finding supported with Jesslin, Adequ
and Churi (2010) who found that there
was no correlation between child‘s
residence, caregiver's works and
frequency of exposing children to
poisoning.
Conclusion
The study concluded that risk factors of
children, caregivers and environment
factors interrelate together to produce
poisoning. Children highly exposed to
accidental poisoning if they are younger,
active male living in large family in
urban areas with working and secondary
educated caregivers. The environment
risk factors are the main causative of
poisoning among children as home
contains a lot of toxic materials which
stored improperly.
Recommendation
In the light of findings of current study,
the following recommendations are
suggested:
 Provide caregivers with an
education program about the
importance of close supervision
for children especially younger
active male children and how to
keep home environment safe
even in the presence of toxic
substances.
231
July 2015


Mass media must be share in
provide
information
about
poisoning material, prevention,
first
aid
and
immediate
management.
Replication of the study on large
sample and in different region.
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Work Environment: the Quality.
enj@nursing.cu.edu.eg
Work Environment: the Quality and Risk Outcomes for Both Nurses and Patients
Nadia Mohamed EL-Sayed, Lecturer of Nursing Administration, Faculty of Nursing,
Suez- Canal University
ABSTRACT:
The achievement of a healthy work environment is multifactor and requires the support of the
team members through an environment of positive communication. Aim of this study: the aim of this
study was to investigate the effect of nurses‘ perceptions of their work environment on the quality and risk
outcomes for both the patients and nurses at Suez-Canal University Hospital in Ismailia city. Research
Design: a cross-sectional design was used in this study. Setting: The study was carried out in the medical
and surgical departments and Intensive Care Units (ICU) at Suez- Canal University Hospital in Ismailia
city. Subjects: The convenient sampling of 90 nurses and 90 patients' from the previous study setting who
fulfilled the inclusion criteria of this study were included. Tools of data collection: tools were used for
nurses at group and at individual levels, and others for patients. The group-level tools included structural
empowerment, group processes, and nurse-assessed quality of care and risk while the individual-level tools
were for psychological empowerment, empowered behaviors, and job satisfaction. The patient tools
measure quality-oriented patient outcomes associated with nursing work effectiveness. They were pilottested and showed high reliability. Data collection was from December 2012 to March 2013. Results: only
the element of structural empowerment had weak and negative statistically significant correlation with the
patients‘ outcomes related to total satisfaction (r=-0.273 ) from one side and the structural empowerment is
the only statistically significant predictor of the nurse‘s job satisfaction, explaining 0.07% of its score in
other side. As well as, the group process is the statistically significant positive predictor of the patient‘s
satisfaction score; whereas the score of structural empowerment and patient female gender are negative
predictors the model explains 0.21% of the score of patient satisfaction. Conclusions: The findings
revealed that an empowering work environment enhances group process and nurses‘ empowered behavior
and job satisfaction, with a positive impact on their appraisal of patients‘ adverse events and on patients'
satisfaction and self-care abilities, especially among male patients. Recommendations: the hospital
administration give more attention to the factors that foster empowerment in the workplace through suitable
organizational budgetary allocations, provision of more authorities and autonomy to nurses, and safe skillmix.
Key Words: Work Environment, The quality Outcomes, Risk Outcomes, Structural Empowerment, Group
Processes, Empowered Behavior.
INTRODUCTION
A healthy healthcare work
environment is a productive and
collaborative setting in which nurses and
other providers are free from physical
and
psychosocial
harm
while
maximizing their ability to provide
quality care, along with meeting
personal needs (Chang et al., 2009 ).
This environment is influenced by
personal factors as stress, burnout, and
motivation; social factors as the relations
among workers, role ambiguity, discord,
and support; and professional factors
such as the values cultivated within
professional disciplines as nursing
(Murtaugh
and
Litke,
2009 ).
Additionally, the physical environment
234
July 2015
work conditions involves physical
characteristics such as light, noise, air
quality, and hazardous exposures as well
as basic workplace design as obstacles,
layout, and distance from nursing
stations (Murff and Kannry, 2005 ).
Moreover,
the
organizational
characteristics of the work setting such
as the nurses‘ status in the hospital
hierarchy, their relationships with
physicians, and the opportunities for
self-development are of importance
(Emold et al., 2010 ). Hence, the
achievement of a healthy work
environment is multifactor and requires
the support of the team members through
an
environment
of
positive
Work Environment: the Quality.
enj@nursing.cu.edu.eg
communication (Gacki- Smith et al.,
2009 and Perhats et al., 2011 ).
Work
environments
and
workplace cultures that offer nursing
autonomy not only do better in terms of
patient outcomes, but also face less
personnel costs for recruitment and
replacement of skilled and experienced
staff (Paganini and Bousso, 2014 ). Job
satisfaction increases when nurses have
good leadership, adequate administrative
support, authority in defining their work
and control over the resources they need
to provide quality care (Unruh, 2008
and Laschinger et al., 2014 ). On the
other hand, inadequate staffing and
overwhelming workloads not only
reduce nurses' ability to deliver quality
care, but also predisposes them to
increased fatigue and higher risk of
errors. In this respect, Robinson et al.,
(2004 ) emphasized that in considering
the contribution of workload to patient
outcomes, it is important to think of the
care nurses do not do when rushing
between too many patients, which
prevents providing optimum nursing
care.
Nurses play a major role in the
relationship between nursing work
environment and patient outcomes
(Heather and Michael, 2006 ). The
patient outcomes that are sensitive to
nursing care include both quality-related
outcomes as functional status, symptom
management, and patient satisfaction as
well as the risk-related or patient safety
outcomes as falls, pressure ulcers,
nosocomial infections, and medication
errors (Doran, 2007 ). Healthy work
environments have been linked to
increased nurse and health care worker
retention, recruitment, job satisfaction
and have decreased stress and burnout,
which subsequently leads to safer patient
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practices (Schmalenberg and Kramer,
2008 and Laschinger et al., 2011 ).
Nonetheless, the design of
workplace empowerment studies in
nursing has been at the individual-level
that fails to capture the contextual effects
of a given patient care unit. Since the
majority of strategies to improve the
workplace are delivered at the unit level,
the outcomes of these efforts should be
observable at the unit or group level. By
measuring the work environment at the
group level, it is possible to capture the
differences in outcomes that can be
attributed to structurally empowering
factors operating within the patient care
unit (Laschinger et al., 2009 ).
Significance of the study
Empowering work environments
for nurses is hypothesized to enhance
their
psychological
empowerment
leading to their engagement in endowed
behaviors that bring about quality care
with better patient outcomes and nurses‘
job satisfaction. The evidence from this
study would reinforce the critical need to
invest in improving nursing work
environments for the benefit of patients
and nurses. In addition, the study can
contribute to the growing body of
knowledge regarding effective work
environments in hospital settings
particularly regarding the link to
objective measures of nursing-sensitive
patient outcomes.
Aim of the study
The aim of this study was to
investigate the effect of nurses‘
perceptions of their work environment
on the quality and risk outcomes for both
the patients and nurses at Suez-Canal
University Hospital in Ismailia city.
Research questions:
1- What is the effect of nurses‘
perceptions
of
their
work
environment on the quality and risk
Work Environment: the Quality.
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outcomes for both the patients and
nurses?
Materials and Methods
Research design:
A cross-sectional design was used in this
study.
Setting:
The study was carried out in the
medical , surgical departments and
Intensive Care Units (ICU) at Suez
Canal University Hospital in Ismailia
city. The hospital has been established
up at 18-12-1993 . The hospital prepared
with advanced equipment and devices
that needed for diagnosis and treatment
of different cases. It consisted of 4
buildings that contains different medical
departments
such
as:
inpatient
departments for different specialists
(including 350 beds), outpatient clinics
(20 clinics in different specialists),
emergency department ( laboratories,
radio diagnostic, MRI and endoscopes),
blood bank and educational parts ,there
are private paid rooms .In addition,
surgical building, oncology building and
building for emergency cases ( under
preparation). The selection was based on
inclusion criteria for study subjects.
Subjects:
The participants in this study
consisted of nurses and patients from the
selected settings.
A. The nurses' group: all nurses
working in the study settings with the
inclusion and exclusion criteria:
Inclusion criteria:
1. Being permanent hospital employees,
2. Providing direct patient care.
3. Working in the current department for
at least one year.
Exclusion criteria:
1. Having had a leave for more than one
month during the previous year.
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July 2015
2. Working as administrative nursing
personnel.
B. The patients' group: They consisted
of a consecutive sample of those
admitted in the study settings during data
collection. Their inclusion criteria were
being conscious, able to respond, and
scheduled to be discharged from the
hospital to home within seven days.
The sample size for each group is
calculated to demonstrate a correlation
coefficient of 0.3 or higher with 80%
power and at a 95% level of confidence
between the score of work environment
and outcomes. Using the sample size
equation for correlation (Stanton and
Glantz, 1992 ), the required sample size
is 83 for each group. This was increased
to 90 to account for a non-response rate
of about 10%.
Tool of data collection:
The tools for data collection
included tools for nurses at group and at
individual levels, and others for patients.
A. Tools for nurses: The tools used were
as follows, in addition to collecting basic
demographic data such as: age, gender,
marital status, level of education, years
of experiences and working department.
1. Group-level
tools:
included
structural empowerment, group
processes, and nurse-assessed quality
of care and risk.
o Conditions
of
Work
Effectiveness
Questionnaire
(CWEQ):
This
19-item
questionnaire was developed by
Laschinger et al., (2000 ) to
assess structural empowerment.
It includes six subscales to
measure the dimensions of
empowering
(opportunity,
information, support, resources)
and the sources of power
(formal and informal) that
enhance access to these factors.
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Each item is measured on a 5point Likert scale scored from 1
(none), 3 (some) to 5 (a lot)
such hat a higher score reflects
more empowering workplace.
The means of subscales and of
total
empowerment
are
calculated to represent the
quality of nursing work
environment. A two-item global
empowerment scale is included
for
construct
validation
purposes.
o Work Group Characteristics
Measure (WGCM): This tool
was
developed
from
a
comprehensive review of the
literature on work group
characteristics
related
to
effectiveness (productivity and
employee
satisfaction)
including
job
design,
interdependence, composition,
context and group processes.
Five subscales were selected for
this study including task
interdependence and four other
process-related
group
characteristics consisting of
potency (team self-efficacy),
social
support,
workload
sharing,
and
communication/cooperation.
Each subscale has 3 items with
responses ranging from 1
(strongly disagree) to 7
(strongly agree).
o Nursing Quality Indicators
Measure (NQIM): Nurses‘
views regarding risk-related
patient
outcomes
were
measured using this instrument
developed
by
Sochalski,
(2001 ) based on the American
Nurses Association (ANA)
Nursing Quality Indicators
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July 2015
(NQI). It has four items
assessing nurse's perceptions of
the incidence of common riskrelated patient outcomes over
the past year on a scale from 1
(never) to 4 (frequently).
o Perceived Quality of Care
Measure (PQCS): A 4-item
tool developed by Aiken et al.,
(2002 )
to
seek
nurse‘s
perceptions of quality-oriented
patient
outcomes.
Three
questions reflect the quality of
care in the unit, and the fourth
refers to changes over the past
year. Each of the four items was
used individually in studies and
showed strong association with
nursing work conditions and
other
patient
outcomes
(Sochalski,
2004
and
Laschinger, 2008 ). Separate
ratings scales are used for each
item: excellent-poor (4-point
scale) for the first two items,
improved-deteriorated (3-point
scale) for third, and very
confident-not-at-all-confident
(4-point scales) for fourth item.
2. Individual-level
tools:
for
psychological
empowerment,
empowered behaviors, and job
satisfaction.
o Psychological Empowerment
Questionnaire
(PEQ):
developed by Spreizter, (1996 )
to
assess
individual
psychological empowerment. It
includes 12 items measuring
four components: meaningful
work, competence, autonomy,
and impact. The responses
range from 1 (strongly disagree)
to 5 (strongly agree).
o Empowerment Questionnaire
(EQ): developed by Irvine et
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al., (1999 ) to measure nurse's
self-rated
empowerment
behaviors at work setting. These
include 1) outcome behaviors
defined as confidence in being
able
to
bring
about
improvements in ones work,
effect change, or make a
difference to organizational
effectiveness;
2)
verbal
empowerment
reflects
communication
such
as
debating or expressing one‘s
point of view to others
regarding work problems; 3)
behavioral empowerment relate
to learning new skills, preparing
reports, taking on new job
challenges and overall job
performance. The 21 items are
rated on a scale ranging from 0
(never) to 10 (always). By
revising the stem of each item
from a cognition perspective,
e.g. “how confident are you that
you can successfully perform
the task” to an action-oriented
perspective, e.g. “the frequency
with which you engage in the
behavior,” actual behaviors that
represent an empowered state
are captured.
o Nurse Global Satisfaction
Questionnaire (NGSQ): This
5-item Likert scale from
1(Strongly Disagree) to 5
(Strongly Agree) was modified
from
Hackman
and
Oldham’s,(1975 )
Job
Diagnostic Survey. The items
include aspects of the job that
are
related
to
overall
satisfaction with the current job
and with co-workers. It has
good reliability with Cronbach
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July 2015
alpha 0.77 to 0.84 (Laschinger
et al., 2009 ).
o Current work environment
effectiveness: This consisted of
2 items asking about nurse‘s
general perception of the work
environment support. It is on a
5-point Likert scale from
1(Strongly Disagree) to 5
(Strongly Agree).
B. Tools for patients: These tools were
used to measure quality-oriented patient
outcomes associated with nursing work
effectiveness. They included:
1. Patient Survey Questionnaire
(PSQ): This tool covers patient's
demographic data such as gender,
age, marital status, level of
education, and job as previous
studies have reported difference
related
to
these
personal
characteristics (Yellen, 2003 ).
Additionally, the severity of
illness was assessed as it may
affect satisfaction regardless of
the quality of care received
(Laschinger et al., 2005 ).
2. Patient
Satisfaction
with
Nursing
Care
Quality
Questionnaire (PSNCQQ): This
19-item tool was developed by
Laschinger et al., (2005 ) to
measure satisfaction specific to
the nursing care received. The
items refer to the patient‘s
perception of all nurses on the
unit with whom they have
interacted and is
thereby
appropriate for the examination
of patient outcomes that are
dependent on membership to a
specific patient care unit. The
responses are on a 5-point Likert
scale from 1 (excellent) to 5
(poor).
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3. Therapeutic self care: This
consisted of 13 items asking
about self-care issues such as the
knowledge of what medication to
take and the ability to carry out
treatments that have been taught.
The responses are on a 5-point
Likert scale from 1 (excellent) to
5 (poor).
Scoring: For each part of the nurse
and patient tools, the points are
summed-up and divided by the
number of items to provide a mean
score. The scores are presented in
terms of means, standard deviations,
and medians.
Pilot study:
The researchers carried out a
pilot study on 10 % nurses and 10 %
patients from the study settings in order
to test the reliability, feasibility and
applicability of the tools. It has also
helped in estimating the time needed for
data
collection.
Cronbach
alpha
coefficients for the nurses‘ tools ranged
between 0.60 for the adverse events
scale to 0.94 for the empowered scale.
For patients‘ tools, it was 0.74 for the
satisfaction scale and 0.51 for the selfcare scale. The tools were finalized
accordingly, and the participants were
not included in the main study sample.
Fieldwork:
Before data collection, face and
content validity of the questionnaire
through rigorous review by a group of
experts in nursing administration were
ascertained. The group consisted of 5
faculty members, from the Faculty of
Nursing at Zagazig and Suez-Canal
universities. Their comments factored
into fine tuning of the tool.
The researchers provided the
nurses and patients with a short
orientation to describe the nature of the
study and invited them to participate.
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July 2015
Those who consented were set in groups
of 10-15 for nurses and smaller groups
for patients. Filling the questionnaire
was done by each individual participant
in the presence of the researchers to
ensure that the forms are filled without
interactions during the process, so as to
avoid any one being influenced by
others. The researchers provided
clarifications in an impartial way if
requested. The process of data collection
lasted for four months from December
2012 to March 2013 .
Administrative
and
ethical
considerations:
An official approval for data
collection was obtained from the
Hospital administration based on a letter
clarifying the purpose of the study
submitted to the authorities in the study
settings. The study protocol was
approved by the research and ethics
committee at the Faculty of Nursing,
Suez Canal University. Potential
participants (nurses and patients) were
informed about the aim and procedures
of the study. They were reassured about
confidentiality
of
any
obtained
information, and were informed about
their rights to refuse or withdraw at any
time. The study procedures could not
entail any harmful effect on participants.
Statistical analysis:
Data entry and statistical analysis
were done using SPSS 16.0 statistical
software package. Spearman rank
correlation analysis was used for
assessment of the inter-relationships
among various scales. In order to
identify the independent predictors of
various scales‘ scores, multiple linear
regression analysis was used, with
analysis of variance for the full
regression
models.
Statistical
significance was considered at p-value
<0.05.
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RESULTS
Table (1) showed that, the study
sample of nurses included 90 nurses, all
females except one and their age ranged
between 21 and 44 years. As well as,
slightly more than half of the sample
(51.5%) was working in surgical
departments. Their median total and
current department experience years
were 17 and 11 respectively.
Table (2) As regards patients‘
characteristics in the study sample. It
illustrated that more than two-thirds
were females (70.0%) and married
(68.9%) and their age ranged between
30 and 58 years, with median 30. The
days of hospital ranged between 2 and
45, with median 13. The patients‘
perception of own health before
hospitalization was mostly fair (47.8%)
while currently it was mostly good
(36.7%) to very good (35.6%).
As shown in Table (3) the
nurses‘ perception of the group level
variables was highest for the global
empowerment
of
the
structural
empowerment variable (median 3.5/5)
while the lowest was for nursing care
(median 1.5/4). Within the structural
empowerment variable, the mean scores
ranged between 2.5 for opportunity and
formal power and 3.4 for informal
power. For group processes, they ranged
between 2.9 for independence and 3.5
for support. For nursing care, they
ranged between 1.5 for quality last shift
to 1.8 for general quality of nursing care.
Lastly, the means for adverse events as
appraised by the nurses ranged between
2.8 for wrong medications to 3.6 for
patients and family complaints.
As regards individual level
variables, the means of psychological
empowerment elements ranged between
3.3 for impact to 3.8 for meaning and
competence, with a total mean score
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July 2015
3.6/5. The empowered behavior
elements had all low scores, with a mean
total score 5.5/10 . Meanwhile, the
nurses‘ perception of job satisfaction and
current work environment effectiveness
were average, 3.3/5 and 2.7/4
respectively.
Table
(4)
indicated
that,
generally low scores of patients‘
satisfaction with nursing care. The
highest mean was related to the item
―nurses give you choices‖ (3.1/5), while,
the lowest was for the item of
―willingness of nurses to be flexible‖
(2.2/5). In total, patients had higher
discharge (2.9/5) than inpatient (2.7/5)
satisfaction. As regards therapeutic selfcare, the table indicates that the mean
scores ranged between 2.1/5 for the item
―know whom to contact for help
regarding daily activities‖ and 2.9/ for
the item ―understand how to control
changes.‖ Meanwhile, patients‘ mean
score of perception of current health
(3.6/5) was higher than their satisfaction
(2.7/5) and self-care (2.8/5) scores.
Table (5) demonstrates the
correlations between the elements of
nurses‘ empowerment and work
environment from one side, and the
patients‘ outcomes from the other side. It
showed that, only the element of
structural
empowerment
had
a
statistically significant correlation with
the patients‘ outcomes related to total
satisfaction. This correlation was weak
and negative (r=-0.273 ).
Table
(6)
regarding
the
multivariate regression analysis for the
nurses‘ perceptions scores . It indicated
that, the structural empowerment is the
only statistically significant predictor of
the nurse‘s job satisfaction, explaining
0.07% of its score. As for the score of
empowered behavior, it is positively
predicted by the scores of group process
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and structural empowerment, which
explain 0.17% of its score. Lastly, the
score of nurses‘ perception of adverse
events is negatively predicted by the
score of empowered behavior, which
explain 0.11% of this score.
Table (7) concerning the
multivariate analysis for patients‘
outcomes scores. It is clear that, the
group process is the statistically
significant positive predictor of the
patient‘s satisfaction score, whereas the
score of structural empowerment and
patient female gender are negative
predictors. The model explains 0.21% of
the score of patient satisfaction. As for
the score of patient self-care, it is
positively predicted by the score of
psychological
empowerment,
and
negatively predicted by the score of
adverse events and by patient‘s female
gender. The model explains 0.10% of
this score.
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July 2015
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Table (1): Socio-demographic characteristics of nurses in the study sample (n=90 )
Frequency
%
(n= 90)
Gender:
Male
1
1.1
Female
89
98.9
Age:
<30
28
31.1
3047
52.2
40+
15
16.7
Range
21-44
Mean±SD
32.3±6.3
Median
33
Experience years (total)
<10
19
21.1
1051
56.7
20+
20
22.2
Range
5-28
Mean±SD
16.4±6.3
Median
17
Experience years (current department)
<10
38
42.2
1024
26.7
20+
28
31.1
Range
2-26
Mean±SD
11.0±5.2
Median
11
Department:
Medical
21
23.3
Surgical
46
51.1
ICU
23
25.6
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Table (2): Socio-demographic characteristics of patients in the study sample (n=90 )
Frequency
%
(n= 90)
Gender:
Male
27
30
Female
63
70
Age:
<30
40
44.4
3029
32.2
40+
21
23.3
Range
30-58
Mean±SD
30.9±11.2
Median
30
Marital status:
Single
12
13.3
Married
62
68.9
Divorced
7
7.8
Widow
9
10
Days of hospital stay:
<7
19
21.1
733
36.7
14+
38
42.2
Range
2-45
Mean±SD
15.2±9.8
Median
13
Perception of own health
Before hospitalization:
Excellent
1
1.1
Very good
12
13.3
Good
21
23.3
Fair
43
47.8
Poor
13
14.4
Current:
Excellent
5
5.6
Very good
32
35.6
Good
33
36.7
Fair
19
21.1
Poor
1
1.1
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Table (3): Group and individual level variables measured among nurses in the study
sample (n=90 )
Scores
(n= 90)
Mean± SD
Median
Group level:
Structural empowerment (Conditions of Work Effectiveness)
Opportunity
Information
Support
Resources
Informal power
Formal power
Total structural empowerment (max=5)
Global empowerment
Group processes (Work Group Characteristics Measure):
Interdependence
Potency
Support
Share workload
Communicate/cooperate
Total group processes (max=5)
Nursing care (Nursing Quality Indicators Measure):
Nurse assessed quality of care
General quality of nursing care
Quality last shift
Positive change in quality over past year
Total nursing care (max=4)
Adverse events (Perceived Quality of Care Measure):
Wrong medication/dose
Nosocomial infection
Patient falls with injury
Patient/family complaints
Total adverse events (max=4)
Individual level:
Psychological empowerment:
Meaning
Competence
Autonomy
Impact
Total psychological empowerment (max=5)
Empowered behavior:
Behavioral empowerment
Verbal empowerment
Outcome empowerment
Total empowered behavior (max=10)
Job satisfaction (max=5)
Current work environment effectiveness (max=4)
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2.5±0.8
3.1±0.8
3.2±0.8
3.3±0.9
3.4±0.9
2.5±0.6
3.0±0.4
3.6±0.9
2.3
3.0
3.3
3.3
3.3
2.5
3.0
3.5
2.9±1.0
3.3±0.8
3.5±0.8
3.4±0.9
3.3±0.8
3.3±0.6
3.0
3.3
3.3
3.3
3.3
3.2
1.6±0.7
1.8±0.8
1.5±0.6
1.7±0.8
1.7±0.6
1.0
2.0
1.0
1.0
1.5
2.8±1.4
3.2±1.0
3.5±0.9
3.6±0.9
3.0±0.5
2.5
3.0
4.0
4.0
3.0
3.8±0.8
3.8±0.8
3.5±0.9
3.3±0.9
3.6±0.6
3.7
3.7
3.5
3.3
3.6
5.2±1.9
5.7±2.4
5.4±1.9
5.5±1.8
3.3±0.8
2.7±0.6
5.2
6.0
5.3
5.6
3.3
2.8
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Table (4): Satisfaction with nursing care and therapeutic self-care as reported by
patients in the study sample (n=90 )
Scores
(n= 90)
Patient satisfaction with nursing care
Mean± SD
Median
Inpatient satisfaction:
2.4±1.3
2.0
 Explains what to expect
2.7±1.0
3.0
 Explains preparation for tests/operations
2.9±0.8
3.0
 Ease of getting information
2.9±0.9
3.0
 How well nurses communicated with family
2.9±1.0
3.0
 Informing family and friends
2.8±0.9
3.0
 Involving family and friends
2.8±1.0
3.0
 Concern and caring by nurses
2.8±1.1
3.0
 How often nurses checked on you
3.1±1.0
3.0
 Nurses give you choices
2.2±1.3
2.0
 Willingness of nurses to be flexible
2.3±1.1
2.0
 Adjusted schedules to patients needs
2.6±1.0
3.0
 Make you comfortable and reassure you
2.7±1.0
3.0
 Nurses response to calls
2.7±1.0
3.0
 Skills and competence
2.9±0.9
3.0
 Coordination of care
2.9±0.9
3.0
 Restful atmosphere
2.9±0.9
3.0
 Provided privacy
Total inpatient (max=5)
2.7±0.4
2.6
Discharge satisfaction:
2.9±1.0
3.0
 Provided clear and complete discharge instructions
2.8±1.0
3.0
 Provided for your needs after discharge
Total discharge (max=5)
2.9±0.9
3.0
Total patient satisfaction: (max=5)
2.7±0.4
2.8
Perception of current health (max=5)
3.6±0.9
4.0
Therapeutic self care
2.4±1.5
2.0
 Knowledge of what medication to take
2.5±1.3
2.0
 Understand purpose of medications
2.7±1.1
3.0
 Able to take medications as prescribed
2.6±0.9
3.0
 Recognize body symptoms related to condition
2.8±1.0
3.0
 Understand symptoms related to condition
2.9±1.1
3.0
 Understand how to control changes
2.7±1.0
3.0
 Able to carry out treatments that have been taught
2.8±1.0
3.0
 Able to look after health in general
2.1±1.3
2.0
 Know whom to contact for help regarding daily activities
2.3±1.2
2.0
 Know whom to contact regarding medical emergencies
2.6±1.2
3.0
 Able to perform regular activities
2.8±1.2
3.0
 Able to adjust regular activities according to symptoms
Total (max=5)
2.8±0.5
2.8
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Table (5): Correlation of nurses and patients’ various domains scores
Spearman's rank correlation coefficient
Patients‘ scores
Nurses‘ scores
Inpatient
Total
Therapeutic
Discharge
Satisfaction
Satisfaction
Self-care
Structural empowerment
-0.26
-0.27
-.273**
-0.03
Psychological empowerment
0.02
0.02
0.02
0.02
Group process
0.14
0.13
0.13
-0.02
Empowered behavior
-0.03
-0.03
-0.03
0.11
Nursing care
0.05
0.04
0.04
0.03
Adverse events
-0.13
-0.14
-0.14
0.01
Job satisfaction
-0.01
-0.02
-0.02
0.17
Work environment
0.00
0.00
0.00
-0.02
Global empowerment
-0.15
-0.17
-0.17
-0.04
(**) Statistically significant at p<0.01
Table (6): Best fitting multiple linear regression model for the scores of job
satisfaction, empowered behavior, and adverse events scores
Constant
Structural
empowerment
Unstandardized
Standardized
Coefficients
Coefficients
B
Std. Error
Job satisfaction
2.10
0.57
0.40
0.19
0.22
95% Confidence
Interval for B
Lower Upper
t-test
p-value
3.67
<0.001
0.96
3.24
2.11
0.04
0.02
0.78
r-square=0.07, Model ANOVA: F=4.43, p=0.038
Variables entered and excluded: age, sex, experience, work department, all other scores of
empowerment, care, and adverse events
Empowered behavior
Constant
2.33
1.86
1.25
0.213
-1.37
6.03
Structural
0.99
0.41
0.24
2.44
0.017
0.19
1.80
empowerment
Group process
1.06
0.31
0.34
3.45
0.001
0.45
1.67
r-square=0.17, Model ANOVA: F=5.45, p=0.001
Variables entered and excluded: age, sex, experience, work department, all other scores of
empowerment, care, and adverse events
Adverse events
Constant
2.39
0.40
5.92 <0.001
1.59
3.19
Empowered behavior
-0.06
0.03
-0.21
-2.05 0.044
-0.12
0.00
r-square=0.11, Model ANOVA: F=3.43, p=0.021
Variables entered and excluded: age, sex, experience, work department, all other scores of
empowerment, care
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Work Environment: the Quality.
enj@nursing.cu.edu.eg
Table (7): Best fitting multiple linear regression model for the patient satisfaction
and self-care scores
Unstandardized
95% Confidence
Standardized
Coefficients
t-test p-value Interval for B
Coefficients
B Std. Error
Lower Upper
Patient satisfaction
Constant
3.67
0.41
8.95 <0.001 2.86
4.49
Structural
-0.28
0.09
-0.28
-2.94 0.004 -0.47
-0.09
empowerment
Group process
0.15
0.07
0.20
2.12 0.037
0.01
0.30
Female gender
-0.35
0.09
-0.37
-3.90 <0.001 -0.53
-0.17
r-square=0.21, Model ANOVA: F=8.95, p<0.001
Variables entered and excluded: age, marital status, nurse sex and experience,
department, hospital stay, all other scores of empowerment, care, and adverse events
Patient self-care
Constant
4.37
0.98
4.45 0.000
2.42
6.33
Psychological
0.18
0.09
0.21
2.03 0.045
0.00
0.35
empowerment
Female gender
-0.80
0.45
-0.18
-1.78 0.079 -1.70
0.10
Adverse events score -0.19
0.09
-0.21
-2.03 0.046 -0.38
0.00
r-square=0.10, Model ANOVA: F=3.50, p=0.019
Variables entered and excluded: age, marital status, nurse sex and experience,
department, hospital stay, all other scores of empowerment, care
DISCUSSION:
The present study was carried out
to test the hypothesis that the work
environment empowering characteristics
would have positive impacts on nurses‘
and patients‘ outcomes. The findings
indicate that certain empowering
characteristics of the work environment
do influence nurses‘ job satisfaction and
empowered behaviors, and patients‘
outcomes of satisfaction and self-care
abilities, which is in congruence with
Kennedy et al., (2014 ) who emphasized
the benefits of empowerment not only
for the nurses but also for the patients
and for the whole organization.
According to the current study
results, the structural empowerment was
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July 2015
the only element of the work
environment that significantly and
independently influenced nurse‘s job
satisfaction. This is quite conceivable
since the nurses who lack the resources
to carry out their duty would feel
frustrated and are often blamed for the
consequent poor quality of service. On
the contrary, a work environment that
supports the nurses through provision of
necessary supplies and equipment would
increase their level of job satisfaction. In
agreement with this, Meng et al., (2014 )
found that the structural empowerment
increased Chinese nurses‘ intent of stay
and decreased their burnout. However,
their study demonstrated also a positive
effect of psychological empowerment,
Work Environment: the Quality.
enj@nursing.cu.edu.eg
which was not shown in our study. This
might indicate the more need for
structural empowerment in our settings.
In congruence with this, Ibrahim et al.,
(2013 ) in a study in Alexandria, Egypt,
highlighted the importance of structural
empowerment and concluded that it is
the nurse managers‘ role to effect
positive changes in workplace structures
to improve quality.
Moreover, the present study
results indicated that the structural
empowerment was also significantly and
independently related to nurses‘
empowered behavior. This gives a
further importance to the structural
empowerment in the work environment
of the present study, which might be
attributed to the generally scarce
resources that are necessary to
accomplish the nursing care. In line with
this, Shields and Ward, (2009 ), in a
study in England, showed that the nurses
were mostly satisfied by improving the
structural aspects of their work
environment such as the opportunities of
training and promotion.
The current study has also
identified the group process as a positive
predictor
of
nurses‘
empowered
behavior. This is expected since the
group
process
elements
involve
interdependence,
support,
sharing
workload and cooperation. A work
environment having all these positive
and strengthening characteristics would
certainly lead to more empowered
behavior among nurses. In congruence
with this, Saxena and Rizk, (2014 ) in a
study in the United States, reported
about the importance of interdisciplinary
team work in empowering providers as
well as clients. On the same line,
Nicotera et al., (2014 ) demonstrated the
effectiveness of improving team
communication in increasing nurses‘
248
July 2015
empowered behaviors and decreasing
their conflicts.
Concerning the current study
nurses‘ perception of adverse events, the
results demonstrated that it is negatively
predicted by their empowered behavior.
Thus, having empowered nurses would
consequently lead to less adverse events
among their patients. This might be
attributed to the fact that an empowered
nurse is more capable of making proper
decisions that may decrease the
incidence of adverse events in her/his
unit.
In
agreement
with
this,
Warshawsky et al., (2013 ) reported that
the nurse managers in a study in the
United
States
described
some
characteristics
of
their
practice
environments that limit their role
effectiveness, and thus may jeopardize
patients‘
outcomes,
particularly
regarding safety.
The present study has also
examined the effects of empowering
work
environment
on
patients‘
outcomes. The first outcome assessed
was patient‘s satisfaction, which was
shown to be positively influenced by
group process but negatively influenced
by structural empowerment. The positive
effect of group process is expected given
the merits of real team work on patients‘
outcomes. However, the negative
relation to structural empowerment
needs to be further studied. It might be
related to the type of setting since the
perception of structural empowerment
may be different in private compared
with public setting as shown by
Hebenstreit, (2012 ). A similar positive
impact of empowered work environment
on patients‘ outcomes was demonstrated
by Purdy et al., (2010 ) in a study in
Canada.
Meanwhile,
and
in
disagreement
with
our
finding,
Armellino et al., (2010 ) reported that
Work Environment: the Quality.
enj@nursing.cu.edu.eg
structural empowerment is essential for
patient safety culture.
The second patient outcome
examined in the present study was that
of patient self-care. The study findings
revealed that it is positively influenced
by psychological empowerment, and
negatively correlated to adverse events.
This is plausible since the empowering
work environment leads to empowered
nurses‘ behaviors, and consequently
leads to more empowered and selfefficacious patients who are able to
achieve proper self-care, and thus the
potential adverse events are minimized.
In agreement with this, Saxena and
Rizk,
(2014 )
showed
that
an
interdisciplinary care with providers
work in a collaborative empowered
environment would decrease the risk of
fragmentation of care, with subsequently
having empowered patients who can
engage in self-care to achieve
therapeutic goals, change their lifestyle
habits, and share in decisions.
Lastly,
the present
study
demonstrated that patient‘s gender is an
independent predictor of both patient
outcomes, i.e. satisfaction and self-care.
The results demonstrated that female
patients have lower scores in both
outcomes. This might be attributed to the
more tolerant and less demanding nature
of male patients. In line with this, Elliot
et al., (2012 ) in a large survey study on
about 2 million patients in the United
States found that men tended to be
positive
towards
their
hospital
experiences while women were less
satisfied with nursing care, staff
responsiveness, and cleanliness. This
gender difference was also shown to
increase with advancing age of the
patient.
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July 2015
CONCLUSIONS:
The study findings lead to the
conclusion that an empowering work
environment enhances group process and
nurses‘ empowered behavior and job
satisfaction, with a positive impact on
their appraisal of patients‘ adverse
events and on patients' satisfaction and
self-care abilities, especially among male
patients.
RECOMMENDATIONS:
Based on results of the present study,
it is recommended that:
1. The hospital administration give
more attention to the factors that
foster
empowerment
in
the
workplace
through
suitable
organizational budgetary allocations
and provision of more authorities and
autonomy to nurses.
2. A safe skill-mix which includes
experienced nurses working each
shift to ensure that graduate and
beginner nurses are adequately
mentored and supervised.
3. Additionally, strategies must be
implemented to ensure effective,
collaborative
and
egalitarian
interdisciplinary
and
intraorganizational communication, with
adequate
remuneration,
and
manageable workloads.
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Association between Menstrual.
enj@nursing.cu.edu.eg
Association between Menstrual Disorders, Body Mass Index and Physical Activities
among Female Adolescents
Abstract
*Dr. Abeer Eswi BSN, MSN, PhD and **Dr. Hanan Fahmy BSN, MSN, PhD
Assistant Prof. of Maternity Nursing
Faculty of Nursing, Cairo University
Background, Adolescence is the transitional phase of physical and mental development between childhood
and adulthood and is characterized by immense of hormonal changes. The most striking change in
adolescent girls is the onset of menstruation.
Aim of this research, was to assess the relationship between menstrual disorders, body mass index and
physical activities among female adolescents. Methods: A descriptive correlational design was utilized for
the study .Setting, Faculty of Nursing, Cairo University, Egypt. Sample, a total of 120 female nursing
students were recruited by simple random sample according to the inclusion criteria: age ranged was from
19 to 22 years, free from medical diseases and unmarried. Tools, data were collected using a selfadministrated structured questionnaire which included data related to demographic data, assessment of
body weight, & height to calculate the body mass index, menstrual profile, premenstrual symptoms,
menstrual disorders as well as the daily physical activities. This tool was developed by the investigators.
Procedures, data were collected through self-administered questionnaire, and assessment phases Results,
of the present study revealed that the most common menstrual disorders among female adolescents were
dysmenorrhea( 65%) , Menorrhagia, postmenstrual spots, and passing of clots with menstruation. A
statistical significant relationship was found between menstrual disorders and underweight these were
significantly more common among female adolescents who were underweight ((p=.000). While, menstrual
disorders such as dysmenorrhea, and passing of clots with menstruation were significantly more common in
girls who ate junk food from 2 to 3 days per week (61.5%, and 57.1% respectively) (P= .000); and girls
who ate junk food only one day per week, who are eating less food (dieting) in order to lose weight had
Menorrhagia and postmenstrual spots (100%, and 68.2% respectively). (P=.000). However, menstrual
disorders such as dysmenorrhea, Menorrhagia, postmenstrual spots, and passing of clots with menstruation
were more common in girls who done physical activities from 2 to 3days per week (84.6%, 57.1%, 72.7%,
& 82.9% respectively). (P=. 000) Conclusion, the current study concluded that there was an association
between the menstrual disorders, Body mass index and Physical Activities among Female Adolescents
Recommendations, Based on the research findings, the following were recommended: The Need for
educating female adolescents regarding adopting healthy life style especially during menstruation;
promoting healthy eating habits should be emphasized which consequently prevent future problems such as
Polycystic Ovarian Disease, hyperlipidemia, obesity and infertility. Finally, female adolescents should get
consultation and referral in case of severe complaints during menstruation and menstrual irregularities or
disorders.___________________
Key Words; Menstrual Disorders- Body Mass index- Physical Activities- Female Adolescents
Introduction
Adolescence is the transitional
phase of physical and mental
development between childhood and
adulthood and is characterized by
immense hormonal changes. The most
striking change in adolescent girls is the
onset of menstruation.
The age of onset of menstruation or
menarche is generally between 11-15
years. Slight variations in the age of
menarche may occur according to the
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July 2015
nutritional status, hereditary pattern, and
climate difference (Lee, Chen, Lee,
&Kaur 2006).
Menstruation is a normal
physiological process that begins during
adolescence and may be associated with
various symptoms occurring before or
during the menstrual flow. Adolescent
girls constitute a vulnerable group,
where a female child is neglected one.
Menarche is a part of the complex
process of growing up. Menarche age is
Association between Menstrual.
enj@nursing.cu.edu.eg
the most widely used indicator of sexual
maturation
and is known to be
influenced
by
genetic
factors,
environmental conditions, body stature,
family size, body mass index (BMI),
socioeconomic status and level of
education. The mean age of menarche is
typically between 12 and 13 years
(Deliwala, 2013 ).
Menstrual cycles are a key driver
of reproductive events in women, which
is a physiological process and associated
with the ability to reproduce. Adolescent
girls are suffering from reproductive
health
morbidities
such
as
dysmenorrhea, pre-menstrual syndrome,
irregular menses, excessive bleeding
during menstruation which are common
in adolescent girls. Most of the
adolescent girls remain silent without
seeking health care. If these are not
treated early, they could lead to various
reproductive disabilities (Omidvar, &
Begum(2011 ) .
After
menarche,
common
menstrual abnormalities that the female
adolescent may encounter include
dysmenorrhea, irregularities in menstrual
flow and premenstrual symptoms. 75%
of girls experience some problems
associated with menstruation. These may
lead to problems in academic excellence,
achievements in sports as well as loss of
self image. (Pinola, Lashen, Bloigu,
Puukka, Ulmanen, & Ruokonen, 2012 )
Moreover, menstrual problems
are commonest gynecological disorders
among adolescent girls. Although not
life threatening, this affects their daily
life
and
work
efficiency
and
performance. This is a major cause of
absenteeism‘s in colleges and business
establishments. Data obtained from
253
July 2015
study carried out in Indian girls showed
that 87% of the females suffering due to
menstrual disorders were having stress
related to one or more reasons as like
studies, job, financial, or social issues.
While, the different Menstrual problems
experienced by these adolescent students
were Amenorrhea (0%), Oligomenorrhea
(6%),
Menorrhagia
(14%),
Hypomenorrhea /scanty bleeeeding
(2%),
Dysmenorrhea
(67%),
Premenstrual syndrome (84%)(Teixeira,
Oliveira, &
Dias, 2013). Health
education, regular routine medical
examination, adequate social support by
family,
school,
job
colleagues,
meditation, stress management program
and dietary improvements and total life
style modification can help to prevent
menstrual problems.Pandit (2014 ).
Rupa vani, Veena , Subitha ,
Hemanth kumar, & Bupathy (2013 )
suggested that change in dietary habit of
consuming more high energy junk food
and shifting to sedentary lifestyle is
likely to be one of the important
precursors of overweight and obesity
among adolescents. Food high in salt,
sugar, fat or calories and low nutrient
content is called junk food. Junk foods
provide suboptimal nutrition with
excessive fat, sugar, or sodium per kcal.
Numerous health risks have been
associated with adolescent overweight,
including hypertension,
respiratory
disease, several orthopaedic disorders,
diabetes mellitus and elevated serum
lipid concentrations. But not many
studies are done on their relation with
menstrual abnormalities. Hence, it is
important to evaluate the present
situation of eating habits and sedentary
lifestyle in adolescent girls and estimate
their influence on menstrual disorders.
Association between Menstrual.
Priy,
Saraswathi,
Saravanan,
Ramamchandran (2011).
enj@nursing.cu.edu.eg
&
Dysmenorrhea is the most
common gynecologic disorder among
female adolescents, with a prevalence of
60% to 93% (Teixeira, Oliveira, & Dias,
2013).
In
the
United
States,
dysmenorrhea is the leading cause of
recurrent short-term school absenteeism
(Singh*, Kiran, Singh, Nel, Singh &
Tiwari, 2008 ). Several studies have
shown
that
adolescents
with
dysmenorrhea report that, it effects their
academic performance, social and sports
activities (Cakir, Mungan , Karakas,
Girisken, Okten , 2007 ).
The
etiology
of
primary
dysmenorrhea
is
not
precisely
understood, but most symptoms can be
explained by the action of uterine
prostaglandins, particularly PGF2- Alfa,
the disintegrating endometrial cells
release PGF2- Alfa as menstruation
begins.
PGF2Alfa
stimulates
myometrial contractions, ischemia and
sensitization of nerve endings. These
levels are highest during the first two
days of menses when symptoms peak
(McEvoy, Chang, & Coupey, 2004). In
Addition, The risk factors for
dysmenorrhea are; age <20 years,
nulliparity, heavy menstrual flow,
smoking, high/upper socioeconomic
status; attempts to lose weight, physical
activity, disruption of social networks,
depression and anxiety ( French, 2005;
Singh*, Kiran, Singh, Nel, Singh &
Tiwari , 2008 ).
Both obesity and underweight are
associated with a high incidence of
menstrual disorders. The menstrual cycle
is usually 28–30 days. Women who have
a long or irregular cycle often exhibit
254
July 2015
ovulation disorders or decreased fertility.
When the body mass index (BMI) is 22–
23, the incidence of menstrual disorders
is the lowest. The risk of menstrual
disorders is double in women with a
BMI of 24–25 and Fivefold higher in
those with a BMI of 35 or more (Kurach,
Takashi, Abe & Omichi, 2005).
Significant
Menstrual problems are generally
perceived as only minor health concern
and thus irrelevant to the public health
agenda particularly for women in
developing countries who may face life
threatening condition. Menstrual cycle is
normal physiological process that is
characterized by periodic and cyclic
shedding of progestetional endometrium
accompanied by loss of blood which is
additional vital sign adds a powerful tool
to the assessment of normal development
and the exclusion of pathological
conditions in adolescent and young girls
(Begum, Hossain, &Nazneen (2009).
Some variety of menstrual
dysfunction occurs in adolescent girls
which may affect normal life of
adolescent and young adult women.
Physical, Mental, Social, Psychological,
Reproductive problems are often
associated with menstrual irregularities
and menstrual problems. Due to change
in life style, habits, diet, the prevalence
of obesity has increased in developed
world which results in decreased age at
menarche (Sunuwar, Saha, Anupa, &
UpadhyayDhungel, 2010 ). In addition,
nutritional status is frequently correlated
with irregularities of menstruation and
problems among the females in different
age groups (Dars, Sayed, & Yousufzai,
(2014 ).
Association between Menstrual.
enj@nursing.cu.edu.eg
Lot of studies have been done in
Egypt on the prevalence of menstrual
problems in adolescent girls, yet much
researches were not done on their
relation with lifestyle factors. In this
study we attempted to find a relation
between dietary habits like eating junk
food, dieting behavior, lack of physical
activity with the menstrual problems
experienced by the adolescent girls as
these are the risk factors which are
modifiable and intervention at this stage
might result in healthier adults. The
health information obtained from the
present study will be useful in
organizing and modifying health
program activities for young females
with a view to improve reproductive
health of women.
Aim of the research study
The aim of this research was to assess
the relationship between menstrual
disorders, body mass index (BMI) and
physical activities among adolescent
females at Faculty of nursing, Cairo
University.
Research questions
1. What is the relation between
menstrual disorders, BMI and
physical activities?
Subjects and Methods
Design
A descriptive correlational design
was adopted in this research to assess the
relationship
between
menstrual
disorders, body mass index (BMI) and
physical activities among adolescent
females at Faculty of nursing, Cairo
University.
Setting
This research was conducted at
Faculty of Nursing, Cairo University. It
is situated at Kaser Al-Aini region.
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July 2015
Sample
A total of 120 female nursing
students from (1st, 2nd, 3rd and 4th
year) were recruited for the research by
simple random method according to the
following inclusion criteria: Students
who were free from medical diseases,
unmarried, their age ranged from 19 to
21 years were chosen for the research.
Students who were suffering from any
chronic health conditions, used any
medicines for long duration (more than a
month), and previously diagnosed with
any gynecological disorders were
excluded from the study.
Data collection Tools
Data were collected by using self
- administered structured questionnaire
that was developed by the investigators
for the purpose of the study. Content of
tool was determined through an
extensive review of literatures about
menstruation, and its disorders. The
Questionnaire included four parts: the
first part included data related to
demographic characteristics as code,
age, academic year, height, weight, BMI,
and residence; the second part included
menstrual profile as age at menarche,
menstrual interval, menstrual duration,
menstrual
amount,
presence
of
dysmenorrhea; third part included
assessment for the presence of any
menstrual disorders as (menorrhagia,
Hypo-menorrhea , Oligomenorrhea,
Menometrorrhagia,
Polymenorrhea,
Secondary
Amenorrhea.),and
premenstrual
symptoms
as
( headaches or migraines,
breast
tenderness, aching muscles and joints,
nausea, vomiting, etc…..); and the forth
part included data related to the daily life
and physical activities as sports,
involvement
in
group
activities,
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involvement in daily home activities,
etc..
Ethical Consideration
An official permission was
granted
from
the
administrative
personnel in the Faculty of Nursing,
Cairo University. A written informed
consent was obtained from female
students to obtain their acceptance to
participate in the research. Students were
informed about the nature of the study.
The researchers introduced themselves
to the students who were willing to
participate and met the inclusion criteria
and informed them about the purpose of
the study, and all information gained
from them was confidential and their
participation was in a voluntary base.
The researchers assured that the research
posed no risks or hazards to the students.
Tool Validity
Validation of the tool was done
through submission to the panel of 5
experts in the field. Modifications were
carried out according to the experts'
judgments on the clarity of sentences
and the appropriateness of content. Some
items were deleted as type of foods and
drinks.
Pilot Study
The questionnaire was tested on
10 % of total sample of female students,
who subsequently were not included in
the study. The aim was to detect
ambiguity and estimate the time required
to fill the questionnaire.
Procedures:
An official permission was
obtained from the administrative
personnel in the Faculty of Nursing,
Cairo University. The subjects who were
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July 2015
willing to participate and met the
inclusion
criteria
were
recruited
randomly by the investigators. In order
to select a representative sample of
female students at faculty of Nursing
Cairo University, a simple random
sampling was used. Lists of all female
students at Faculty of Nursing in all
different academic years was obtained
from responsible person, these were used
to select a random sample of students by
using randomly generated numbers
through choosing the odd numbers
students who met the illegible criteria
from the lists . In order to recruit the
required sample (120 female students), it
was decided to recruit 25% of the
students in each academic year. Each
student was given a questionnaire(selfadministered questionnaire) to be
completed which included back ground
information about the female students
that entailed : age, academic year,
anthropometric Measurement of the
height and weight was done using a
portable digital weight scale with shoes
and heavy clothing removed, and BMI
was calculated as the student‘s weight in
kilograms divided by square of the
height in meters (kg/m2), and classified
into underweight (˂ 18.5kg/m2), normal
weight (18.5- 24.9kg/m2), overweight
(25- 29.9kg/m2), and obese (≥
30kg/m2);physical activities and dietary
habits were assessed, while the Physical
activities were assessed in terms of
number of days of regular physical
exercise per week (activities for >20
minutes that make them sweat) was
categorized as follows: one day of
physical exercise per week (category a);
2–3 days of physical exercise per week
(category b); 4–7 days of physical
exercise per week (category c) and no
regular physical exercise (Category d).
Similarly, the dietary habits were
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assessed in term of
junk food
consumption by assigning categorieseating junk food 1day/ week (category
a); eating junk food 2-3 days/ week
(category b); eating junk food 4-7 days/
week (category c) and eating junk foods
regularly (category d).; questions related
to menstruation, which elicited data
related to age at menarche, variation in
menstrual patterns like length of cycle,
duration of bleeding period, blood loss
per cycle, (in this study abnormal
menstruation was defined as subject with
length of cycles <20 or >35 days;
duration of flow <2 or >7days and loss
of blood per cycle >100ml),history of
dysmenorrhea,pre-menstrual symptoms.
Irregular menstrual cycles are defined as
past history of irregular cycles
experienced by the students within 6
months prior to the study. Interviewing
was carried out using the questionnaire
where each participant was given 20
minutes to complete the questionnaire;
they were advised not to write their
name on the questionnaire and were told
that, their responses would remain
confidential. The research investigators
supervised and facilitated the process of
data collection, and also, clarified any
difficult questions.
Statistical analysis
Collected data were coded and
tabulated using personal computer.
Statistical package for social science
(SPSS) version 18 was used. The
researcher used the descriptive as well as
inferential statistics. The descriptive
statistics include the arithmetic Mean as
an average, describing central tendency
of observation of each variable studied;
the standard deviation as a measure of
dispersion of results around the mean;
and the frequency distribution and
percentage of observation for each
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July 2015
variable studied were used. Statistical
significance was considered at p-value
<0.05.
Results
Findings of this research were
presented in two main sections: 1)
Description of the sample was displayed
in the first section; 2) Factors that might
affect menstruation were presented in the
second section.
Section I: Description of the sample
This section included four parts
a) Demographic & Life Style
characteristics of the study sample
included age, height, weight, and Body
Mass Index; b) Menstrual characteristics
included age at menarche, menstrual
(duration,
flow,
interval
and
consistency);
c)
Premenstrual
Symptoms, and Menstrual disorders; and
d) physical activities.
a) Demographic
&
Life
Style
Characteristics of the Study Sample:
Regarding to the age, 66.7% of
the studied sample their age ranged
between 19-21 years old and their mean
age was 19.6±1.27 and more than one
third (33.3%) of the studied sample aged
above 20 years old. Near two thirds of
the studied sample (63.3%) their height
ranged from157cm to 167 cm with mean
160.23±5.59 . Thirty- six point seven
percent of the studied sample weighed
between 61-70 kgm with mean weight
63.2 ± 5.5. As regarded to their body
mass index ( BMI)more than half of the
studied sample (56.7%) had normal
body weight (BMI = 18.5-24.9 kg/m2);
about third of the sample (31.7%) had
underweight (BMI= ˂18.5kg/m2);
while 11.6% had overweight (BMI= 2529.5 kg/m2); none of the study sample
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were obese with total Mean ± SD =
days/week), and 18.3% ate junk food (421.27±3.99 (table,1).Eighty-three point
7 days/week). Seventy percent of sample
four percent of the sample were from
were doing physical activities (2-3
urban areas, and 16.6% were from rural
days/week), and 17.5% were doing
areas. Thirty percent of the sample ate
physical activities ( 4-7 days/week)
less (had dieting), while 56.7% of the
(table, 1).
study sample ate junk food (2-3
Table (2)
Distribution of the studied sample in relation to Menstrual Characteristics (n=120 )
Menstrual characteristics
Age
menarche
at
No.
%
64
53.3
54
2
45.0
1.7
83
69.2
27
22.5
10
8.3
Scanty
8
6.7
Moderate
84
70
Heavy
28
23.3
Every 28 days
50
41.7
Every 30 days
48
40
11-13
14-16
17-19
Mean ± SD = 13.43±1.29
3-5
Duration
of
6-7
menstruation
˂7
Mean ± SD = 5.15±1.105
Menstrual flow
Menstrual
interval
More than 30 -35
22
days
18.3
b) Premenstrual symptoms
Regarding to complaints reported by the studied sample during menstruation ,
results revealed that most of the studied sample complained from fatigue, mood
changes, abdominal cramp, and backache (95%, 95%, 93.3%, and 80% respectively)
(table 3).
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July 2015
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Table (3) Distribution of the studied sample as regards Premenstrual Symptoms
(n=120 )
Premenstrual Symptoms
Yes
No.
%
No
No.
%
Abdominal cramp
112
93.3
8
6.7
Distention
81
67.5
39
32.5
Feeling of gases
67
55.8
53
44.2
Backache
96
80.0
24
20.0
Fatigue
114
95.0
6
5.0
Loss of appetite
75
62.5
45
37.5
Vaso-vagal attack
43
35.8
77
64.2
Nausea
59
49.2
61
50.8
Vomiting
22
18.3
98
81.7
Headache
52
43.3
68
56.7
Breast tenderness
69
57.5
51
42.5
Muscle cramp
62
51.7
58
48.3
Mood changes
114
95.0
6
5.0
d) Menstrual Disorders
As regard to menstrual disorders, 65% of the studied sample had no menstrual
problem, while, 35% had menstrual problems. Moreover, slightly near of two thirds of
the studied sample (65%) revealed that dysmenorrhea was the main menstrual problem;
one third of the studied sample (36.7%) revealed that post menstrual spots was the main
menstrual problems while, menorrhagia was the least reported problem that represented
(23.3%).In relation to passage of clots, more than half of the studied sample (58.3%)
passed clots with menstruation and more than one third of the them (32.5%) passed no
clots with menstruation(table, 4. Fig. 1).
Table (4) Frequency of menstrual disorders among the study Sample (n=120 )
Yes
No
Menstrual disorders
No.
%
No.
%
Dysmenorrhea
78
65.0
42
35.0
Menorrhagia
28
23.3
92
76.7
Post menstrual spots
44
36.7
76
63.3
Passage of Clots
70
58.3
50
41.7
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July 2015
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Fig, 1 Frequency of Menstrual Disorders Among Study Sample
c)
Daily living activities:
According to daily living activities, the two-third(75.8%) of the studied sample
didn't visit friends, 55.8% of them didn't involve in household activities, while, 70% of
them going to the faculty, 60% did their homework, and 92% of them took shower
during menstruation (table, 5).
Table (5)
Distribution of the studied sample in relation to daily Living activities during
menstruation (n=120 )
Daily activities
Visit friends
Going
faculty
to
%
No
91
75.8
Yes
29
24.2
36
30.0
Yes
84
70.0
No
48
40.0
Yes
72
60.0
No
9
7.5
Yes
111
92.5
No
67
55.8
Yes
53
44.2
the No
Doing homework
Taking shower
Involved
household
activities
No.
in
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July 2015
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e) Association between menstrual characteristics, diet and physical activities pattern
Results of this research study showed that menstrual disorders such as
dysmenorrhea, Menorrhagia, postmenstrual spots, and passing of clots with menstruation
were significantly more common among female adolescents who were underweight (
48.7%, 100%, 86.4%, and 54.3% respectively).(
χ2= 47.602 , χ278.81, χ96.44, and
50.299 respectively, p=.000). While, menstrual disorders such as dysmenorrhea, and
passing of clots with menstruation were significantly more common in girls who ate junk
food from 2 to 3 days per week (61.5%, and 57.1% respectively) (χ2= 57.94, and 52.23
respectively, P= .000); and girls who ate junk food only one day per week, who are
eating less food (dieting) in order to lose weight had Menorrhagia and postmenstrual
spots (100%, and 68.2% respectively). (χ2= 85.21 , 47.59 , 88.83 , and 34.69 respectively,
P=.000). However, menstrual disorders such as dysmenorrhea, Menorrhagia,
postmenstrual spots, and passing of clots with menstruation were more common in girls
who done physical activities from 2 to 3days per week (χ2= 57.83 , 84.6%, 57.1%, 72.7%,
& 82.9% respectively). (
P=. 000) (Table, 6).
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July 2015
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Table (6)
Association between menstrual characteristics and diet and physical activity pattern
Dysmenorrhea (n=78)
BMI
Underweight
Normal weight
Overweight
Dieting
Yes
No
Eating Junk Food
1 day/ week
2-3 days /week
4-7 days /week
Physical Activities
1 day/week
2-3 days/week
4-7 days/week
Menorrhagia (n= 28)
P
value
n
%
P value
Post menstrual Spots
(n= 44)
n
%
P value
n
%
38
40
0
48.7
51.3
0
.000
28
0
0
100
0
0
.000
38
6
0
86.4
13.6
0
.000
38
32
0
54.3
45.7
0
.000
36
42
46.2
53.8
.000
28
0
100
0
.000
36
8
81.8
18.2
.000
36
34
51.4
48.6
.000
30
48
0
38.5
61.5
0
.000
28
0
0
100
0
0
.000
30
14
0
68.2
31.8
0
.000
30
40
0
42.9
57.1
0
.000
12
66
0
15.4
84.6
0
.000
12
16
0
42.9
57.1
0
.000
12
32
0
27.3
72.7
0
.000
12
58
0
17.1
82.9
0
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Passage of Clots (n= 70)
n
%
P value
.000
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Discussion
In this research study the
investigators attempted to find a relation
between various lifestyle factors like
eating junk food, dieting behavior, lack
of physical activities with the menstrual
problems experienced by the adolescent
girls as these are the risk factors which
are modifiable and intervention at this
stage might result in healthier adults in
the future. The findings of this research
study were approved the research
question which is "what is the
association between Menstrual disorders,
Body Mass Index, and Physical activities
among Female Adolescents". Findings
of this research study found that dieting
behavior was observed in almost third of
the girls who had significantly
Menorrhagia,
dysmenorrhea
and
postmenstrual spots, and passage of clots
with menstruation.
The findings of this study were
very close to that is reported by Pinola
et.,al. (2012) who studied 1147 urban
Spanish adolescents, and found that
nearly 40% of the adolescents tried to
lose weight. Attempting to lose weight is
significantly associated with an increase
in
irregular
menstruation
and
dysmenorrhea. Also, these findings were
in agreement with that found by the
study done by Fujiwara et al. (2007)
among 18 to 20 year-old Japanese girls,
who reported that the intensity of
dysmenorrhea was high in those with a
history of dieting in adolescence,
suggesting that diet in adolescence has
long-lasting
adverse
effects
on
reproductive function in young women.
These findings warn us of the possibility
that diet limitation in adolescence can
become a trigger for the subsequent
development of organic gynecologic
diseases. Inadequate dietary habits may
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July 2015
influence women‘s quality of life not
only in the present but also in the future.
This might be due to nutritional
deficiency is considered one of the
important
factors
that
induce
hypothalamic-pituitary-ovarian
dysfunction, and recently, adolescents
have tended to lose body weight by
dietary restriction for cosmetic purpose.
Results showed that menstrual
disorders such as dysmenorrhea, and
passing of clots were significantly high
among girls who were eating junk food
from two to three days per week
(P=0.000 ). Results revealed that more
than half of the adolescent females
consumed junk food. These findings
were similar to the findings of Fujiwara,
Sato, Awaji, Sakamoto, & Nakata
(2009 ) who found an association
between fast food consumption and
dysmenorrhea. This might be due to
Junk foods being rich in saturated fatty
acids which might interfere with the
metabolism of progesterone in the luteal
phase of menstrual cycle and resulted in
menstrual disorders. Moreover, Junk
foods being deficient in micronutrients
like vitamin B6, calcium, magnesium
and potassium, which might also be
responsible for triggering menstrual
disorders.
Results revealed that menstrual
disorders such as dysmenorrhea,
Menorrhagia, postmenstrual spots, and
passage of clots were also significantly
high in girls who done physical activities
two to three days per week (P=0.000 )
and this findings were similar to the
study findings which done by Teixeira,
Oliveira, & Dias(2013 ) and Seedhom,
Mohammed, & Mahfouz (2013 ) while
found similar association between
menstrual disorders and physical
Association between Menstrual.
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activities. However, in the study done by
Lee, et al.(2006 ) who reported that there
no association was found between
physical activities and menstrual
disorders, and this contradictory in the
results came from that study done by Lee
et al. focused on whether the subjects
exercised in the seven days prior to the
study. But in the current study the
investigators concentrated on how
regular the subject was doing physical
exercise.
Conclusion
There was an association
between the menstrual problems and
lifestyle factors. Menstrual Disorders
were significantly more common among
girls who were underweight, in girls who
were eating junk food, who are eating
less food (dieting) in order to lose weight
and in those who were doing regular
physical activity. Also, concluded that
life style modifications like regular
physical activity, decreasing the intake
of junk food, and promoting healthy
eating habits should be emphasized
which consequently prevent future
problems such as Polycystic Ovarian
Disease, hyperlipidemia, obesity and
infertility.
Recommendations
Based on the research findings,
the following was recommended:
- Need for educating female adolescents
regarding adopting healthy life style
especially during menstruation.
-Female Adolescents should getting
consultation and referral in case of
severe complaints during menstruation
and menstrual irregularities or disorders.
-
Future research should be done
with large sample size, various
settings and utilization of
different design.
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July 2015
Limitations of the Study:
Collection of data from only one
setting, this is hinder the generalizability
of the study findings
Acknowledgment:
Our sincere gratitude and thanks for the
students who agreed to participate in the
study and gave us the opportunity to
accomplish
it,
Also,
to
the
administration of Faculty of Nursing,
Cairo University.
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Impact of a Nursing Educational Program.
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Impact of a Nursing Educational Program about Early Detection and Management
of Cardiac Arrhythmias on Critical Care Nurses’ Knowledge and Practices
Gehan A. Younis 1 and Safaa E. Sayed Ahmed 2
Lecturers of Critical Care Nursing,
Faculty of Nursing, Tanta University, Egypt
1
Corresponding author: gehan.younas@nursing.tanta.edu.eg.
ABSTRACT: Cardiac arrhythmias are a common problem encountered in the Coronary Care Unit (CCU)
and represent a major source of morbidity and they lengthen hospital stay. Critical care nurses are
responsible for arrhythmia monitoring. They are responsible, professionally and legally for arrhythmia
detection, as well as providing total and direct care for patients within the CCU. This study aimed to
evaluate the impact of a nursing education program about early detection and management of cardiac
arrhythmia on nurses‘ knowledge and practices. To achieve this aim, a quasi-experimental research design
was utilized. The study was carried out in the Intensive Cardiac Care Unit at Tanta University Hospital.
A convenient sample of thirty five critical care nurses was included, with one group, before and after
intervention. Two tools were used for data collection: Tool I: nurses interview questionnaire and Tool II:
an observational checklist for nurses‘ practice regarding detection and nursing intervention of arrhythmia.
Hypotheses: H1: the post test mean knowledge scores of critical care nurses who are exposed to
educational program will be higher than pretest mean knowledge scores. H2: the posttest mean practice
scores will be higher than pre-test practice score. Results: the majority of nurses (91.4%) had poor
knowledge scores about cardiac arrhythmia in the pre-test as compared with (100%) and (88.6%) of them
had good knowledge score immediately and after 6 weeks of program implementation respectively. A
minority of nurses (2.9%) had good practice scores about cardiac arrhythmia in the pre-test as compared to
the majority (94.3%) and (100%) of them had good practice score immediately after and 6 weeks after the
educational program respectively. Also, the mean post test knowledge and practice scores immediately and
6 week after program (38.94±2.363 , 35.94±4.734 ), (70.80±3.411 , 66.63±1.816 ) differed significantly
than the mean pre-test knowledge and practice scores (19.09±8.265 ), (54.34±4.130 ), respectively with
P<0.05.
Conclusion: The mean posttest knowledge and practices scores (38.94±2.363 , 70.80±3.411 ) about cardiac
arrhythmias were improved significantly immediately after program. However, mean post test score was
reduced to (35.94±4.734 , 66.63±1.816 ) respectively after 6 weeks of program implementation. Based on
findings of the study it is recommended to carry out continuing educational programs for updating
knowledge and skills of nurses working in Coronary Care Unit regarding early detection and management
of cardiac arrhythmias; establish a written updated guideline about cardiac arrhythmias to ensure enough
knowledge and safe nursing practice.
Key words: cardiac arrhythmia, coronary care unit, critical care nurses‘ knowledge and practices.
INTRODUCTION:
Cardiac
arrhythmias are a common problem
encountered in the Coronary Care Unit
(CCU) and represent a major source of
morbidity and they lengthen hospital
stay. Arrhythmias are most likely to
occur in patients with structural heart
disease. It is abnormal electrical
conduction within the cardiac muscle
that causes the heart to beat too slowly,
too fast or irregularly. Arrhythmias
represent the main cause of death as they
may reduce pumping efficiency of the
myocardium and lead to heart failure.
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However, certain arrhythmias pose these
threats while others can be tolerated
without serious consequences (1, 2, 3). Life
threatening cardiac arrhythmias that
cause sudden cardiac death claims more
than a thousand lives a day (Ann 2007 )
worldwide, and cardiovascular disease is
estimated to be leading cause of death in
the world 2020 (4,5).
The risk factors for arrhythmias
may include hypoxia, infection, cardiac
ischemia,
catecholamine
excess
(endogenous or exogenous), or an
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electrolyte abnormality (1). Cardiac
arrhythmias vary in severity, from those
that are mild and require no treatment
such as sinus arrhythmia to catastrophic
ventricular fibrillation, which requires
immediate resuscitation (6). In many
instances, cardiac arrhythmias are
symptomless and in this case, doctors
suggest having an electrocardiogram of
the patient‘s heartbeat for the diagnosis
and monitoring prognosis of cardiac
arrhythmias (7).
The electrocardiogram (ECG) is
a noninvasive and inexpensive technique
that has become the most commonly
conducted cardiovascular diagnostic
procedure and a fundamental tool of
clinical practice. It is indispensable for
the diagnosis and prompt initiation of
therapy in patients with acute coronary
syndromes and is the most accurate
means of diagnosing intra-ventricular
conduction
disturbances
and
arrhythmias. It contains a wealth of
diagnostic information routinely used to
guide clinical decision making in
hospitalized patients (8, 9). Abnormal heart
rhythms and their accompanying cardiac
symptoms often come and go in a transient
manner, they may be difficult to detect.
Tests such as electrocardiograms only allow
a doctor to look at the heart‘s activity at one
point in time. Until a patient is diagnosed
with an arrhythmia, he or she may be at risk
for future symptoms. Therefore continuous
cardiac monitoring is necessary for the
continuous observation of cardiac function
over time so the doctor can make an
accurate diagnosis (10, 11).
The goals of using cardiac
monitor have expanded from simple
tracking of heart rate and basic rhythm to
the diagnosis of complex arrhythmias,
the detection of myocardial ischemia,
and the identification of a prolonged QT
interval. A major improvements have
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occurred in uses of cardiac monitoring
systems which include computerized
arrhythmia detection algorithms, STsegment, ischemia monitoring software,
multi lead monitoring, and reduced lead
sets for monitoring-derived 12-lead
ECGs with a minimal number of
electrodes (12). Despite these advances in
technology, the need for human
oversight in the interpretation of ECG
monitoring data is important today
because cardiac monitor algorithms are
intentionally set for high sensitivity at
the expense of specificity. As a result,
numerous false alarms occur that must
be evaluated by healthcare professionals
so that over treatment of patients will not
occur (13, 14).
Critical care nurses have
traditionally been responsible for
arrhythmias monitoring. They may be
responsible, professionally and legally
for arrhythmias detection, as well as
providing total and direct care for
patients within CCU. Lack of knowledge
regarding cardiac status may result in a
generalized
care
unit
nurse
unintentionally placing the patient in a
life-threatening situation, a situation
which reflects patient fragmentation (15).
So, the aim of this study is to evaluate
the impact of a nursing educational
program about early detection and
management of cardiac arrhythmias on
critical care nurses‘ knowledge and
practices.
SUBJECTS & METHOD
Aim of the study: To evaluate the
impact of a nursing educational program
about early detection and management of
cardiac arrhythmia on critical care
nurses‘ knowledge and practices.
Research hypotheses:
H 1: The post test mean knowledge
scores of critical care nurses who are
exposed to educational program will be
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higher than the pretest mean knowledge
scores.
H 2: The post test practice score will be
significantly higher than pre-test practice
score.
SUBJECTS
Research design: A quasi experimental
research design (pre- test/ post test
design) was utilized in the current study.
Setting: The study was carried out in the
Intensive Cardiac Care Unit at Tanta
University Hospital.
Variables: The independent variable is
the educational program while the
dependant
variables
are
nurse's
knowledge and practices related to
cardiac arrhythmia.
Subjects:
A convenience sample consisted of thirty
five critical care nurses who were
working in the selected setting was
included. The inclusion criteria were:
both sexes, having responsibility
concerned with direct patient care,
having educational status at least
diploma in nursing, and at least 6 months
of working experience in selected unit.
The exclusion criteria: Subjects who
refused voluntarily to participate in the
study, or attended courses or workshops
about cardiac arrhythmias.
Tools: Two tools were developed by
researchers after reviewing relevant
literature and used to collect data
pertinent to the current study.
Tool
I:
Nurses’
interview
questionnaire, it consisted of two parts:
Part A: Nurses’ socio-demographic
data, to assess data related to age, sex,
marital status, years of experiences and
level of education.
Part
B:
Nurses’
knowledge
questionnaire (4, 7)
to assess nurses‘
knowledge regarding identification and
management of cardiac arrhythmias. It
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was used three times; before,
immediately after and 6 weeks after the
educational program. It consisted of 40
questions divided into four domains as
follow:
 1: Definitions, causes and types of
most common arrhythmias (10
questions).
 2: Symptoms and complications of
arrhythmia (5questions).
 3: Diagnosis and representation of
most common cardiac arrhythmias on
the ECG (12 questions).
 4:
Nursing
management
of
arrhythmias (13 questions).
Scoring system: Each correct answer
(for multiple choice questions) was
given one score and the wrong answer
was given zero score. Each short answer
question was given 2 scores for correct
and complete answer, one score for
incomplete answers, and zero score for
incorrect answers. The total scores of
knowledge assessment questionnaire
were 56. They were classified as: score
less than 50% were considered as poor,
score 50% to less than 75% were
considered as fair, and score more than
75% were considered as good.
Tool II: An observational checklist for
nurses’ practice regarding detection
and
nursing
intervention
for
(4, 14)
arrhythmias
This
tool
assesses
nurses
performance related to detection and
management of cardiac arrhythmias. It
included 39 steps divided into four
domains;
1: Nurses‘ role during preparation of
bedside cardiac monitoring (9 items),
2: Nursing care during preparation of
ECG machine (16 items),
3: Monitoring of vital signs during ECG
changes (5 items),
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4: Nursing care after identification of
ECG changes (9 items).
Scoring system: Two scores were
allotted for complete and correct step,
one score for incomplete and correct
done step, and zero score was given to
incorrect or not done step.
The
total
scores
of
practice
observational checklist were 78. The
higher scores indicated higher level of
practice. They were classified as: scores
< 50 % were considered as poor, scores
from 50 % to < 75% were considered as
fair, and scores > 75% were considered
as good practice level.
Tools validity and reliability: The
content validity of the developed
knowledge
questionnaire
and
observational checklist tools was done
by revision of five panels of experts in
medical surgical and critical care nursing
department to ensure their validity. The
reliability
of
the
knowledge
questionnaire was confirmed by using
Crobach alpha test and it was 0.95. The
reliability of the practice was confirmed
by using Crobach alpha test and it was
0.89.
Pilot Study: A pilot study was carried
out on 5 nurses to test the developed
tools for the clarity, applicability,
feasibility & relevance of the tools used.
Modifications on tools were done and
the 5 nurses were excluded from the
final study sample.
Procedure: The study was carried out
through three phases (Preparatory,
implementation and evaluation phases):
1. The preparatory phase: This phase
was concerned with obtaining an
official permission to conduct the
proposed study from the ethical
committee and hospital directors.
Participation in this study was
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voluntary. Each subject was informed
about the purpose, procedure,
benefits, and nature of the study and
that he/she had the right to withdraw
from the study at any time without
any rationale. Confidentiality and
anonymity of each subject was
assured through coding of all data.
Data collection for this study was
carried out in the period from August
2014 until February2015.
The researchers reviewed the
related literature and a designed
program was developed based on the
needs and requirements that were
translated to objectives of the
program. As well, this phase was
concerned with constructing, testing
and piloting different data collection
tools.
Also,
the
managerial
arrangements were obtained to
conduct the current study. Nurses
were interviewed individually to
know the nature and purpose of the
study. The researchers selected
teaching methods which were
lectures, small group discussion, and
problem solving situations. Teaching
aids such as audiovisual materials on
electrocardiogram recording rhythm,
interpretation, and effective technique
of cardio pulmonary resuscitation
with handouts that covered theoretical
and practical parts. Also, data show,
pen and paper were used.
2. The implementation phase: Data
were collected throughout three
phases of assessment. The first phase
was carried out prior to conducting
the program using two tools to have
base line data about nurse‘s
knowledge and practice about
detection and management of cardiac
arrhythmias. The second phase of
assessment was done immediately
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after program, and the third phase
was carried out after six weeks of
implementing the program to evaluate
the impact of the program. A pre-test
was carried out individually for each
nurse to assess knowledge regarding
cardiac arrhythmias. The time taken
for pre-test was one hour to fill out
the questionnaires.
Regarding practices, each nurse
was observed individually before
implementation of the educational
program to evaluate the practices
regarding detection and management
of cardiac arrhythmias in the
intensive care unit. It took an average
of 15-30 minutes for each to
complete.
A booklet containing the
component of the program based on
literature review and the results of
pretest evaluation was prepared in
Arabic
language
and
was
supplemented
by
photos
and
illustrations to help the nurses
understanding of the contents. An
educational program was carried out
for all nurses in educational class
room in the intensive care unit. The
program consisted of eight sessions:
four sessions were conducted for four
consecutive days for the theoretical
part and four sessions were conducted
for four consecutive days for practical
part.
Every
session
took
approximately one hour. The teaching
program was conducted in small
groups (5-7 nurses/session).
For the theoretical part: Four
sessions were used for four
consecutive days one hour for each
session. Session one of the program
consisted of explaining aim of the
study, introduction about arrhythmias,
definition, causes, and predisposing
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factors, and importance of detecting
arrhythmia; Session two consisted of
diagnosis and representation of most
common arrhythmias on the ECG,
symptoms and complications of
arrhythmia; Session three consisted
of treatment and nursing management
of arrhythmia; Session four was
carried out for revision and open
discussion between researchers and
subjects.
Each
nurse
was
supplemented with the knowledge
booklet and received printed materials
with guidelines after each session.
During the classes, nurses were
encouraged to ask questions and
provide feedback. Communication
was kept open between the
researchers and the nurses. Teaching
methods utilized were lectures, group
discussions, and demonstrations.
Immediately post, and after six weeks
of the program, knowledge tests were
carried out.
For the practical part: four
sessions were used for four
consecutive days one hour each.
Subjects were divided into small
groups (5-7 nurses) in each group.
Session one included, diagnosis of
arrhythmias, nursing role during
preparation and application of ECG
machine. Session two covered
nursing care during preparation and
application of cardiac monitor.
Session three consisted of nursing
management of detected arrhythmias.
Session four involved demonstration
and re-demonstration the practical
part of program. Teaching media
included group discussion with power
point and real case study.
3. The evaluation phase: This phase was
carried out immediately and after six
weeks of implementing the program.
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Each nurse was evaluated to determine
the effect of the program performance
using tools II.
Limitations of the study:
- The sample size was restricted due to
administrative constraints.
- This study was limited to the staff
nurses
working
in
previously
determined settings (CCU).
Statistical analysis: The analysis was
performed using statistical software
SPSS version 18.
 For quantitative data, the range, mean
and
standard
deviation
were
calculated.
 For qualitative data, a comparison
between groups before and after
intervention was done by using Chisquare test. For a comparison between
more than two means, the F-value of
ANOVA
was
calculated.
A
significance was adopted at P<0.05
for interpretation of results of tests of
significance. Person‘ correlation
coefficient (r) was used for
comparison between quantitative
variable
Results
Regarding
sociodemographic
characteristics, the age of the studied
nurses ranged from 20-40 years with a
mean age of 29.06±6.005 years. The
majority (94.3%) of sample was females
and about two thirds (62.9%) were
married. As regards the level of
education, about two thirds (62.9%) of
studied nurses had bachelor degree and
28.6% of them had technical nursing
diploma and only 8.6% had diploma
nursing school. Regarding years of
experience, about 48.6% of nurses had
years of experience ranged from one to
four years and more than one third (40%
) of them had ten years or more, see Fig
1.
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July 2015
Table (1) shows comparison of total
and subtotal mean knowledge scores
among the studied nurses throughout
different assessment times. In this
table, statistical significant differences
were observed in relation to all four
domains of basic knowledge about
arrhythmia at P<0.05. Also, the total
mean score of four basic knowledge
domains was increased immediately
after the program (38.94±2.363 ) as
compared to mean score before the
program (19.09±8.265 ) and it was
decreased again after six weeks of the
program (35.94±4.734 ).
Table (2) shows comparison of nurses’
mean knowledge scores in relation to
definitions, causes and types of most
common
cardiac
arrhythmia
throughout different assessment times.
In this table, significant statistical
differences were observed in relation to
definition
of
arrhythmia,
atrial
fibrillation,
atrial
flutter,
WolffParkinson-White syndrome, premature
ventricular contractions, ventricular
tachycardia, and ventricular fibrillation,
a bundle branch block, causes and types
of cardiac arrhythmias throughout period
of the study with P<0.05. Also, the mean
knowledge score of this domain was
increased immediately after the program
(11.20±0.868 )
compared
to
(6.77±2.157 ) before the program and it
was decreased gradually after 6 weeks of
the program (10.17±1.403 ).
Table (3) represents comparison of
nurses’ mean knowledge scores in
relation
to
symptoms
and
complications
of
arrhythmia
throughout different assessment times.
This table shows that the mean
knowledge scores of nurses in relation to
symptoms of arrhythmia, symptoms
associated with complete heart block,
problems
associated
with
atrial
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fibrillation after 24 hours, complications
of atrial flutter, methods of diagnosis of
cardiac arrhythmia, and problems
associated with prolonged QT>0.50
were increased immediately after the
program and decreased gradually after 6
weeks. Significant statistical differences
were observed regarding these items
with P<0.05. In addition, the total mean
knowledge score of this domain was
increased (4.60±0.604 ) immediately and
decreased gradually (3.77±1.239 ) after
six weeks of the program.
Table (4) shows comparison of nurses’
mean knowledge scores in relation to
diagnosis and representation of most
common
cardiac
arrhythmias
throughout different assessment times.
This table shows that the total mean
scores of nurses‘ knowledge regarding
methods of diagnosis of cardiac
arrhythmia, best lead for monitoring
arrhythmias, duration of normal P wave,
QRS
wave
and
Q-T
interval,
representation of atrial flutter, atrial
fibrillation, ventricular premature beats,
ventricular tachycardia and bundle
branch block on the ECG were increased
immediately
after
the
program
(11.31±0.993 ) and decreased gradually
after 6 weeks (10.40±1.594 ) compared
to (4.11±2.908 ) before the program.
Significant statistical differences were
observed regarding all items of this
domain with P<0.05.
Table (5) represents comparison of
nurses’ mean knowledge scores in
relation to treatment and nursing
management
of
arrhythmia
throughout different assessment times.
This table shows that the total mean
nurse‘s knowledge scores regarding
arrhythmia treatment, first-line treatment
for the ventricular fibrillation and
tachycardia, uses of beta-adrenergic
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July 2015
blockers, DC shock uses, adverse
reactions of anti- arrhythmic drugs,
nurses‘ role during episodes of
ventricular tachycardia, nurse's role
during frequent premature ventricular
fibrillation, causes of using cardiac
massage for rapid rate atrial fibrillation,
nurse's role for patient with eight PVCs
in one minute on cardiac monitor,
priorities of care for ventricular
fibrillation in CCU and number of
compression to breathing rate in CPR
were increased immediately and 6 weeks
after the program. Significant statistical
differences were observed regarding
these items with P<0.05. The total mean
score of this domain was 5.89±3.402
before the program and increased to
11.83 ±1.175
and
11.60±1.735
immediately and six weeks after the
program, respectively.
Table (6) shows comparison of total
and subtotal mean practice scores
among the studied nurses throughout
different assessment times. Statistical
significant differences were observed in
relation to preparation of bedside cardiac
monitoring,
nursing
care
during
preparation of 12 lead ECG and
monitoring of vital signs domains where
P<0.05. On the other hand, no statistical
significant difference was observed in
relation to domain of nursing care after
identification of ECG changes while P ≥
0.05. In addition, the total mean
practices score was 54.34±4.130 before
the program and increased to
70.80±3.411 immediately after the
program while after six weeks of the
program was 66.63±1.816 .
Table (7) shows comparison of nurses’
practice in relation to preparation of
bedside
cardiac
monitoring
throughout different assessment times.
This table represents that more than two
thirds (71.4%) of nurses provided proper
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skin preparation before placing cardiac
monitor electrodes before the program
compared to the majority (94.3%) of
sample done it correctly immediately
after the program and increased to 100%
after 6 weeks of the program with
P<0.05. On the other hand, none of the
sample determined goals of monitoring
for each patient before the program
while all studied nurses done it
immediately after the program and
decreased to 91.4 % after 6 weeks of the
program.
In addition, nearly half of the sample
(51.4 %) checked that alarms were set to
the ―ON‖ position before the program
compared to 100% of them done it
correctly immediately and 6 weeks after
the program and a significant difference
was observed with P<0.05. Also, the
majority (94.3 %) of nurses didn‘t select
the leads to be displayed before the
program while less than half of them
(48.6%) done it correctly immediately
after the program and decreased to only
2.9 % after 6 weeks with P<0.05. Also,
the minority of sample (2.9 %) obtained
a rhythm strip in the patients record
correctly before the program while all of
them done it correctly immediately after
the program and the percentage
decreased to 77.1% after 6 weeks. Also,
none of the sample measured PR, QRS
and QT interval before the program
compared to 42.9%, 48.6 % and 42.9 %,
respectively
measured it correctly
immediately after the program with
P<0.05.
Table (8) shows comparison of nurses’
practice in relation to nursing care
during preparation of 12 lead ECG
preparation of bedside cardiac
monitoring
throughout
different
assessment times. In this table it was
observed that the majority of nurses (80
%) checked cables before connection of
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July 2015
ECG leads before the program and all of
them done it correctly immediately and
after 6 weeks of the program. Also more
than half of nurses (54.3%) explained
the procedure to the patients before the
program compared to all studied nurses
immediately after the program and the
percentage decreased to 74.3% after 6
weeks. In addition, minority of nurses
(28.6%) exposed only the necessary
parts of the patient's body during
preparation of ECG before the program,
and the percentage increased to 77%
immediately after the program and
decreased to 54.3% after 6 weeks.
Regarding correct site of ECG lead,
only 11.4% of nurses identified the
angle of sternal notch before the
program compared to all of them (100%)
done it correctly immediately and 6
weeks after the program. Nearly one
third (34.3%) of nurses placed lead V1
and V2 at correct site before the program
while all of nurses done it correctly
immediately and 6 weeks after the
program. Also, 71.4% of nurses placed
lead V3 in correct site before the
program compared to the other two
periods of the study.
Low percent (2.9%) and (22.9%) of
nurses placed lead V4, V5 at correct site
before the program respectively, while
all of them done it correctly immediately
after the program and decreased to 71.4
% and 68.6 % after 6 weeks of the
program respectively. Also more than
half of nurses (54.3%) placed lead V6 at
correct site before the program while all
of them done it correctly immediately
after the program compared to 97.1% of
them after 6 weeks of the program.
There were significant statistical
improvement among these items
(P<0.05).
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Table (9) shows comparison of nurses’
practice in relation to monitoring of
vital signs to detect cardiac
arrhythmia
throughout
different
assessment times. It was observed that
about one quarter (11.4%) of nurses
before the program Palpated and noted
pulse rate and its regularity but the
percentages was changed immediately
and 6 week after the program to be
100% and 54.3%, respectively.
Also the minority (14.3%) of studied
samples noted the presence of extra and
dropped heartbeats before the program
while the majority of them (71.4%) done
it correctly immediately after the
program and decreased to 34.3 % after 6
weeks. As regards checking presence of
pulsus alternans, bigeminal pulse, or
pulse deficit, more than one quarter
(25.7%) of nurses done it correctly
before the program while the percentage
was changed immediately and 6 week
after the program to 51.4 % and 28.6 %,
respectively.
Table (10 ) shows comparison of
nurses’ practice in relation to nursing
care after identification of ECG
changes
throughout
different
assessment times. In this table, no
significant statistical changes were
observed among the studied sample in
relation
to
calling
physicians,
applying lead in correct site,
administering O2 therapy and giving
medications as doctor order throughout
the three periods of assessment times.
Also this table reports that none of the
sample
used
stress
management
behaviors correctly pre program and the
percentage increased to more than two
thirds (62.9%) immediately after the
program and decreased again to 25.7%
after six week, where P<0.05.
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July 2015
On the other hand, the majority of
nurses
(94.3%)
initiated
Cardio
Pulmonary Resuscitation (CPR) and
monitored laboratory studies correctly
before the program and the percentage
increased to 100 % immediately and
after six weeks. In addition, the majority
(85.7%) and (88.6%) of the sample
prepared the patients for elective cardioversion and assisted with insertion of
pacemaker respectively before the
program and it improved to 100%
immediately and sex weeks after the
program with significant statistical
differences, where P<0.05.
Table (11 ) shows distribution of the
total knowledge and total practice
scores of the studied nurses
throughout different assessment times.
This table reveals that the majority of
nurses (91.4%) had poor knowledge
score about cardiac arrhythmia before
the program as compared to 100% and
88.6% of them had good knowledge
score immediately and after 6 weeks of
the program, respectively.
According to the total practice score
throughout period of study, this table
reveals that the minority of nurses
(2.9%) had good practice score about
cardiac arrhythmia before the program
compared to the majority (94.3%) and
(100%) of them had good practice score
immediately and after 6 weeks of
program, respectively.
Table (12 ) represents correlation
between total knowledge scores, total
practice scores, age and years of
experience of the studied sample
throughout different assessment times.
There was no statistical significant
correlation between nurses‘ total
knowledge score and age, and years of
experience at pre and post 6 weeks of the
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educational program, where r=0.28 ,
r=0.03, and r=0.19, r=0.27, respectively.
and age and years of experience before
and immediately after the program
where r=0.66, r=0.63, and r=0.37,
r=0.35, respectively.
Also,
significant
statistical
correlations were observed in this table
between total practice score of nurses
Fig 1: Distribution of the studied nurses according to their socio-demographic data.
Table (1): Comparison of Total and Subtotal Mean Knowledge Scores among the
Studied Nurses Throughout Different Assessment Times.
Mean ± SD
Assessment time
Domains of basic
knowledge
Pre
program
Immediately
Post
Post
6 weeks
F
6.77±2.157
11.20±0.868
10.17±1.403
76.481
2.31±1.388
4.60±0.604
3.77±1.239
36.740
3. Diagnosis and representation
of cardiac arrhythmias
4.11±2.908
11.31±0.993
10.40±1.594
134.60
8
4. Treatment
and
nursing
management of arrhythmia
5.89±3.402
11.83±1.175
11.60±1.735
74.549
Total
19.09±8.26
5
38.94±2.36
3
35.94±4.73
4
124.91
8
1. Definitions, causes and types
of cardiac arrhythmia
2. Symptoms and complications
* Significant at level P˂0.05.
276
July 2015
P
0.000
*
0.000
*
0.000
*
0.000
*
0.000
*
Impact of a Nursing Educational Program.
enj@nursing.cu.edu.eg
Table (2): Comparison f Nurses’ Mean Knowledge Scores in Relation to Definitions,
Causes and Types of Most Common Cardiac Arrhythmia Throughout Different
Assessment Times.
Items of domain (1)
Pre
program
0.89±0.323
0.51±0.507
0.46±0.505
Mean ± SD
Immediately
Post
1.00±0.000
1.00±0.000
0.91±0.284
0.37±0.490
F
P
1.00±0.00
0.91±0.284
0.97±0.169
4.387
20.891
22.876
0.015 *
0.00 *
0.00 *
0.66±0.482
0.54±0.505
2.984
0.055
0.26±0.443
0.94±0.236
0.69±0.471
26.585
0.00 *
1.6 Definition
of
Premature
0.74±0.443
ventricular contractions
1.7 Definition
Ventricular
0.46±0.505
tachycardia
1.8 Definition
Ventricular
0.63±0.490
fibrillation
1.9 Causes of Arrhythmias
1.20±0.759
1.10 Types of Arrhythmias
1.26±0.741
Total
6.77±2.157
1.00±0.000
0.91±0.284
6.491
0.002 *
0.91±0.284
0.83±0.382
12.854
0.00 *
0.97±0.169
0.86±0.355
8.102
0.001 *
1.97±0.169
1.83±0.382
11.20±0 .868
1.94±0.236
1.51±0.507
10.17±1.403
30.410
9.025
76.481
0.00 *
0.00 *
0.000 *
1.1 Definition of arrhythmia
1.2 Definition of Atrial fibrillation
1.3 Definition of Atrial flutter
1.4 Definition
of
Paroxysmal
supraventricular tachycardia
1.5 Definition of Wolff- ParkinsonWhite syndrome
Post 6 weeks
Table (3): Comparison of Nurses’ Mean Knowledge Scores in Relation to Symptoms
and Complications of Arrhythmia Throughout Different Assessment Times.
Items of domain (2)
Pre
Program
Mean ± SD
Immediately
Post
Post 6
weeks
F
P
2.1 Symptoms of arrhythmia
0.74±0.443
1.00±0.000
1.00±0.00
11.76
9
0.000
*
2.2 Symptoms associated with
complete heart block
2.3 Problems associated with atrial
fibrillation after 24 hours
2.4 Complications of Atrial Flutter
0.60±0.497
0.83±0.382
0.63±0.490
2.570
0.081
0.26±0.443
0.91±0.284
0.89±0.323
37.96
9
0.54±0.505
0.94±0.236
0.69±0.471
8.098
2.5 Problems
associated
prolonged QT >0.50
0.17±0.382
0.91±0.284
0.57±0.502
30.30
2
0.000
*
0.001
*
0.000
*
2.31±1.388
4.60±0.604
3.77±1.23
9
36.74
0
0.000
*
with
Total
* Significant at level P˂0.05.
277
July 2015
Impact of a Nursing Educational Program.
enj@nursing.cu.edu.eg
Table (4): Comparison of Nurses’ Mean Knowledge Scores in Relation to Diagnosis
and Representation of Most Common Cardiac Arrhythmias Throughout Different
Assessment Times.
Mean±SD
Items of domain (3)
F
P
1.51±0.507
16.614
0.000 *
0.86±0.430
0.89±0.323
44.806
0.000 *
0.26±0.443
0.86±0.355
0.51±0.507
16.409
0.000 *
3.4 Duration of normal P wave
0.00±0.000
0.94±0.236
0.89±0.323
183.779
0.000 *
3.5 Duration of normal QRS wave
0.11±0.323
1.00±0.000
0.86±0.355
103.117
0.000 *
0.11±0.323
0.66±0.482
0.46±0.505
13.378
0.000 *
0.37±0.490
0.97±0.169
0.89±0.323
29.635
0.000 *
0.49±0.507
0.94±0.236
0.86±0.355
14.134
0.000 *
0.51±0.507
0.97±0.169
0.94±0.236
20.182
0.000 *
0.43±0.502
1.00±0.000
0.91±0.284
29.965
0.000 *
0.54±0.505
0.94±0.236
0.97±0.169
17.757
0.000 *
0.26±.443
0.57±0.502
0.71±0.458
8.717
0.000 *
4.11±2.908
11.31±0.993
10.40±1.594
134.608
0.000 *
3.1 Methods
of
diagnosis
of
cardiac arrhythmia
3.2 Best
lead
for
monitoring
arrhythmia
3.3 Duration
of
normal
PR
interval
3.6 Duration of
normal
QT
interval
3.7 Representation of atrial flutter
3.8 Representation of AF on the
ECG
3.9 Representation of Ventricular
Premature Beats on the ECG
3.10 Representation of VT on the
ECG
3.11 Representation of V F on
the ECG
3.12 Representation of BBB on
the ECG
TOTAL
Pre
Immediately
Post 6 weeks
0.89±0.676
1.60±0.497
0.14±0.355
* Significant at level P˂0.05.
278
July 2015
Impact of a Nursing Educational Program.
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Table (5): Comparison of Nurses’ Mean knowledge Scores in Relation to Treatment
and Nursing Management of Arrhythmia throughout Different Assessment Times.
Items of domain (4)
Pre
0.66±0.482
4.1 Arrhythmia treatment
4.2 First-line treatment for the
0.17±0.382
VF
0.46±0.505
4.3 First-line treatment for VT
4.4 Uses of beta-adrenergic
0.49±0.507
blockers
4.5 Defibrillation DC shock
0.43±0.502
uses
4.6 Cardioversion DC shock
0.57±0.502
uses
4.7 Adverse
reactions
of
0.40±0.497
antiarrhythmic drugs
4.8 Nurse's role during episode
0.23±0.426
of VT
4.9 Nurse's
role
during
frequent
premature 0.26±0.443
ventricular contractions
4.10 Causes of using cardiac
0.51±0.507
massage for rapid rate AF
4.11 Nurse's role for patient
with eight PVCs in one
0.69±0.471
minute
on cardiac
monitor
0.46±0.505
4.12 Priorities of care for VF
4.13 Number of compression/
0.57±0.502
breathing rate in CPR
TOTAL
5.89±3.402
* Significant at level P˂0.05.
279
July 2015
Mean±SD
Immediately
1.00±.000
Post 6 weeks
1.00±0.000
F
P
17.739
0.000 *
0.83±0.382
0.97±0.169
59.545
0.000 *
0.94±0.236
0.94±0.236
22.537
0.000 *
0.83±0.382
0.83±0.382
7.486
0.001 *
14.733
0.000 *
11.585
0.000 *
0.83±0.382
1.00±0.000
0.91±0.284
0.80±0.406
0.74±0.443
0.69±0.471
5.323
0.006 *
0.91±0.284
0.71±0.458
27.648
0.000 *
0.97±0.169
0.91±0.284
54.082
0.000 *
0.91±0.284
0.94±0.236
15.329
0.000 *
0.94±0.236
1.00±0.000
10.612
0.000 *
0.97±0.169
0.91±0.284
22.876
0.000 *
0.94±0.236
0.97±0.169
15.555
0.000 *
11.83±1.175
11.60±1.735
74.549
0.000 *
Impact of a Nursing Educational Program.
enj@nursing.cu.edu.eg
Table (6): Comparison of Total and Subtotal Mean Practice Scores among the
Studied Nurses Throughout Different Assessment Times.
Assessment
time
Basic practice
Domains
1. preparation
of
bedside
cardiac monitoring
2. Nursing
care
Mean ± SD
F
P
13.66±0.639
510.299
0.000 *
29.77±0.426
28.31±1.105
128.193
0.000 *
7.11±1.105
8.77±1.215
7.89±1.323
16.229
0.000 *
16.51±0.507
16.83±2.526
16.77±0.490
0.428
0.653
54.34±4.130
70.80±3.411
66.63±1.816
240.251
0.000 *
Pre
Immediately
Post
program
Post
6 weeks
6.43±1.737
15.43±1.119
24.29±2.283
during
preparation of 12
lead
ECG
3. Monitoring of vital signs
4. Nursing
care
identification
of
after
ECG
changes:
Total
* Significant at level P˂0.05.
280
July 2015
Impact of a Nursing Educational Program.
enj@nursing.cu.edu.eg
Table (7): Comparison of Nurses’ Practice in Relation to Preparation of Bedside
Cardiac Monitoring Throughout Different Assessment Times.
Items of practice domain (1)
2.1 Skin
preparation
placing
cardiac
electrodes
before not done
monitor incomplete
Done correctly
2.2 Proper position of electrodes.
Done correctly
2.3 Determine goals of monitoring not done
for each patient.
incomplete
Done correctly
incomplete
2.4 Check the alarms to the ON
position
Done correctly
2.5 Select the
displayed
leads
be not done
to
incomplete
Done correctly
duration
of
0
0
33
94.3
35
100
0
3
5
3
5
0
0
0
0
0
0
3
8.6
35
100
3
2
91.
4
0
0
0
0
35
100
3
5
100
0
0
0
0
97.
1
2.9
0
0
0
1
7
1
8
3
3
48.
6
51.
4
94.
3
2
5.7
18
51.4
0
17
48.6
3
4
1
0
0
0
0
0
8
100
--
2.9
35
100
2
7
3
5
100
0
0
0
0
91.
4
8.6
Done correctly
not done
QT not done
Done correctly
* Significant at level P˂0.05
281
9
0
0
20
57.1
0
3
5
0
15
42.9
3
2
3
100
0
0
0
0
91.
4
8.6
0
0
18
51.4
0
3
5
0
17
48.6
3
2
3
100
0
0
0
0
3
2
3
91.
4
8.6
0
0
20
57.1
0
0
15
42.9
P
100
1
Incomplete
July 2015
0
χ2
15.98
8
0.003
*
Done correctly
Done correctly
duration
0
22.
9
77.
1
Incomplete
2.9 Measure
interval.
0
2
5
Incomplete
2.8 Measure duration of QRS
complex
5.7
Incomplete
PR not done
of
2
Immediately
0
25.
7
71.
4
2.6 Obtain a rhythm strip in the not done
patient record.
2.7 Measure
interval.
(n=35 )
N
%
Post 6
weeks
(n=35 )
N
%
Pre
(n=35 )
N
%
25.
9
7
1
2.9
2
71.
5
4
3
100
5
1
37.
3
1
2
62.
2
9
93.86
1
0.000
*
40 .56
8
0.000
*
1.248
0.000
*
77.73
2
0.000
*
1.212
0.000
*
1.256
0.000
*
1.212
0.000
*
Impact of a Nursing Educational Program.
enj@nursing.cu.edu.eg
Table (8): Comparison of Nurses’ Practice in Relation to Nursing Care During
Preparation of 12 lead ECG Preparation of Bedside Cardiac Monitoring
Throughout Different Assessment Times.
Done correctly
incomplete
Done correctly
incomplete
Done correctly
Done correctly
Done correctly
incomplete
Done correctly
not done
incomplete
N
35
7
28
19
16
35
35
25
10
35
0
%
100
20
80
45.7
54.3
100
100
71.4
28.6
100
0
N
35
0
35
0
35
35
35
8
27
35
0
%
100
0
100
0
100
100
100
22.9
77.1
100
0
Post 6
weeks
(n=35 )
N
%
35
100
0
0
35
100
9
25.7
26 74.3
35
100
35
100
16 45.7
19 54.3
33 94.3
2
5.7
Done correctly
35
100
35
100
35
100
--
Done correctly
incomplete
Done correctly
not done
incomplete
Done correctly
not done
incomplete
Done correctly
incomplete
Done correctly
incomplete
Done correctly
incomplete
Done correctly
incomplete
Done correctly
35
31
4
1
22
12
1
22
12
10
25
34
1
27
8
16
19
100
88.6
11.4
2.9
62.9
34.3
2.9
62.9
34.3
28.6
71.4
97.1
2.9
77.1
22.9
45.7
54.3
35
0
35
0
0
35
0
0
35
0
35
0
35
0
35
0
35
100
0
100
0
0
100
0
0
100
0
100
0
100
0
100
0
100
35
0
35
0
0
35
0
0
35
0
35
10
25
11
24
1
34
100
0
100
0
0
100
0
0
100
0
100
28.6
71.4
31.4
68.6
2.9
97.1
-87.973
0.000 *
Pre
(n=35 )
Items of practice domain (2)
2.1 Prepare all necessary equipment
2.2 Check cable and lead wires of monitor
2.3 Explain procedure
2.4 keep patient in supine position
2.5 Keep patient calm,
2.6 Expose only the necessary parts of the
patient's body
2.7 Shave area if needed
2.8 Strap limp electrodes around right &
left arm about 5 cm above wrists
2.9 Strap electrodes around left & right leg
2.10 Identify the angle of sternal notch
2.11 Place V1 lead at correct site
2.12 Place V2 lead at correct site.
2.13 Place V3 lead at correct site
2.14 Place V4 lead at correct site
2.15 Place V5 lead at correct site
2.16 Place V6 lead at correct site
* Significant at level P˂0.05.
282
July 2015
Immediatel
y (n=35 )
χ2
P
-15.00
0.001 *
20.265
0.000 *
--16.607
0.000 *
4.078
0.130
58.902
0.00 *
58.902
0.000 *
22.105
0.000 *
71.669
0.000 *
45.613
0.00 *
33.830
0.000 *
Impact of a Nursing Educational Program.
enj@nursing.cu.edu.eg
Table (9): Comparison of Nurses’ Practice in Relation to Monitoring of Vital Signs
to Detect Cardiac Arrhythmia Throughout Different Assessment Times.
Items of practice domain (3)
3.1 Palpate
and
noting
regularity of pulse
rate,
Incomplete
Done correctly
not done
Incomplete
Done correctly
not done
Incomplete
Done correctly
Done correctly
Done correctly
3.2 Noting presence of dropped and
extra beats.
3.3 Document presence of pulsus
alternans, bigeminal pulse, or
pulse deficit.
3.4 Monitor blood pressure
3.5 Monitor Respiratory rate
Pre
(n=35 )
N
%
31
88.6
4
11.4
12
34.3
18
51.4
5
14.3
7
20
19
54.3
9
25.7
35
100
35
100
Post 6
weeks
(n=35 )
N
%
16
45.7
19
54.3
0
0
23
65.7
12
34.3
8
22.9
17
48.6
10
28.6
35
100
35
100
Immediatel
y (n=35 )
N
%
0
0
35
100
0
0
10
28.6
25
71.4
0
0
17
48.6
18
51.4
35
100
35
100
χ2
P
55.543
0.000 *
43.773
0.000 *
11.697
0.020 *
---
* Significant at level P˂0.05.
Table (10 ): Comparison of Nurses’ Practice in Relation to Nursing Care After
Identification of ECG Changes Throughout Different Assessment Times.
Pre
(n=35 )
Items of practice domain (4)
4.1 Call physician
4.2 Ensure that monitoring lea
d in correct site
4.3 Administer O2 therapy.
4.4 Give medication as doctor
order
4.5 Use of stress management
behaviors.
4.6 Prepared to initiate CPR as
indicated.
4.7 Monitor laboratory studies
4.8 Prepare patient for elective
cardio version.
4.9 Assist
with
insertion
pacemaker function.
Post 6
weeks
(n=35 )
χ2
P
Done correctly
N
35
%
100
N
35
%
100
N
35
%
100
--
Done correctly
35
100
35
100
35
100
--
Done correctly
35
100
35
100
35
100
--
Done correctly
35
100
35
100
35
100
--
not done
Incomplete
Done correctly
not done
Done correctly
not done
Done correctly
not done
Done correctly
not done
Done correctly
17
18
0
2
33
2
33
5
30
4
31
48.6
51.4
0
5.7
94.3
5.7
94.3
14.3
85.7
11.4
88.6
4
9
22
0
35
0
35
0
35
0
35
11.4
25.7
62.9
0
100
0
100
0
100
0
100
1
25
9
0
35
0
35
0
35
0
35
2.9
71.4
25.7
0
100
0
100
0
100
0
100
* Significant at level P˂0.05.
283
July 2015
Immediatel
y (n=35 )
56.284
0.000 *
4.078
0.130
4.078
0.130
8.317
0.012 *
8.317
0.016 *
Impact of a Nursing Educational Program.
enj@nursing.cu.edu.eg
Table (11 ): Distribution of the Total Knowledge Scores and Total Practice Score of
The Studied Nurses Throughout Different Assessment Times.
Pre
(n=35)
N
%
Total
knowledge
score
< 28 Poor
28-34 Fair
Total
practice
score
< 54 Poor
54-67 Fair
>= 35 Good
Total
>= 68 Good
Total
32
2
91.4
5.7
1
35
2.9
100
10
24
28.6
68.6
2.9
100
1
35
Immediately
(n=35)
N
%
0
0
0
0
100
35
35
100
Post 6 weeks
(n=35)
N
%
0
0
11.4
4
88.6
31
35
100
0
4
0
11.4
0
0
31
35
88.6
100
35
35
χ2
P
98.925
0.00 *
0
0
100
100
86.354
0.00 *
* Significant at level P˂0.05.
Table (12 ): Correlation Between Total Knowledge Scores, Total Practice Scores,
Age and Years Of Experience of The Studied Sample.
Years
of exp.
Age
1. Age
2. Years
of
0.95*
experience
3. Total knowledge
0.28
score pre
4. Total knowledge
score immediate
5. Total knowledge
0.19
score post
6. Total
Practice
0.66**
score pre
7. Total
Practice
0.37*
score immediate
8. Total
Practice
score post
Total
knowle
dge
score
(pre)
Total
knowled
ge score
(post)
Total
Practice
score (pre)
Total
Practice
score
Immed.
0.03
-
-
0.27
0.103
-
0.63**
0.148
-
0.175
0.35*
0.103
-
-0.129
0.536 **
-
-
-
-
-
* Significant at level P˂0.05.
** Significant at level P˂0.001.
284
July 2015
Total
knowled
ge score
immed.
-
Total
Practice
score
post
Impact of a Nursing Educational Program.
enj@nursing.cu.edu.eg
DISCUSSION: Cardiac arrhythmias are
very common and nearly everyone will
experience an abnormal heart rhythm
some time during their lives (16). Nurses
who work in critical care units in
hospitals
have
an
important
responsibility to monitor patients
‗cardiac rhythms and to intervene
(17)
promptly
.The
emergency
management of cardiac arrhythmias is a
major challenge faced with potentially
life-threatening situations. The physician
and nurse have a short time to make
strategic decisions and initiate concrete
measures. So this requires knowledge of
the various causes, different types of
cardiac arrhythmias and the measures to
be taken in an emergency (18). So the aim
of this study was to evaluate the impact
of a nursing education program about
early detection and management of
cardiac
arrhythmia
on
nurses‘
knowledge and practices.
Regarding
socio-demographic
characteristics of the studied nurses, the
present study revealed that, the majority
was female and their ages ranged from
20-30 years. About two thirds had
bachelor degree. Nearly, half of the
sample had years of experience ranged
from one to four years. These results
were in the agreement with Pickham et
al (2012 ) (19 ) who found in a study
entitled as ―Quasi-Experimental Study to
Improve
Nurses'
QT-Interval
Monitoring‖ that most of the studied
nurses were women possessed a
bachelor‘s degree or higher.
Also
(20)
Mahrous (2003 )
reported in a study
entitled as ―Standards of nursing care for
cardiac arrhythmic patients‖ that, more
than half of the nurses had a diploma
degree with age of 20–29 years. On the
other hand, this study was inconstant
with Sheta (2006 ) (21) who reported in a
study entitled as "effect of an
285
July 2015
educational program on the performance
of nurses working with cardiac patients
at Benha University Hospital" that, the
majority of nurses were a secondary
school diploma nurse, with years of
experience ranged from 5-7 years.
Regarding mean knowledge score of
definitions, causes, and types of most
common cardiac arrhythmia, the present
study showed a significant improvement
of knowledge scores among studied
nurses immediately after the educational
program. This contributed that the
researcher had enough time, proper
environment, suitable learning media
and material for teaching. After six
weeks, the mean scores of these items
were decreased. This is interpreted that
the majority of nurses have no time to
refresh their knowledge and read about
critical problems as arrhythmias in CCU.
Also, some nurses in this study have
diploma and technical institute of
nursing. This finding may be on line
with Shiny et al (2005 ) (22) who
emphasis that all the staff nurses requires
to have sufficient knowledge to manage
patients with arrhythmia efficiently. And
it is essential for the nurses to conduct
studies on the existing knowledge of the
colleagues on arrhythmias in ICU and
non-ICUS and assist them in acquiring
up-to-date knowledge.
Concerning knowledge related to
symptoms
and
complications
of
arrhythmia, this study concluded all
nurses had poor knowledge scores before
the application of program while
immediately after an educational
intervention, their knowledge scores
were successfully increased compared
with their scores after six weeks. This
result was supported by Keller et al
(2005 ) (4) who concluded in a study
entitled as ―Arrhythmia knowledge: A
qualitative study‖ that deficit in nurses'
Impact of a Nursing Educational Program.
enj@nursing.cu.edu.eg
ability to recognize and identify
arrhythmias varied among participants
and high level of arrhythmia knowledge
are needed for the development of
competency measures and evidencebased teaching strategies.
Regarding
diagnosis
and
representation of most common cardiac
arrhythmias on the ECG, monitoring
duration of normal P, QRS wave, QTinterval, this result revealed that all
nurses before the program reported a
decrease in the mean scores of
knowledge. This was unexpected
because the majority of sample had a
high level of education (a Bachelor‘s
degree or higher), and more than one
third of them having 5 years or more of
direct nursing experience. This may be
due to the complexity of arrhythmias and
the studied sample had not received
formal instruction in performing QRS
and QT-interval monitoring. However
Following education, nurses‘ ability to
define the best lead for monitoring
arrhythmia, identify duration of QT, and
QRS
interval
were
improved
significantly.This
study
was
in
concordance with
Drew B et al
(2004 )(23 ) they reported in a study
entitled as ―Practice standards for ECG
monitoring
in
hospital
settings:
executive summary and guide for
implementation‖ that fewer than half of
all nurses were able to measure the QT
correctly before the education and
nurses‘ ability to measure it improved
after education. Also, they stated that
knowledge
regarding
basic
electrocardiography concepts is needed.
As regarding treatment and nursing
management of arrhythmia, the present
study documented a significant increase
in nurse's knowledge post program as
compare to pre program. This might be
due to that majority of them are young,
286
July 2015
secondary school nurse, and have 1-5
year of experience. This was in the
agreement with Heng et al (2011 ) (24 )
who stated in a study entitled ―the role of
nurses in the resuscitation of in-hospital
cardiac arrests‖ that the nurses should
be
knowledgeable
for
checking
emergency equipment and giving
nursing care to critically ill patients.
Regarding knowledge about CPR, the
present findings reported a significant
improvement of knowledge post
teaching program than before the
program. Also, studied nurses had
extremely poor knowledge about CPR
technique as well inability to remember
the exact sequences of the procedure.
This might be due to the majority of
professional curriculum does not taught
enough to nursing students during their
study years at school. This result was
similar with Taha A (2012 ) (25) who
stated in a study about ―Impact of a
designed Teaching Protocol about
Advanced Cardiac Life Support (ACLS)
On Critical Care Nurse‘s Knowledge and
Practices‖ that nurse‘s knowledge scores
regarding cardiopulmonary resuscitation
(CPR) was significantly improved post a
designed teaching protocol than preImplementation.
Also,
Hamed
(26)
(2009 )
and Berdowski et al, (2009 )
(27)
found the majority of the studied
nurses had unsatisfactory knowledge
level
about
cardiopulmonary
resuscitation and nurses play a key role
in the management of cardiac arrest in
hospital.
Concerning nurse‘s knowledge scores
about defibrillation, the present study
documented a significant improvement
of
knowledge
post
program
implementation. This finding was in the
same line with Taha (2006 ) (28) who
documented
in
a
study about
―Emergency nursing care for critically ill
Impact of a Nursing Educational Program.
enj@nursing.cu.edu.eg
patients: Impact of a designed teaching
protocol on nurse‘s knowledge and
practices at Intensive Care Units
(ICUS)‖ that, knowledge of nurses about
defibrillator are significantly increased
post program implementation. On the
contrary, Hamed, (2009 ) (26 ) revealed
that the majority of nurses had satisfied
knowledge about nursing care for
external
defibrillator,
uses
and
complications.
Regarding nurses‘ practice about
early detection and management of
cardiac arrhythmia, the current study
showed
a
highly
significant
improvement in nurses total and subtotal
practice scores at immediate post test as
compared to pretest. However, findings
of the current study reported a gradual
decrement in nurse‘s practice six week
after implementation of the program.
This may be due to the fact that cardiac
arrhythmias weren‘t incorporated in
nursing curriculum and the educational
program makes refreshment in nurses‘
knowledge, which in turn leads to
improvement in their practice.
Concerning nurses‘ practice about
nurse‘s role during preparation of
cardiac monitoring, this study concluded
that there was a significant improvement
in nurse‘s practice immediately post- and
after six
weeks
post program
implementation compared with pre
program. This finding was supported by
Taha (2012 )(25) in study about impact of
a designed teaching protocol about
Advanced Cardiac Life Support (ACLS)
on critical care nurses knowledge and
practices at Benha University Hospital,
who found that there were a highly
significant improvement of nurses
performance about cardiac monitoring.
Also, the current study showed that
nearly all nurses provide proper skin
preparation before placing cardiac
287
July 2015
monitor electrodes immediately and six
weeks post program with a significant
difference between three phases of the
study. In this regard, Patel (2008 ) (29)
and Cvach (2012 ) (30) stated that Skin
preparation prior to electrode application
enhances conductivity by promoting
adhesion and skin-electrode contact.
Also the present study revealed that
none of the samples determine goals of
monitoring for each patient before the
program, while almost all studied nurses
done it correctly immediately and 6
weeks after the program. In this regard,
Kumar (2014 ) (31) reported in a study
about ―New trends and capabilities:
Learn how advances in technology and
research have enhanced your ability to
monitor patients for dysrhythmias and
ischemia‖ that cardiac nurse must
determine the best way to monitor the
patient and the purpose for monitoring.
This can lead to accurate diagnosis,
appropriate treatment, and improved
patient outcomes.
Also, Khalil & Elfeky (2011 )(32)
concluded in a study entitled as
―Teaching the Skill of Interpreting
Common
ECG
Rhythms
for
Undergraduate Nursing Students at
Cairo University: Technology Based
Versus Traditional Method‖ that nurses
undergone a combination of the
technology based teaching and the
traditional lecture methods of teaching
ECG interpretation achieved higher
mean posttest knowledge score.
Accurate electrode placement is
especially important because inaccurate
lead placement is common in hospital
units and results in misdiagnosis. In this
regards, the majority of nurses in the
present study didn‘t select the leads to be
displayed and didn‘t obtain a rhythm
strip in the patient record pre program,
while they improved significantly
Impact of a Nursing Educational Program.
enj@nursing.cu.edu.eg
immediately after program and the
percentage decreased after 6 weeks of
program. This may be due to that the
physicians did not ask for it, and the
nurses‘ routine care not include which
the lead to be displayed at cardiac
monitor. This result was consistent with
Drew et al (2004 )(23) they found that
monitoring the routines of critical care
nurses has indicated that nurses do not
select leads according to diagnosis or
history of coronary disease. Also, none
of the sample measured PR, QRS and
QT interval pre program while
immediately following program, nurses‘
ability to measure them improved
significantly; however, the majority of
nurses were still unable to measure them
at 6 week after program.
One
explanation for the low level of
proficiency among the majority or the
entire sample had not received formal
instruction in monitoring PR, QRS and
QT interval before this study. This
finding was in line with Pickham et al
(2014 )(19) they found that nurses‘ ability
to measure the QT and RR intervals
improved After didactic education;
however, approximately 30% of nurses
were still unable to measure the RR
interval correctly.
Regarding nurses practice during
preparation of 12 lead ECG, the current
study revealed that nurses performance
improved significantly in area related to
checked cable and lead wires before
connecting ECG leads, explained the
procedure, exposed only the necessary
parts of the patients and identify the
angle of sternal notch before placing
lead at immediate and 6 weeks post
program compared with pre program.
This may be due to the effect of
educational program. These findings
were in agreement with Keller (2005 )
(4)
and Thompson (2011 ) (33) they
288
July 2015
emphasized that the educational program
help the nurse to enhance and develop
skills and information and found large
differences between pre-post tests.
As regards correct site of ECG chest
lead electrode, the present study showed
that there was a highly significant
improvement immediately and 6 week
post program than pre program. While,
all 4 limb electrodes were placed in the
correct location before and after
implementation of educational program.
This finding agreed with Sangkach et al
(2011 ) (34 ) they showed in a study
entitled
―Continuous
ST-Segment
Monitoring: Nurses' Attitudes, Practices,
and Quality of Patient Care‖ that limb
electrodes were always accurately placed
both before and after institution of ST
Map, whereas chest electrodes were
accurately placed 83.8% of the time
before ST Map and 97.1% to 99.0% of
the time after ST Map.
As well, Hassan et al (2013 ) (16 )
found that good improvement with
highly significant differences in study
group between pre -post tests in main
domains related to observational check
list in the all items of nurses' practice in
preparation the ECG machine, location
of chest electrodes Placement and
nursing practice during the ECG
application and after identification of
any change in ECG. On the other hand,
this study was inconstant with Schultz
(2010 ) (17 ) who concluded in his study
that there were no significant differences
in correct electrode placement between
the three audits between baseline and 6
weeks (P=0.76), baseline and 18 weeks
(P=0.66), and 6 weeks and 18 weeks.
Regarding monitoring of vital signs to
detect cardiac arrhythmia, the current
study showed a significant improvement
at the immediate and post 6week of
Impact of a Nursing Educational Program.
enj@nursing.cu.edu.eg
program implementation compared with
pre program .in this regard, Lockwood
et al (2004 ) (35) reported that vital signs
recorded by a nurse can be a true
reflection of the patient‘s condition or
response to clinical treatment. Also
Chalfin et al (2007 ) (36) supported this
finding. They concluded that prompt
detection and reporting of changes in
vital signs are essential in initiating
appropriate treatment which can affect
the patient‘s outcome. Additionally,
Hammon (1992 )(37 )
found that
Individuals
experiencing
major
arrhythmias
had
a
significantly
decreased BP and respiratory rate with
an increased heart rate during postural
drainage and chest percussion (PDP) and
recommend that critically ill patients
should be carefully monitored during
postural drainage and chest percussion.
Concerning nurse‘s practice about
nursing care of cardiac arrhythmia, the
presenting results showed that none of
the studied nurses done stress
management behavior pre program and
the majority of them done it at the
immediate test and deterioration in
nurses skills was found 6 week post
program implementation . This may be
due to the absence of continuous
education and training for nurses about
non pharmacological treatment of
cardiac arrhythmias. Also, the nurse may
have no time to perform this procedure.
In this respect, Blumenthal et al (2005 )
(38 )
reported in a study entitled as
―Effects of Exercise and Stress
Management Training on Markers of
Cardiovascular Risk in Patients with
Ischemic Heart Disease‖ that patients
with stable ischemic heart disease,
exercise and stress management training
reduced emotional distress and improved
markers of cardiovascular risk more than
usual medical care alone. In addition,
289
July 2015
Kranitz (2004 ) (39 ) pointed in his study
about ―Biofeedback Applications in the
Treatment of Cardiovascular Diseases‖
that some patients with cardiac
arrhythmias have learned to control their
heart rate using biofeedback training.
Also the present finding showed that
nurses practice significantly improved
immediately and six week post program
implementation compared to preprogram
in the area related to initiate
cardiopulmonary resuscitation (CPR),
monitor laboratory studies, prepare
patient for elective cardio-version and
assist with insertion pacemaker function.
This finding was congruent with
Madden et al (2006 ) (40 ) they showed
an acquisition in nurses' CPR knowledge
and psychomotor performance following
a 4 h CPR training program. However,
deterioration in both CPR knowledge
and skills was found 10 weeks following
CPR training. Also, the students'
knowledge and skills had improved
when compared with their pre training
scores.
Similarly, Hamilton (2005 ) (41 )
examining factors that enhance retention
of knowledge and skills during and after
resuscitation training and found that
skills and knowledge decline over time
and training should occur frequently and
reflect potential situations nurses may
face in their practice. On the same line,
Broomfield (1996 ) (42 ) concluded in his
study that knowledge and skill of basic
cardiopulmonary
resuscitation
by
qualified nurses following a course in
professional development deteriorate in
a period as short as 10 weeks if not used
or updated regularly.
Concerning total knowledge and
practice score of nurses, the present
finding showed that the majority of
nurses had poor knowledge and fair
Impact of a Nursing Educational Program.
enj@nursing.cu.edu.eg
practice scores about cardiac arrhythmia
in the pre-test. This may be due to all
studied nurses didn‘t attend any training
program about cardiac arrhythmias.
However, the majority of them had good
knowledge
and
practice
score
immediately and after 6 weeks of
program application. This result was in
cocordance with Mohamed (2011 ) (43)
in experimental study about ―effects of
implementing nursing care standards for
nurses caring for patients with cardiac
arrhythmia in CCU at Ain Shams
University‖. The study concluded that
the majority of nurses had unsatisfactory
knowledge
and
practice
before
implementation of standards and after
applying the standards there were
improvement in practice and knowledge
score.
The same finding was indicated by
Suchitra and Lakshmi (2007 ) (44) who
reported in a study about ―impact of
education on knowledge, attitude and
practices among various categories of
health care worker‖ that education has
positive impact on knowledge and
practice of nurses. In addition, Mallik et
al (2002 )(45) added that the educational
programs always keep the nurses
familiar with recent advances in their
area of specialty and maintain their
speed and efficiency in carrying out their
respective activities so the quality of
care will be improved.
Regarding correlation of total
knowledge
score
with
selected
demographic variables, the current study
showed that there was no statistical
significant correlation between nurses‘
total knowledge score ,age, educational
level and years of experience at pre and
post 6 week of educational program.
This study was in agreement with Shiny
(2005 ) (22) who concluded that there was
no association between the knowledge
290
July 2015
level and selected demographic variables
as age and exposure to in–service
education when assessing the knowledge
of nurses regarding interpretation and
management of cardiac arrhythmias. But
there was significant association
between
knowledge
level
and
demographic variables as level of
education and years of experience.
In relation to correlation of total
practice
scores
with
selected
demographic variables, there was a
significant correlation between nurses‘
total practice scores and age, educational
level and years of experience pre and
immediately
after
program
implementation. This finding was in
agreement with Taha (2006 ) (28) they
found that, correlation between nurses
practice and level of education where
bachelor degree nurses received
significantly better scores than diploma
nurses because they are more involved
and more responsible for checking
apparatus
such
as
pacemaker,
defibrillator, O2 availability, record and
report any changing in rhythm. Also
Taha (2012 )(25)
showed that in his
study , a positive correlation between
nurses knowledge, practice and their age
with a highly statistical significant along
different assessment periods of program
implementation. On the other hand, these
findings were in contradicted with
Hamed (2009 ) (26) who revealed that
there is no statistical significant relation
between level of education and practice.
Finally, nearly half of deaths from
cardiac disorders are due to arrhythmia.
These deaths can be prevented by
recognizing and treating arrhythmias in
an early stage. The nurse in CCU should
therefore be familiar with the early
identification and management of such
arrhythmias (46).
Impact of a Nursing Educational Program.
CONCLUSION
RECOMMENDATIONS
enj@nursing.cu.edu.eg
AND
Conclusion: Based on the findings of
the present study, it can be concluded
that the educational program was
beneficial in improving critical care
nurses knowledge and practice regarding
identification and management of
cardiac arrhythmias among patients at
coronary care units. Nurses' knowledge
and
practices
were
improved
significantly concerning important areas
of nursing care of patients with cardiac
arrhythmias. However this improvement
was reduced by time.
Recommendations:
 There should be a continuous
educational/ training program for
updating the knowledge and skills of
nurses working in coronary care unit.
 Establish a written updated protocol
about cardiac arrhythmias to ensure
enough knowledge and safe nursing
practice.
 Enhancing collaboration between
health care providers and offering
appropriate counseling should also be
emphasized.
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2004 ; 13(8): 440–46.
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July 2015
A Pilot study on infection control.
enj@nursing.cu.edu.eg
A Pilot study on infection control knowledge and practice in selected Governorates
in Egypt
MahaMoussa Mohamed Moussa(1), Naglaa Ibrahim Mohamed(2),EmanShokryAbdallh(3)
*Corresponding Address mahamoussa10 @yahoo.com
(1,2 )
Lecturers Department of Community Health Nursing, Faculty Of Nursing , Port Said
University ,Egypt (3) Professor of Community Health Nursing and Geriatric Nursing
,Faculty of Nursing ,Zagazig University, Egypt
Abstract: Infection control is quality standard patient care and essential for the well being of
patients and the safety of both patients and staff. According to the Centers for Disease Control and
Prevention (CDC), approximately 1 in 20 hospitalized patients falls victim to hospital acquired
infection ( HAIs) leading to nearly 100,000 deaths per year. Objectives: The aim of the study to
assess infection control (IC) knowledge and practice measure among nurses in Governmental
Hospitals of Port Said ,Damietta ,and Ismailia cities in Egypt .Design: A descriptive comparative
research design will be utilized in this study. Setting: The study involved136 hospitals in(General
and University) in three governorates; Port Said, Damietta and Ismailia Sample: The Study
population included 649 nurses working in surgical, obstetric, pediatric and reception departments
of the study hospitals. Tools: Data were collected using a questionnaire with 3 parts about
knowledge of hospital infection control, and practices .Results: The majority of the study sample
had unsatisfactory knowledge regarding infection control, disinfection and sterilization. Nurse‘s
knowledge about wound dressings showed satisfactory knowledge in Ismailia hospital and Damietta
hospital .The majority of the study sample had satisfactory practice regarding hand hygiene in the
different three regions.While unsatisfactory practices were shown in personal protection.
Conclusion: The majority of the studied sample has unsatisfactory knowledge about infection,
disinfection and sterilization. While the majority of the study sample had satisfactory practice
regarding hand hygiene in the different three regions, unsatisfactory practices was show in personal
protection. Recommendation: The study recommended increase the supply of personal protective
equipment and monitoring compliance of nurses with the standard precautions in the hospitals.
Key words: Infection control, Standard precaution
Introduction
Hospital acquired infection (HAI) is
serious global public health issue and a
major health problem today and causing
the suffering of about 1.4 million people
across the world at any given time (En
and Gan, 2011 ).Although it is difficult
to assess the exact incidence of hospital
acquired infections in our hospitals, a
sample evidence (exists to indicate the
magnitude of HAI and related problems
(Abou Shady, et al., 2003and Van der
Kooi, et al., 2010 ).Most often it is
observed that patient comes to hospital
for treatment of a particular illness but
has acquired infection prolonging his
hospital stay sometimes leading to
septicemia, multisystem organ failure
and death (Adebimpe and Wasiu, 2011).
HAI not only prolongs the stays of
295
July 2015
patients but also increases bed
occupancy and therefore puts extra
burden on already strained hospital
resources (Allison, et al.,2012 ) .
Hospital acquired infection are caused
by pathogens transmitted from one
patient to another by way of nursing staff
who do not follow standard precautions
(Doebbeling,2003 and Alnoumas,et
al.,2012 ). Although (Wiw, 2002 )
demonstrated more a century ago that
hand washing itself was sufficient in
reducing the incidence of hospital
acquired
infection.
Inadequate
knowledge among nursing staff leads to
this poor compliance with hand washing
(Zapata,et al.,2010 ).The inadequate
knowledge and poor practice of nursing
staff might lead to prolonged hospital
A Pilot study on infection control.
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stay, long term disability, increased
resistance
of
microorganisms
to
antimicrobials,
massive
additional
financial burden, high costs for patients
and their families, and excess deaths
(Rajinder, et al.,2008 ) . Although the
risk of acquiring HCAI is universal and
pervades every healthcare facility and
system around the world, the global
burden is unknown because of the
difficulty of gathering reliable diagnostic
data (Jain, et al.,2012 ) .
2. Objectives of study:
2.1 . General Objectives: to assess
knowledge and practice regarding
infection control measure among nurses
in Governments District Hospitals of
Port Said, Damietta, and Ismailia cities
in Egypt.
2.2 . Specific Objectives:
- Assess the knowledge and practice
regarding infection control among nurses
in three Governorates.
- Compare between infection control
measure among nurses in general
hospitals and universityhospitals.
3. Subjects and Methods:
3.1 . Research design
A descriptive comparative research
design was utilized in this study
3.2 . Setting
This study was carried out in Egypt in
the three governorates, 136hospitals of
Port Said, Damietta and Ismailia cities.
Study population all nurses working in
surgical, obstetric,
pediatric and
reception of above hospitals.
3.3 . Sample
Convenience nurses of samplings in both
three governorates in the mentioned
setting before were included in this
study. They were649 nurses.
3.4 . Tool of data Collection:
This questionnaire is developed and used
by the researcher to collect the following
data:
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July 2015
The questionnaire consisted of
three parts:
The questionnairecomprised 28 main
questions related to knowledge's and
practices
The first part is concerned with: The
demographic
characteristics
of
nurses'(age, marital status, years of
experience, and qualification degree).
The second part (Nurses knowledge
regarding infection control); it is divided
into two items:Item one: knowledge about definition of
sterilization, proper isolation, methods of
infection control, types of sterilization,
equipment that may be sterilized in
autoclave (6 questions)
Item two : knowledge about wound
dressing including the following : types
of
wound
,
factors
causing
contamination of wounds , signs appear
on the wound indicate contamination,
stages of wound healing, factors that
affect the healing process complications
that result from contamination of
wounds, goal of dressing and types of
antiseptic solutions and
,... (10
questions).
The other tool (check list): practice
through observation sheet including the
following: hand washing and personal
protection gloves, Gowns and mask,
…..(12 questions).
3.5 . Pilot Study
Pilot study was carried out by using the
tools on
the nurses to test its
applicability
then
necessary
modification was done according to
the results of pilot study and
expertise opinions . Sixty five nurses
working in above mentioned centers
were included from the sample of
research work.
3.6 . Methods
A pilot study was conducted in
healthcare settings of three governorates
A Pilot study on infection control.
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in Egypt, which were selected randomly
from Lower Egypt:Port Said, Damietta
and Ismailia. These settings represented
different affiliations belonging to the
Ministry of Health and Population,
Health Insurance and University
hospitals.Comparative research design.
The areas of study included three
governorates, 136hospitals of Port Said,
Damietta and Ismailia cities. Study
population all nurses working in
surgical, obstetric,
pediatric and
reception of above hospitals was 649
nurses (Appendix). Data were collected
using a questionnaire with 3 parts
comprising. The questionnaire was used
after approval of its validity and
reliability. The study was conducted for
the staff nursing working in the
outpatients clinics (surgical, obstetric,
pediatric and reception) hospitals within
2 years which started at from September
2008 to December 2010 . The study was
a cross-sectional survey including nurses
involved with direct patient care. The
Purpose of the study was explained
prior to get the questionnaire sheet
and the questionnaire was distributed
during regularly scheduled to be
answered within (20 -30 minutes) .The
respondents were required to fill the
survey and return it on the same day to
avoid any response bias because of any
collaboration amongst them. Only the
completed questionnaires were included
for the final analysis and any
questionnaire which was incomplete was
excluded from the final analysis.The
content of the questionnaire was based
on the infection control protocols
followed in our hospital with further
relevant questions related to the
everyday practice of the nursing staff.
3.7 . Ethical considerations
1. Formal approval was taken from
three Governments District Hospitals of
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July 2015
Port Said, Damietta, and Ismailia cities
in Egypt.
2. The aim the study was explained to
each nurse working in mentioned setting
3.8 . Statistical analysis
Data were fed to the computer
and analyzed using IBM SPSS software
package version 20.0 (Leslie,et al.,1991
and Kirkpatrick & Feeney 2012
).Qualitative data were described using
number and percent. Quantitative data
were described using mean and standard
deviation for normally distributed data.
Comparison between different groups
regarding categorical variables was
tested using Chi-square test. For
normally distributed data, comparison
between two independent population
were done using independent t-test while
more than two population were analyzed
F-test
(ANOVA)
to
be
used.
Significance test results are quoted as
two-tailed probabilities. Significance of
the obtained results was judged at the
5% level. A scoring system for assessing
the nurse's knowledge regarding
infection control.
4.Result
Table ( 1) Findings on demographics
characteristics of nurses in outpatient's
clinics, reception and emergency
hospitals (general and university) in the
three governorates. According to the
table the most age of the studied were 20
– <30 years old, and nearly more than
half of the studied were married.
More than half of the nurses had a
diploma degree in Damietta Hospitals,
El Azhar University Hospitals, Ismailia
Hospitals , Ismailia University Hospitals,
Port Said Hospitals, were (64.3, 55.9 ,
64.6, 59.3
69.2) respectively.
Regarding years of experience in work,
about half of them had less than 5 years
of experience in Ismailia university
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Hospital and Port Said Hospitals (51.6 ,
50.0) respectively, while 42.2 ,39.9 and
18.5 in Ismailia Hospitals , Damietta
Hospitals and El Azhar University
Hospitals. More than half of the nurses
Get a training course on Infection Control in
Damietta Hospitals, El Azhar University
Hospitals , Ismailia Hospitals, Port Said
Hospitals, ( 60.7, 57.4 , 66.1, 57.7)
respectively .While 75.8 of them in
Ismailia University Hospitals.
Table ( 2) Comparison between
knowledge regarding infection control
among nurses in outpatient clinics,
reception and emergency hospitals in
three Governorates are illustrated in
table 3 . Statistically significant are
noticed in most items of hospital
infection p=0.001 .
Table (3) show comparison between
general hospitals and universities
hospitals according to knowledge and
practice. Statistically significant were
found in total knowledge comparison
between general
hospitals and
universities hospitals the percentage of
unsatisfactory knowledge's reached
59.4% and 70.4% respectively, while
the total unsatisfactory practices in
general
hospitals and universities
hospitals reached 54.1% and 64.2%
respectively.
Table (4) Regarding Compassion
between
general
hospitals
and
universities hospitals regarding barriers
that prevent using personnel protection
of equipment There were statistically
significantly difference
of Total
Personal protection between general
hospitals and universities hospitals .
In figure (1) nurses knowledge about
infection control in outpatient clinics,
reception and emergency hospitals
(general and university) in three regions
Concerning nurses knowledge about
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July 2015
wound dressing; the satisfactory
knowledge was shown in Ismailia
hospitals and Damietta hospitals (66.7%
and
56.5%)
respectively.
The
statistically
was
shown
highly
significant.
In figure (2) the present study show that
the majority of the study sample had
Satisfactory practice (>60%) regarding
hand hygiene in deferent three region
(general
and
university).
While
Unsatisfactory practices ( ≤60 %) was
show in personal protection and Total
practice There are present statistically
significant was show Mean ± SD in all
item ( p ≤ 0.05).
A Pilot study on infection control.
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Table (1): Demographic characteristics of nurses in outpatient clinics, reception
and emergency hospitals (general and university) in the three
governorates.
Damietta hospitals(n=236 ) Ismailia hospitals (n=283 )
General
(n=168 )
El Azhar
University
(n=68 )
General
(n=192 )
University
(n=91 )
Port Said
Hospitals
(n=130 )
No
%
No
%
No
%
No
%
No
%
<20
20
11.9
17
25.0
21
10.9
19
20.9
22
16.9
20 – <30
115
68.4
37
54.4
136
70.8
66
72.5
86
66.1
30 – 40
26
15.5
13
19.1
28
14.6
3
3.3
14
10.8
≥40
7
4.2
1
1.5
7
3.6
3
3.3
8
6.2
Single
63
37.5
35
51.5
76
39.6
45
49.4
58
44.6
Married
100
59.5
31
45.6
109
56.8
44
48.4
68
52.3
Widow
0
0.0
0
0.0
0
0.0
0
0.0
1
0.8
Divorced
5
3.0
2
2.9
7
3.6
2
2.2
3
2.3
Diploma
108
64.3
38
55.9
124
64.6
54
59.3
90
69.2
Institute
34
20.2
18
263.5
37
19.3
19
20.9
20
15.4
Bachelor
26
15.5
12
17.6
31
16.1
18
19.8
20
15.4
<5
67
39.9
33
18.5
81
42.1
47
51.6
65
50.0
5 – 10
57
33.9
15
22.1
60
31.3
29
31.9
33
25.4
≥10
44
26.2
20
29.4
51
26.6
15
16.5
32
24.6
No
102
60.7
39
57.4
127
66.1
69
75.8
75
57.7
Yes
66
39.3
29
42.6
65
33.9
22
24.2
55
42.3
Age
Marital status
Education
Years of experience in work
Get a training course on
Infection Control
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July 2015
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Table (2) Comparison between knowledge regarding infection control among nurses in outpatient
clinics, reception and emergency hospitals in three Governorates
Damietta hospitals(n=236 )
Hospital infection
Ismailia hospitals (n=283 )
Port Said
Hospital
(n=130 )
General
(n=168 )
El Azhar
University
(n=68 )
General
(n=192 )
University
(n=91 )
Mean± SD
1.52 ± 0.73
1.29 ± 0.81
1.41 ± 0.75
1.33 ± 0.73
1.51 ± 0.73
% score
36.69
40.57
70.57
36.56
36.43
Mean± SD
1.13 ± 0.87
0.66 ± 0.84
0.67 ± 0.82
1.0 ± 0.76
0.95 ± 0.84
% score
56.25
33.09
33.33
50.0
47.31
Mean± SD
1.0 ± 0.34
0.96 ± 0.32
1.14 ± 0.47
1.24 ± 0.50
1.18 ± 0.52
% score
50.30
47.79
56.77
62.09
58.85
Mean± SD
1.13 ± 0.82
0.72 ± 0.75
0.84 ± 0.78
1.04 ± 0.73
0.78 ± 0.69
% score
56.55
36.03
41.93
52.20
38.85
Mean± SD
0.57 ± 0.56
0.63 ± 0.69
0.94 ± 0.70
0.88 ± 0.63
0.75 ± 0.61
% score
28.27
31.62
47.14
43.96
37.69
Mean± SD
1.03 ± 0.78
0.63 ± 0.52
0.85 ± 0.77
0.74 ± 0.49
0.65 ± 0.55
% score
51.49
31.62
42.45
36.81
32.69
Mean± SD
0.92 ± 0.65
0.71 ± 0.49
0.77 ± 0.50
0.88 ± 0.59
0.76 ± 0.52
% score
46.13
35.29
38.54
43.96
38.08
Mean± SD
1.17 ± 0.57
0.89 ± 0.55
0.95 ± 0.44
0.98 ± 0.34
1.01 ± 0.53
% score
58.33
44.85
47.40
48.90
50.77
Mean± SD
0.62 ± 0.72
0.51 ± 0.59
0.61 ± 0.59
0.57 ± 0.54
0.38 ± 0.52
% score
30.95
25.74
30.47
28.57
19.23
Mean± SD
1.07 ± 0.68
0.82 ± 0.77
0.89 ± 0.67
0.87 ± 0.54
0.88 ± 0.67
% score
53.57
41.18
44.27
43.41
44.23
Mean± SD
0.95 ± 0.72
0.79 ± 0.72
0.93 ± 0.75
1.07 ± 0.76
0.82 ± 0.67
% score
47.32
39.71
46.61
53.30
40.77
Mean± SD
0.98 ± 0.61
0.81 ± 0.63
0.95 ± 0.65
1.0 ± 0.65
0.95 ± 0.61
% score
49.11
40.44
47.40
50.0
47.69
Mean± SD
1.02 ± 0.72
0.79 ± 0.61
1.13 ± 0.61
1.03 ± 0.59
0.70 ± 0.58
% score
51.19
39.71
56.51
51.65
35.0
P
Define the following
( hospital infection ) :
1.
2.
3.
4.
5.
7.
8.
9.
0.104
Infection
<0.001 *
Infection proper care in the hospital
<0.001 *
Methods of transmission
<0.001 *
Infection Series consists of six elements
To prevent the spread of infection to be cut chain of
infection
Types of most frequent infections in
hospital
Most important sources of infection within
the hospital
Persons who are most susceptible to
infection
10. Factors that affect the degree of human resistance to
infection
11. Standard precautions to prevent the transmission of
infection
12. Disinfection
<0.001 *
<0.001 *
0.015 *
<0.001 *
0.008 *
0.022 *
13. Sterilization
0.354
<0.001 *
14. Wound dressing
p: p value for F test (ANOVA) for comparing between the different studied group
*: Statistically significant at p ≤ 0.05
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July 2015
0.070
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Table (3): Comparison between general hospitals and universities hospitals
according to knowledge and practice
General hospitals
(n = 490 )
University hospitals
(n = 159 )
No.
%
No.
%
403
82.2
134
84.3
Test of sig.
Hospital infection
Unsatisfactory
Satisfactory
87
17.8
25
Mean± SD
46.91 ± 17.50
44.03 ± 15.87
Unsatisfactory
294
60.0
105
66.0
Satisfactory
196
40.0
54
34.0
Mean± SD
51.57 ± 24.12
48.08 ± 24.56
207
87
χ2
p=0.556
15.7
t
p=0.065
Disinfection and
sterilization
χ2
t
p= 0.174
p=0.115
Wound dressing
Unsatisfactory
42.2
57.8
72
54.7
Satisfactory
283
Mean± SD
59.07 ± 17.04
55.87 ± 16.56
291
112
χ2
p=0.006 *
45.3
t
p= 0.039 *
Total knowledge
Unsatisfactory
59.4
40.6
47
70.4
Satisfactory
199
Mean± SD
52.52 ± 16.63
49.33 ± 15.63
150
45
χ2
p= 0.13 *
29.6
t
p= 0.033 *
Hand hygiene
Unsatisfactory
30.6
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July 2015
28.3
χ2
p= 0.581
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Satisfactory
340
69.4
114
71.7
Mean± SD
66.57 ± 17.46
66.90 ± 17.97
373
136
t
p= 0.838
Personal protection
Unsatisfactory
76.1
23.9
85.5
Satisfactory
117
23
Mean± SD
39.03 ± 24.80
33.18 ± 24.62
265
102
χ2
p= 0.012 *
14.5
t
p= 0.010 *
Total Practice
Unsatisfactory
54.1
Satisfactory
225
45.9
Mean± SD
52.80 ± 17.51
64.2
57
χ2
p= 0.026 *
35.8
t
50.04 ± 17.50
p= 0.084
p: p value for comparing between the two studied groups
t: Student t-test
χ2: Chi square test
*: Statistically significant at p ≤ 0.05
Table (4): Comparison between different hospitals according to knowledge and practice
Damietta hospitals(n=236 ) Ismailia hospitals (n=283 )
General
(n=168 )
El Azhar
University
(n=68 )
General
(n=192 )
University
(n=91 )
Port Said
Hospital
(n=130 )
No.
%
No.
%
No.
%
No.
%
No.
%
Unsatisfactory
90
53.6
48
70.6
112
58.3
64
70.3
89
68.5
Satisfactory
78
46.4
20
29.4
80
41.7
27
29.7
41
31.5
Mean ± SD
54.95±17.37 46.19±18.08 52.75±16.29 51.67±13.13 49.03±15.65
Test of sig.
Total knowledge
χ2
p = 0.010 *
F
p=0.001 *
Total Practice
Unsatisfactory
88
52.4
46
67.6
101
52.6
56
61.5
76
58.5
Satisfactory
80
47.6
22
32.4
91
47.4
35
38.5
54
41.5
Mean ± SD
54.58±17.06 45.76±20.21 51.51±18.73 53.23±14.47 52.41±16.11
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July 2015
χ2
F
p = 0.140
p=0.012 *
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(Figure .1) Nurses knowledge about infection control in outpatient clinics, reception
and emergency hospitals in three region
100
Damitta General
El Azar university
Ismalia General
Ismalia university
Port Said General
90
80
70
Percentage
60
50
40
30
20
10
0
Unsatisfactory
Satisfactory
Unsatisfactory
Hospital infection
Satisfactory
Unsatisfactory
Disinfection and sterilization
Satisfactory
Unsatisfactory
Wound dressing
Satisfactory
Total knowledge
(Figure .2) Nurses practice about infection control in outpatient clinics, reception
and emergency hospitals in three regions
90
Ismalia
Damitta
80
El Azar
Port Said
Ismalia university
70
Percentage
60
50
40
30
20
10
0
Unsatisfactory
Satisfactory
Hand hygiene
July 2015
Unsatisfactory
Satisfactory
303
Personal protection
Unsatisfactory
Satisfactory
Practice
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Discussion
Infection control guidelines designed to
protect people from disease spread by
blood and contain body fluids. Most of
the participants were the age group
between 20 – 30 years in the all
hospitals. As regards their experience,
about 50% had experience less than five
years and more than thirty percent had
experience more than five years. Also,
about two thirds of them attended
training course about infection control.
The finding of the present study agree
with (Mehrdad, et al.,2007) who showed
that approximately two thirds of his
study group had previous courses on
infection control at Iran. Also, the study
agree with (Ahmed, et al.,2008 ) who
stated that about two thirds of
participants attended training courses
about infection control at Mansoura
international specialized hospitals. The
finding of the present study agrees with
(Shaaban, et al.,2009 ) who stated that
the hospitals are responsible for
performing in- service education
particularly those who have higher
incidence of nosocomial infection.
Furthermore, infection control education
program should be widely implemented
in critical care units setting it can
markedly reduce the morbidity and
mortality attributed to HAI .In addition
to substantial decrease in cost.
Regarding nurses‘ knowledge about
infection control in outpatient clinics,
reception and emergency hospitals, the
majority of the study sample had
unsatisfactory
knowledge
about
disinfection and sterilization. This
finding goes in the same line with study
by(Jain, et al.,2012 ) who stated that
study among nurses should lack of
adequate knowledge of infection control
measures. Rational education is a critical
element in the training of all nurses to
304
July 2015
improve knowledge about infection
control(McGaw, et al., 2012). While in
the present study nurses knowledge
about wound
addressing showed
satisfactory knowledge, the study done
in Tanta and Assiut by(Shaaban, et
al.,2009 ) revealed that the nurses had
low knowledge score about wound
dressing The majority of the study
sample
has
satisfactory
practice
regarding hand hygiene in deferent
regions while unsatisfactory practices
were showed in personal protection.
These
findings
were
consistent
with(Ahmed, et al.,2008 ) who showed
infection control equipment and supplies
were inadequate. These findings come
in consistence with an Iranian study
(Mehrdad, et al.,2007 ) who mentioned
that occupational exposure increased
because of
inadequate supply of
personal protective equipment, improper
disposal of medical waste, and lack of
effective needle disposal system. These
findings was consistent with (Ahmed
2001, Eltourkhy, 2007 , Foster,et
al.,2010 ,
McGaw,
et
al.,
2012andYamini,et al., 2012) who
reported that the obstacles behind the
application of the universal precaution of
the shortage of equipments and supplies.
This study proved that the failure of
nurses and lab technicians in application
of standard precaution during their work
might be due to lack of their knowledge
as well as unavailable equipment and
supplies.
6.Conclusion
The present study have shown
satisfactory hand hygiene practices
among study nurses, while most of
nurses have shown unsatisfactory
knowledge
regarding
disinfection
,sterilization and wound dressing. In
addition to unsatisfactory practice in
personal protection.
A Pilot study on infection control.
enj@nursing.cu.edu.eg
7. Recommendation
- Increasing supply of personal
protective equipment is essential.
- Monitoring compliance with
standard precautions in hospital
is a must.
- Educational and assessment
among nursing staff should be
regularly conducted
- Training programs to different
level of nurses should be
developed as effective and longlasting
means
to
foster
compliance
with
standard
precaution measures .
Competing Interests:
The author(s) declare that they have
no competing interests.
Authors' Contributions
Maha Moussa conceived the study
idea, collected data, designed the
review methodology, conducted the
critical appraisal of the studies and
drafted the manuscript.
Naglaa Ibrahim developed the search
strategies, conducted the searches,
conducted the critical appraisal of the
studies and prepared the final
manuscript for publication.
Eman Shokry assisted in designing
the review methodology.
All authors read and approved the
final manuscript.
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Effect of Uterotonic Drugs.
enj@nursing.cu.edu.eg
Effect of Uterotonic Drugs (Misoprostol versus Methyl-ergometrine and Oxytocin)
for The Prevention of Primary Atonic Postpartum Haemorrhage
Hala Abd El fttah Ali1, Sabah Ramadan Hussein Ahmed2 and Magdy H. A. Kolaib3
1
Lecturer of Women's Health &Obstetric Nursing, Faculty of Nursing, Kafr El Sheikh
University
2
Lecturer of Maternal & Newborn Health Nursing, Faculty of Nursing, Helwan
University
3
Professor of Obstetrics & Gynecology, Faculty of Medicine, Ain Shams University
Abstract:
Primary postpartum hemorrhage (PPH)is an important cause of maternal morbidity and mortality after
delivery. Active management of PPH by an uterotonic drug decreases the rate of PPH. The aim of this
studywas to assess the effect ofuterotonic drugs (Misoprostol versus Methyl-ergometrine and Oxytocin) for
the prevention of primary atonic postpartum hemorrhage (APPH). Methods: Quasi experimental study
carried out at Labor Ward atMaternity Hospital, affiliated to Ain Shams University, Egypt. A systematic
random study sample of 300 parturient out of 400 randomized women was recruited for this study
according to certain criteriaincluding age and parity. They were randomly assigned to three groups;each
composed of 105 women were given 1000μg of oral Misoprostol102 womenwere given Methyl
ergometrine 0.2 mg IM injection and 93 women were given 10 IU Oxytocin in 1 L ringer serum (rate of 10
ml/min IV)was received immediately after delivery. Three tools were used for data collection: A Structured
interviewing questionnaire tool, labour assessment tools and estimation of blood loss tool. Results:The
incidence of total primary APPHin Misoprostol group was significantly less than other groups which was
(5.7 % Vs 11.8 % and 26.9% respectively)(p<0.001).The blood loss was significantly different in the
studied three groups (p<0.001 ). Conclusions:The incidence of total APPH in Misoprostol group was
significantly less than non-users. Oral Misoprostol doses of 1000 μg may be used for managing
APPH.Recommendations:The present study recommended the use of oral Misoprostol 1000 μg in the
treatment of primary APPH. It was necessary to study the effect of different doses of Misoprostol and to
compare them with the Oxytocin drug that still been used in some poor underdeveloped countries on
management of third stage of labour to reduce maternal morbidity and mortality.
Key Words: Misoprostol, Methyl-ergometrine, Oxytocin and APPH
Introduction:
Primary PPHis an important cause of
maternal morbidity and mortality after
delivery. Active management of PPHby
an uterotonic drug decreases the rate of
PPH. Postpartum hemorrhage is usually
caused by excessive hemorrhage from
placenta implantation area or damage to
genital system (Rush; 2000, Brabin,
Hakimi,
Pelletier;
2001
&Hoj,
Stensballe, Aaby; 1999). PPH involves
more than half of the cases of
postpartum deaths in developing
countries (Kwast; 1991 , Enkin, Keirse,
Neilson; 2000 & Gulmezglu, Forna,
Viller, Hofmeyer; 2002). Bleeding may
occur before delivery (such as placenta
praevia or placental detachment) or more
common after delivery (such as bleeding
caused from uterine atony or rupture of
308
July 2015
genital system) (Gulmezoglu, Villar,
Ngoc, Piaggio, Carroli, Adetoro, et al;
2001&Maternal and Neonatal Health
Program; 2005 ).
Postpartum hemorrhage is defined as
bleeding ≥500 cc after completing of
labour third phase which is divided into
two types of primary (at first 24 hrs.
after delivery) and secondary (after first
24 hrs. after delivery) (Tang, Schweer,
Seyberth, Lee, Ho; 2002). One of the
common causes of bleeding is uterine
inability for suitable contraction after
delivery. In most cases, we can doubt to
uterine atony during delivery process.
For example, more stretched uterus after
delivery is susceptible to being
hypotonic.
For treatment of PPH, different drugs
with uterotonic characteristics are used
Effect of Uterotonic Drugs.
enj@nursing.cu.edu.eg
(Lam, Tang, Lee, Ho; 2004&Lars,
Placido, Birgitte, Nielsen, Lone, Jens
and Peter; 2005 ). First line treatment of
mothers with PPHis administration of
Oxytocin. However; most studies have
shown that administration of Oxytocin
alone is not enough and it is required to
use drug and non-drug methods. If
bleeding is not controlled by oxytocic
drugs, other methods should be used
such as uterine massage with two hands,
ligation of intra-iliac artery, uterine
artery, uterine compression sutures,
angiographic
embolization,
uterine
package and finally hysterectomy
(Amali, Lokugamage, Keith, Sullivan,
Losif, Patrick, Felix; 2001 & WHO;
1994).
Several drugs reduce PPH by stimulating
the uterus to contract. Ergot derivatives
have been used for decades, although
Oxytocin is the drug of choice in some
centers, Methyl-ergometrine is still been
used
in
some
places.
Several
prostaglandins are used as second or
third line agents. These drugs, however,
must be refrigerated to remain effective.
Moreover, most uterotonics must be
administered by injection, which
requires sterile equipment and training in
safe administration, prerequisites which
are unavailable for most women
delivering in poor underdeveloped
countries(Gulmezglu, Forna, Viller,
Hofmeyer; 2002 ).
Misoprostol; a prostaglandin E1
analogue, can be administered orally,
rectally, or sublingually. A multi-center
study found that Misoprostol was less
effective
for
prophylaxis
than
intravenous or intramuscular injections
of Oxytocin but did not investigate the
possible benefit of Misoprostol to the
large number of women who give birth
outside health facilities(Gulmezoglu,
Villar, Ngoc, Piaggio, Carroli, Adetoro,
309
July 2015
et al; 2001). Distribution of Misoprostol
in Indonesia in certain areas reduced the
frequency of excessive bleeding and the
need for emergency referral to hospitals
for PPH compared with the data from a
control area where Misoprostol was not
available(Maternal and Neonatal Health
Program; 2005 ). Most of the randomized
studies of prophylactic Misoprostol have
used oral and rectal administration
(Tang, Schweer, Seyberth, Lee, Ho;
2002). A recent pilot study found that
oral Misoprostol and intravenous
Syntometrine have comparable effects
on blood loss in the third stage of
labour(Lam, Tang, Lee, Ho; 2004 ).
Nursing
management
of
PPH
aremassage the uterus while supporting
the lower uterine segment,express
clots,insert an indwelling catheter to
empty the bladder and allow accurate
measure of output,place the woman in
supine position,avoid Trendelenburg
position which may interfere with
respiratory and cardiac function,maintain
IV access and start a second IV with
large-bore catheter capable of carrying
whole blood,administer IV fluids,
volume expanders, and blood as
directed,draw blood (per protocol or
orders) for hemoglobin and hematocrit,
type and cross match, platelets,
prothrombin time, activated partial
thromboplastin time (APTT), fibrinogen,
fibrin degradation products, and fibrin
split products,administer prescribed
drugs, such as Oxytocin, prostaglandins,
or Methyl-ergometrine andapply a pulse
oximeter to determine the oxygen
saturation; administer oxygen by snug
face mask at 8 to 10 L/min or as directed
by the physician or facility protocol,
anticipate further medical interventions
(uterine
packing,
ligation
or
embolization of uterine, ovarian, or hypo
gastric arteries, or hysterectomy) if other
Effect of Uterotonic Drugs.
enj@nursing.cu.edu.eg
measures fail to control bleeding.In
addition, the nurse willmonitor the
condition
of
the
woman
and
communicate with the health care
provider, provide explanations and
emotional support for the woman and
her family and obtain signed consents
for specific surgical procedures or blood
transfusions(Obstet Gynecol Neonatal
Nurs Organization; 2000& American
Journal
of
Maternal
Child
Nursing,MCN; 2000 ).
Significance of the study:
In the developing world about 1.2% of
deliveries are associated with primary
PPH and when PPH occurred about 3%
of women died. About 0.4 women per
100,000 deliveries die from PPH in the
United Kingdom while about 150
women per 100,000 deliveries die in
Africa.Anaemia is very common in
pregnant
women
in
the
poor
underdeveloped
countries
(Weeks;
2015). Maternal mortality is four times
higher in severely anaemic women than
non-anaemic ones and PPH is the most
common cause of death. Its main cause
is uterine atony, which accounts for
more than 70%. Active management of
the third stage of labour is recommended
for all parturient women. It is the most
effective means of preventing APPH. It
reduces more than 50% of the PPH risk,
and routine prophylaxis reduces 70% of
the need for therapeutic oxytocic to treat
excessive PPH(Global Burden of
Disease Study; 2014 ).
In Egypt, in multivariate models,
decrease of antepartum hemoglobin
level, history of previous PPH, labour
augmentation and prolonged labour were
significantly associated with PPH. Post
model probability estimation showed
that, even among women with three or
more risk factors, PPH could only be
310
July 2015
predicted in 10% of the cases(Pregnancy
and Childbirth BMC; 2011 ).
The aim of this studywasto assess the
effect of uterotonic drugs (Misoprostol
versus
Methyl-ergometrine
and
Oxytocin) on the prevention of primary
APPH.
Study research hypothesis:
Pregnant
womenwho
receivedoral
Misoprostol in doses of 1000μgareless
likely
todevelop
primary
APPH
thanMethyl-ergometrine or Oxytocin.
Material and Methods:
Design: Quasi experimental study
(posttest design).
Setting:LaborWard
atMaternity
Hospital, affiliated to Ain Shams
University, Egypt.
Sampling:
Participants in this research who
assigned during the period from 1 stof
March 2015 to the end of June 2015
were
allocated
to
intervention
groupsafter they admitted to the Labor
Ward with the following inclusion
criteria: Inactive labour with age of 20
years or more, full term with single
living fetus, no medical disorders
associated with pregnancy, spontaneous
and instrumental vaginal deliveries with
or without episiotomy were included in
the study intervention groups. While
traumatic PPH, Cesarean Section (CS)
delivery, blood diseases, women with
chorioamnionities, placenta praevia and
abruptio placenta, multiple gestation and
previous history of PPH were excluded
from the study. A sample size of 300
subjects, were enrolled in this study. The
sample size was calculated according to
the following formulae:
Where:
n= the number of patients in each arm of
the trial.
Effect of Uterotonic Drugs.
enj@nursing.cu.edu.eg
Zα/2= this is the value of the normal
distribution which cuts off an
upper tail probability of α/2. (If
α=0.05 then Zα/2=1.96).
Zβ= this is the value of the normal
distribution which cuts off an
upper tail probability of β. (if β
=0.2, then Zβ =0.84).
σ= the presumed standard deviation of
the outcome.
Δ= the difference sought between the
means of the two groups.
The target variable in this study is blood
loss. If the clinically relevant difference
in the blood loss between the
intervention groups is presumed to be 25
ml and the standard deviation 60; and if
two-sided significance level of 0.05 (or
5%) is to be used and the power should
be 0.8 (or 80%) then by substitution of
these data in the sample size formula we
have: 2(60)2(1.96+0.84 )2/(25)2=90.3.
Hence, 99.6 participants per treatment
arm are required. Some participants may
drop out from the study by assuming
that.
Group assignments:
In arrangement of studygroups, a
systematic randomization method was
used.A study sample of 300pregnant
women out of 400 randomized women
was randomly assigned tothree groups;
each group was further divided and
randomly allocated into one of three
groups, each composed of 105 women
were
given
1000 μg
of
oralMisoprostol,102
women
were
givenMethyl-ergometrine 0.2 mg IM
injection and 93 women were given 10
IU Oxytocin in 1 L ringer serum(rate of
10 ml/min IV) was received immediately
after delivery. A flow chart of the
women assignments is presented in
Figure 1.
Tools of data collection: Data collection
was obtained by using the following
311
July 2015
tools:
1) A
Structured
interviewing
questionnaire was developed by the
researchers and was used to collect the
maternal characteristics such as,
maternal age and parity. It reviewed by
expert in the fieldand implemented by
the researchers.
2) Labour assessment tools were reviewed
by expert in the field and implemented
by researchers to assess labour progress
and any raised problems. Also to assess
third stage of labour through:
 Incidence of primary APPH in different
groups
 Estimation of blood loss
 Incidence of anemia
 Duration of the third stage
 Effect of drugs on the women‘s blood
pressure
 Haemoglobin deficit after 24 hrs. of
delivery
 Side effects of drugs
3) Estimation of blood loss tool (Patel,
Goudar, Geller, et al; 2006 ): It was
reviewed by expert in the fieldand
implemented by researchers.Blood drape
(Nigeria): International Implemented the
Continuum of Care Project using a blood
drape. The blood drape is a plastic sheet
that is placed under the woman and
siphons the blood into a calibrated
measuring pocket on the sheet. The
sheetis decontaminated and then
disposed of as medical waste or
incinerated after use.
Validity and reliability:
Tools content validity assessed by a
panel of 3 experts in the field of
maternity nursing and lookedfor
modifications were carried out while
their reliability was tested by Combachk
Alpha test.
Effect of Uterotonic Drugs.
enj@nursing.cu.edu.eg
Ethical consideration:
Permission to carry out the study was
obtained from the Director of Maternity
Hospital
affiliated
toAin
Shams
University, the Head of Obstetrics and
Gynecology
Departmentand
the
supervisor of Maternity and Gynecology
of Nursing Department. The researcher
introduced herself to all health care
providers and parturient women then the
aim of the study was explained prior to
their participation to obtain their
acceptance and written consent was
obtained.
Pilot study:
Pilot study was conducted on 10% total
sample.
It
aimed
to
assess
feasibility,confidentially and a normality
of the study. Thepilot sample was
excluded from the study.
Procedures:
The researcher introduced herself to the
eligible women, briefly explained the
nature of the study, and then written
consent was obtained from them.In
arrangement of study groups, a
systematic randomization method was
used.The Labor Ward hasbeen visited
three days a week, three hrs. daily to
select these pregnant women.The
duration was 5 to 10 minutes with each
woman
in
intervention
group.A
Structured interviewing questionnaire
was used to collect the maternal
characteristics. Three hundred parturient
were allocated randomly intothree
groups;each composed of 105 women
were
given
1000 μg
of
oral
Misoprostol,102 women were given
Methyl-ergometrine 0.2 mg IM injection
and 93 women were given 10 IU
Oxytocin in 1 L ringer serum(rate of 10
ml/min IV) was received immediately
after delivery.
Participants
were
subjected to thorough history taking,
physical examination and routine
312
July 2015
investigations such as complete blood
count and abdominal ultrasound
examination.Randomization
and
allocation of women to study groups
were done through a computer
generation; the study researcher handled
out an opaque closed envelope
containing the orders to manage the
women
according
to
planned
protocol.Labour assessment tools were
used to assess labour progress and any
raised problems. The above medications
were given to the participants
immediately after delivery of the baby
by the nurses.The nurse monitored the
conditionof
the
woman
and
communicated with the health care
provider. Placenta was delivered by
Brandt‘s Andrew technique. Retained
placenta for more than 30 minutes was
removed manually under general
anesthesia, and thenassessed. Duration
ofthe third stage of labor was carried out.
Excess bleeding before and after
placental expulsions was evaluated and
treated
according
to
WHO
recommendation(WHO;
1994).Anaemiadiagnosed
when
haemoglobin less than 10.5 g/ml, sever
blood loss exceeding 1000 ml while
average blood loss was between 500 –
1000 ml (WHO; 1994 ). A detailed
stepwise management protocoldescribes
4 stages of obstetrical hemorrhage after
childbirth and its application reduces
maternal mortality.Stage 0:Normal treated with fundal massage and
IVOxytocin.Stage 1:More than normal
bleeding, consider the use of methergine,
perform fundal massage and prepare 2
units of packed red blood cells.Stage
2:Bleeding
continues
check
coagulation status, assemble response
team, move to operating room, place
intrauterine
balloon,
administer
additional uterotonics (IV Misoprostol,
Effect of Uterotonic Drugs.
enj@nursing.cu.edu.eg
carboprost,
Tromethamine).Consider
uterine artery embolization, dilatation,
curettage and laparotomy with uterine
compression
stitches
or
hysterectomy.Stage
3:Bleeding
continues - activate massive transfusion
protocol, mobilize additional personnel,
recheck laboratory tests, perform
laparotomy
and
consider
hysterectomy.Blood samples were taken
on admission and after 24 hrs. of
delivery for haemoglobin estimation.
Side effects that were observed or were
complained of by participants were
reported to the nurses and were recorded.
The outcome measures in the study
were:
 Incidence
of primaryAPPH in
different groups
 Estimation of blood loss
 Incidence of anemia
 Duration of the third stage
 Effect of drugs on the women‘s blood
pressure
 Haemoglobin deficit after 24 hrs. of
delivery
 Side effects of drugs
Limitations of the study:
Oral Misoprostolwas sometimes difficult
to be accepted by women as well as
estimation of blood loss was sometimes
difficult. It was difficult to determine the
amount of blood loss from episiotomy.
Statistical analysis:
Data were collected and analyzed using
SPSS program version 11 for windows
using F value and ANOVA test for
statistical significance. Differences were
considered significant when the p value
was less than 0.05.
Results:
Table 1 showed that, the age of women
in studied groups were not statistically
significantly different, While parity in
studied groups were statistically
significantly different p<0.001. The
313
July 2015
duration of the third stage of labour was
significantly different in studied three
groups. The mean blood loss was 125
±66 ml in the studied group I. The other
groups had blood loss 130.3 ±83 and
155 ±90.1 ml respectively in the studied
group II and III. The blood loss was
significantly different in three studied
groups p = 0.022 . Table 2 showed the
changes in mothers‘ haemoglobin and
hematocrit before and after delivery in
the three groups. Before delivery, mean
of
mothers‘
haemoglobin
was
statistically different between three
groups (p <0.001 ). Increase in
haemoglobin was significantly more
observed in Oxytocin group than
Misoprostol and Methyl-ergometrine
groups as well as hematocrit level. While
decrease
in
hemoglobin
was
significantly more observed in Oxytocin
group than Misoprostol and Methylergometrine groups after delivery (mean
decrease of hemoglobin was 9.3 ± 2.1 in
Oxytocin group). Mean of mothers‘
haemoglobin was statistically different
between three groups (p <0.001 ) as well
as hematocrit level. The incidence of
anaemia (haemoglobin less than 10.5
g/ml) in the Misoprostol group was
62.8%. There was statistically difference
between three groups related to anaemia
(p <0.001 ).Table 3 showed the incidence
of primary APPH in Misoprostol group
was significantly less in anaemic than
other groups which was (2.8 % Vs 6.9 %
and 12.9% respectively) p=0.025 as well
as blood loss was not significantly less
in the Misoprostol group than the nonMisoprostol groups. APPH was severe
with blood loss exceeding 1000 ml was
seen in anemic cases and the women had
blood transfusion while average blood
loss between 500 – 1000 ml was seen in
non-anemic cases while the incidence of
APPH in Misoprostol group was
Effect of Uterotonic Drugs.
enj@nursing.cu.edu.eg
significantly less in non anaemic than
other groups which was (2.8 % Vs 4.9%
and 14% respectively) p=0.025 . As well
as, blood loss was not significantly less
in the Misoprostol group than the nonMisoprostol groups. On the other hand;
the incidence of total APPH in
Misoprostol group was significantly less
than other groups which was (5.7 % Vs
11.8 % and 26.9% respectively)
p<0.001 . Figure 2 showed that, the
incidence of total APPH in Misoprostol
group was significantly less than other
groups which was (5.7 % Vs 11.8 % and
26.9% respectively) p<0.001. Table 4
showed the frequency of side-effects in
three groups. The most common sideeffect was shivering, but no significant
difference was observed between three
groups. Vomiting reported as 10.4% in
Misoprostol group Vs 19.6% and 46.2%
respectively in groupsII and III.
Significant difference was observed
between three groups, p <0.001. Three
groups were not statistically different in
terms of side-effects except for
vomiting. There was no statistically
significant drop in systolic and diastolic
blood pressure in the studied groups.
314
July 2015
Effect of Uterotonic Drugs.
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Figure 1. Flow chart of the women's assignments
Assessed eligibility 500
Excluded not meeting inclusion criteria 50, declined to participate 30, other reasons 20
Randomized 400
Misoprostol group
Methyl-ergometrine group
Oxytocingroup
150
148
102
Excluded
Included
Excluded Included
Excluded
Included
45
105
46
102
9
93
Reason
Reason
Trauma to
perineum and
vagina or
cervix during
labour
Traumatic
excessive
bleeding
Analyzed105
Analyzed102
Reason
Trauma to
perineum
and vagina
or cervix
during
labour
Analyzed93
Table 1 Comparison of maternal and delivery characteristics between studied
groups.
Variables
GroupI
GroupII
GroupIII
ANOVA test
Misoprostol
Methyl-ergometrine
Oxytocin
(n=105 )
(n=102 )
(n=93 )
Mean ±SD
Mean ±SD
Mean ±SD
F
P
3.965
0.020
Age (years)
28 ±6.4
29.4 ±5.9
27 ±5.6
31.292
Parity
1.8±1.8
2.7±1.8
3.8±2
<0.00
1
Delivery characteristics
9.890
Duration of
7.3 ±3.4
8.5 ±3.4
9.4 ±3.2
<0.00
third stage of
1
labour/min
3.885
Blood loss/ml
125 ±66
130.3 ±83
155 ±90.1
0.022
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Effect of Uterotonic Drugs.
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Table 2.The changes in mothers’ hemoglobin and hematocrit before and 24 hour
after delivery and incidence of anemiain three groups
Variables
GroupI
GroupII
GroupIII
ANOVA test
Misoprostol
Methyl-ergometrine
Oxytocin
(n=105 )
(n=102 )
(n=93 )
Mean ±SD
Mean ±SD
Mean ±SD
F
P
Before delivery
128.521 <0.00
Haemoglobin
12.5 ± 0.8
13.4 ± 0.8
14.4 ± 0.9
g/ml
1
26.575
Hematocrit g/ml
34.3 ± 1.7
35.1 ± 1.8
36.1 ± 1.7
<0.00
1
After delivery
24.226
Haemoglobin
<0.00
11.8 ± 2.1
10.2 ± 2.3
9.3 ± 2.1
1
35.655
Hematocrit
<0.00
33.1 ± 1.3
32.3 ± 1.7
31.3 ± 1.6
1
Incidence
of
<0.00
66 (62.8%)
72 (70.6%)
87(93.5%)
26.38
anemia
1
Table 3.The incidence of primary atonic postpartum hemorrhage in anemic and
non-anemic cases and mean blood loss in three groups
Variables
GroupI
GroupII
GroupIII
ANOVA test
Misoprostol
MethylOxytocin
(n=105 )
ergometrine
(n=93 )
(n=102 )
Mean ±SD
Mean ±SD
Mean ±SD
F
P
Primary
APPHin anemic
3(2.8%)
7 (6.9%)
12 (12.9)
7.375
0.025
cases
Primary APPH
in non-anemic
3 (2.8%)
5 (4.9%)
13 (14%)
7.395
0.025
cases
Total APPH
6(5.7%)
12 (11.8%)
25(26.9%)
18.827 <0.001
Blood loss in
anemic
cases 145.8 ±78.4
160.5 ±91.3
177.4 ±89.4
3.300
0.038
/ml
Blood loss in
non-anemic
105.4±83.2
124.5±115
140.7±86.2
3.355
0.036
cases /ml
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Effect of Uterotonic Drugs.
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Table 4. Side effects andchanges in mean blood pressure among study groups
Variables
GroupI
GroupII
GroupIII
ANOVA test
Misoprostol Methyl-ergometrine
Oxytocin
(n=105 )
(n=102 )
(n=93 )
Mean ±SD
Mean ±SD
Mean ±SD
F
P
Shivering
89 (84.7%)
95 (93.1%)
90 (96.8%)
9.626
0.002
Fever
24 (22.8%)
28 (27.4%)
40 (43.0%
10.173
0.006
Vomiting
11 (10.4%)
20 (19.6%)
43 (46.2%)
30.306
<0.001
Diarrhea
3 (2.8%)
6 (5.9%)
7 (7.5%)
2.222
0.329
Headache
30 (28.5%)
39 (38.2%)
40 (43%)
4.687
0.096
Pyrexia
0(0)
1(0.9%)
1(1%)
1.091
0.580
Blood pressure change BP/mmHg
Change
in
systolic
0.9±7.5
0.7±8.3
0.68±9.3
0.022
0.979
BP/mmHg
Change
in
diastolic
0.3±9.5
0.3±6.2
0.58±7.4
0.041
0.960
BP/mmHg
Figure 2: The incidence of primary atonic postpartum hemorrhage in three
intervention groups
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July 2015
Effect of Uterotonic Drugs.
enj@nursing.cu.edu.eg
Discussion:
The aim of this study was to assess the
effect of uterotonic drugs(Misoprostol
versus. Methyl- ergometrine and
Oxytocin) for the prevention of primary
APPH.To fulfill the aim of this study,
research hypothesis was tested: Pregnant
women withoral Misoprostol in doses of
1000μg wereless likely to develop
primary APPHaccordingly, the study
hypothesis was accepted. This study
finding was consistent with prior
research
studies
revealed
thatMisoprostol has been used for more
than a decade for prophylaxis and
management of PPH after vaginal birth
(El-Refaey, Obrien, Morafa, Walder,
Rodeck; 1997 & Hofmeyr, Nikodem, de
Jager, Gelbart; 1998 ).
In the present study, the administration
of 1000 μg of oralMisoprostolwas
compared with Oxytocin received 10 IU
in 1 L ringer serum intravenously and
Methyl-ergometrine 0.2 mg IM as a part
of the routine active management of
PPH. The outcomes of both groups were
comparable and Misoprostol was
significantly more effective than
Oxytocin and Methyl-ergometrinein
reducing the incidence of PPH.
Another
prospective
randomized
controlled study was carried out on 1200
parturient delivered in Mallawy General
Hospital, El-Menia, Egypt, full term
single living fetus reported that blood
loss in women of studied groups
(Misoprostol and Methyl-ergometrine)
were
significantly
reduced
in
comparison to women of the control
group(Soltan, Gendi, Imam, and Fathi;
2007). In a previous study to compare
the efficacy of oral administered
Misoprostol with intravenous Oxytocin
infusionin preventing uterine atony and
blood loss during cesarean delivery. Six
hundred and fifty eight primipara women
318
July 2015
were randomly allocated in randomized
control trial in Saudi Arabia.A total of
96 and 94 women were analyzed in the
Misoprostol,Oxytocingroups,
respectively.
Intraoperative
and
postoperative
blood
loss
was
significantly lower in Misoprostol than
Oxytocin
(Surbek,
Fehr,
Hosli,
Holzgreve; 1999 ). The previous
researches have supported our study
results which showed that, PPH in
anemic and non-anemic caseswas
significantly lower in Misoprostol than
Oxytocin group p=0.025 .While the
incidence of total APPHin Misoprostol
group was significantly less than other
groups which was (5.7 % Vs 11.8 % and
26.9% respectively)p<0.001 .
In a previous study performed to
compare
oralMisoprostol
versus
intravenous Oxytocinfor prevention of
PPH. A total of 514 Iranian primipara
women in labour were randomized into
two groups (257 women in each) in a
randomized control trial. Within 1 min
of delivery, the participants in group 1
received 800 μg of oralMisoprostol;
group 2 received 5 IU of Oxytocin in 5
mL
lactated
ringer
solution
intravenously. Two groups were not
significantly different in term of 24
hrs.PPH; there were no significant
differences in hemoglobin or hematocrit
values 24 hrs. postpartum (Bamigboye,
Merrell, Hofmeyr, Mitchell; 1998 ). The
previousfinding was not supported by
the findings of our study which showed
that,mean of mothers‘ hemoglobin and
hematocritwere statistically different
between three groups (p <0.001). This
difference may be due to the higher dose
of Misoprostol used in our study or may
be explained by the difficulties of
determination the amount of blood loss
from episiotomy.
Effect of Uterotonic Drugs.
enj@nursing.cu.edu.eg
On the other hand, in a prospective
randomized controlled study was in
accordance with the findings of our
study, it can be seen that there was
significant
differences
between
Misoprostol and Methyl-ergometrine
group related to mean of mothers‘
hemoglobin and hematocrit, higher doses
(800 and 1000 μg) were significantly
better than the injectable Methylergometrine in reducing third stage
blood loss and haemoglobin deficit
(Soltan, Gendi, Imam, and Fathi; 2007 ).
In a prospective randomized controlled
studystated that the duration of the third
stage of labour not had statistically
difference between Misoprostol and
other studied groups (Methyl-ergometrin
and control). This study was in
agreement with results of all previous
Misoprostol studies. Because the cease
of bleeding in uncomplicated third stage
of labour normally occurs within 10 min
after delivery and the peak concentration
of oral Misoprostol is usually reached
after 26 mintherefore one would not
expect that the drug affect the third stage
duration (Soltan, Gendi, Imam, and
Fathi; 2007 ,Cook, Spurrett, Murray;
2013, Amant, Spitz, Timmerman,
Corremans,
Van,
1999,
Villar,
Gülmezoglu, Hofmeyr, Forna; 2002 ,
Gulmezoglu, Viller, Hofmeyr; 2004 &
Clinical practice guidelines SOGC;
2000).
The previous studieswerenotconsisted
with the current study which reported
that the duration of the third stage of
labour was significantly different in
three studied groups and was lessin
Misoprostol
group
than
other
groupswhich was 7.3 ±3.4.This may be
explained by high dose of Misoprostol
used.
In previous studies in agreement with
the current study,a placebo-controlled
319
July 2015
trial1620 full term women in rural India
was randomized to receive oral
Misoprostol, a study evaluating oral
administered
Misoprostol
as
a
prophylaxis
versus
conventional
intravenous Oxytocin and Methylergometrine IM in PPH showed no
significant difference between two
groups in terms of reducing the
incidence of PPH; therefore reported that
orally administered Misoprostol may be
effective in the prevention of PPH as an
alternative to conventional intravenous
Oxytocin and Methyl-ergometrine IM.
Another
prospective
randomized
controlled study was carried out on 1200
parturient delivered was in agreement
with the current study reported that the
incidence of APPH in anaemic group
(women not using Misoprostol) in this
study was higher than non-anaemic
women,
which
suggested
that
Misoprostol may have a protective effect
against APPH in third stage in anaemic
pregnant
women(Amant,
Spitz,
Timmerman, Corremans, Van, 1999
&Aman, Carlan, Hamm, Lamberty,
White, Richichi; 2004 ).
In a previous study which showed the
third stage outcome in anaemic and nonanaemic subgroups. The incidence of
anaemia (haemoglobin less than 10.5
g/ml) in the studied population was
28.5%. It can be seen from this result
that the third stage blood loss is nonsignificantly higher in the anaemic than
the non-anaemic women. The incidence
of APPH in Misoprostol non-user is
higher in anaemic than non-anaemic
women (4.5% Vs 2%), while these
incidences were similar in the three
studied groups (Soltan, Gendi, Imam,
and Fathi; 2007 ). This result was in
accordance with the findings of the
current study which reported thatthe
incidence of anaemia (haemoglobin less
Effect of Uterotonic Drugs.
enj@nursing.cu.edu.eg
than 10.5 g/ml) in the Misoprostol group
was 62.8%. There was statistically
difference between three groups (p
<0.001 ).The incidence of APPH in
Misoprostol group was significantly less
in anaemic women than other groups
which was (2.8 % Vs 6.9 % and 12.9%),
while,the incidence of APPH in
Misoprostol group was significantly less
in nonanaemic than other groups which
was(2.8 % Vs 4.9% and 14%).
A randomized controlled trial, 200 full
term Iranian pregnant women in
Misoprostol group and 200 in Oxytocin
group evaluated Oxytocin versus oral
Misoprostol for active management of
third stage of labour; they reported that
oral Misoprostolwas associated with
significantly less blood loss than
Oxytocin; also, shivering and pyrexia
was significantly more observed in
Oxytocin group than oral Misoprostol
group (Cook, Spurrett, Murray; 1999).
In addition, a previous study which was
used
Misoprostol
and
Methylergometrine
for
preventingAPPH
reported that it can be seen that the
differences between side effects in
studied women and controlledwere
highly statistically significant (Soltan,
Gendi, Imam, and Fathi; 2007 ). These
previousresultswereparallel with current
findings.Another study reported that the
incidence of shivering was significantly
higher in Misoprostol group. And added
thatfever was significantly higher among
Misoprostol patients (18.7%
vs.
0.8%)(Surbek, Fehr, Hosli, Holzgreve;
1999).This result was not in accordance
with the findings of our study which
reported
thatno
significant
differenceswere observed between three
groups in terms of side-effects
andshivering was not significantly less
in Misoprostol group.
320
July 2015
In previous studies reported that it was
difficult to explain the drop in blood
pressure that occurred in the 800 or
1000 μg oral Misoprostol group,
especially, the majority of these women
had simultaneous shivering and fever.
However, the blood pressure of these
women had returned to normal within
short time without treatment (Soltan,
Gendi, Imam, and Fathi; 2007 &Aman,
Carlan, Hamm, Lamberty, White,
Richichi; 2004). Thesestudies in
accordance with the present study which
reported that, blood pressure drop was
not significantly higher in Misoprostol
group.In addition, multiple controlled
trials investigated Misoprostol as a
prophylactic agent to prevent PPH
(Lumbiganon,
Villar,
Piaggio,
Gülmezoglu, Adetoro, Carroli; 2002 ,
Caliskan, Meydanli, Dilbaz, Aykan,
Sonmezer, Haberal; 2002 &Diab, Ramy,
Yehia; 1999 ). These studies findings
were consistent with the present study.
Conclusions:
Oral Misoprostol as a prophylaxis versus
conventional intravenous Oxytocin and
intramuscular Methyl-ergometrine in
APPH showed significant difference
between three groups in terms of
reducing
the
incidence
of
APPH.Therefore;it was reported that
orally administered Misoprostol might
be effective in the prevention of APPH.
In addition; the incidence of total APPH
in Misoprostol group was significantly
less than other groups which was (5.7 %
Vs 11.8 % and 26.9% respectively)
p<0.001 . The most common side-effect
was shivering, but no significant
difference was observed between three
groups. Vomiting reported as 10.4% in
Misoprostol group Vs 19.6% and 46.2%
respectively in groupsII and III and
significant difference was observed
between three groups, p <0.001. Three
Effect of Uterotonic Drugs.
enj@nursing.cu.edu.eg
groups were not statistically different in
terms of side-effects except for
vomiting. There was no statistically
significant drop in systolic and diastolic
blood pressure in the studied groups.
Recommendations:
Therefore;the
present
study
recommended the use of oral
Misoprostol 1000 μg in the treatment of
primary APPH. It is necessary to study
the effect of different doses of
Misoprostol and to compare them with
the Oxytocin drug that still have been
used in some poor underdeveloped
countries on management of third stage
of labour to reduce maternal morbidity
and mortality.
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323
July 2015
Nutritional status of critically.
enj@nursing.cu.edu.eg
Nutritional status of critically ill patients receiving enteral nutrition at minia
university hospital: nurses knowledge and practices.
Mohamed Mamdouh Yehia 1 *, Warda Youssef Mohammed Morsy2, Hanaa Ali Ahmed Elfeky3,
1. Demonstrator of Critical care & emergency Nursing, Faculty of Nursing Minia University.
2. Professor of Critical care and emergency Nursing, Faculty of Nursing Cairo University.
3. Assistant Professor of Critical care & emergency Nursing, Faculty of Nursing Cairo University.
Abstract
Background: Nutritional support has become a routine part of caring for critically ill patients. It is widely
accepted as a treatment for prevention of malnutrition and specific nutrient deficiencies in intensive care
units where malnutrition is common, associated with poor patients‘ outcomes and increased health care
costs. Therefore, critical care nursesare required to have up to date knowledge, and the ability to assess
nutritional status to prevent and compete the negative impact of malnutrition. Aim of the study:to assess
nurses‘ level of knowledge and practice regarding monitoring nutritional status of critically ill patients
receiving enteral nutrition. Research design:A descriptive exploratory research design was utilized in the
current study. Sample:A convenient sample of 30 nurses was included in the current study.Setting:This
study was carried out at the surgical and medical intensive care units of Minia University Hospital.Tools of
data collection:Two tools were developed by the research, and tested for clarity, and feasibility: a- Nurses‘
interview questionnaire; b- Nurses‘ practice observational checklist. Results: Allthe studied sample
(100%) had unsatisfactory knowledge and practice levels regarding monitoring nutritional status with
means of 30.93 ± 9.56&56.366 ± 11.360 respectively.Unsatisfactory levels were found regarding
knowledge about enteral nutrition.the needed caloric requirement, the balanced diet, protein and water
requirements, and nutritional assessment parameters in percentage of 96.7%, 96.7% &
93.3%,respectively.However, unsatisfactory practices were found regarding preparation and administration
of enteral nutrition, nursing care after administration and monitoring patient‘s nutritional status in
percentages of 93.3%, 100% & 100% respectively.No significant statistical differences were found in the
mean total and subtotal knowledge and practice scores in relation to gender.However, the mean total
practice scores differed significantly in relation to educational levels (t = 6.82 at p ≤ 0.004), and the work
setting (t = 6.23 at p ≤ 0.01).A positive correlation was found between total mean knowledge scores and
total mean practice scores (r = 0.455, at p ≤ 0.011) respectively.Conclusion: In spite of having vital role in
assessment and management of critically ill patients, critical care nurses in the current study had in general
unsatisfactory knowledge and practice regarding care of critically ill patients‘ receiving enteral nutrition.
Recommendation: updating knowledge and practice of critical care nurses through carrying out continuing
educational programs about nutritional support modalities (enteral/parenteral), and nutritional assessment;
strict observation of nurses' practice when caring for patients receiving enteral nutrition; provision of
guidance to correct poor practices; and replication of this study on larger probability sample selected from
different geographical locations.
Key Words: Critical
nutrition,Malnutrition.
care
nurses,
Knowledge,
Introduction
Malnutrition is common in critically ill
patients. It is common at hospital
admission and tends to worsen during
hospitalization. It occurs in up to 40% of
critically ill, and 50% of acutely ill
hospitalized adults. It occurs when
endogenous and exogenous supplies of
calories are not sufficient to meet the
metabolic requirement. It is consistently
associated
with
adverse
clinical
outcomes,
including
increased
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July 2015
Practice,
Nutritional
assessment,Enteral
morbidity, mortality, length of hospital
/intensive care unit (ICU) stay, increased
health care costsand as well as reduced
quality of life (Stewart, 2014
&Chakravarty,
2013 ).Critically
ill
patients
may
experience
stress,
inflammatory
responses,
hypermetabolism, and hyper-catabolism as
physiologic responses to critical illness
(Seron, 2013 ). During the catabolic
state, stored nutrients such as fats,
proteins and carbohydrates are depleted
Nutritional status of critically.
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due to the body‘s additional demands for
substrates required for tissue repair. This
in addition to accelerated lipolysis,
insulin
resistance,
and
protein
catabolism, thus weight loss is
commonly observed (Myrie, 2013 ).
Studies have revealed that
underfeeding occurs in up to 30% of
hospitalized patients and asmany as 50%
of ICU patients (Karnad & Sanjith
2012). As revealed by Sungurtekin,
Oner & Okke, (2010 ), up to 40% of
critically ill patients didn‘t receive
nutritional support during their ICU stay.
Furthermore, patients who received
nutritional support frequently remained
unfed for up to 48 hours after ICU
admission. That is why nutritional
support has become a routine part of the
care of critically ill patients. It is now
widely accepted as a treatment for
preventing malnutrition and specific
nutrient deficiencies in intensive care
units (ICU).Critically ill patients may
not eat any or enough food because of
illness. They may have decreased
appetite, difficulties in swallowing, or
undergo certain types of surgeries that
interfere with eating. When this occurs,
and the patient becomes unable to eat,
nutrition must be supplied in different
ways (Bozzetti, 2011 ). Nutrients can be
provided through either parenteral or
enteral route (tube feeding) (Ziegler,
2009).
The goals of nutritional support
are to attenuate the metabolic response
to stress, prevent oxidative cellular
injury, modulate immune response,
prevent nutrient deficiencies, avoid
complications related to nutrition
delivery, and improve patients‘ outcome
(Quenot, Plantiefeve & Baudel, 2010). It
can help in preserving muscle mass,
decreasing infection, improving wound
healing,
maintaining
gut
barrier
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July 2015
functions, supporting immune, renal, and
hepatic muscle function, reducing length
of ICU stay, reducing morbidity and
mortality, thus decreasing cost of
healthcare
(McClave,
et
al,
2009).However, patients on enteral
nutrition may suffer from certain
problems such as lean body mass
reduction; higher susceptibility to
infections; impairment of wound
healing; development of pressure ulcers;
respiratory insufficiency/failure; delayed
weaning from mechanical ventilation;
increased
cost
and
length
of
hospitalization; and higher mortality
rates.However, imparity in nursing
practice contributes to developing
serious deficiencies and complications
resulting from poor nutritional care.
Certain nursing practices can contribute
to hypo-caloric, under-feeding. Specific
factors such as using improper tube,
feeding intolerance and gastric retention
are associated with nutritional failure.
Previous studies suggest that, although
using enteral nutrition protocols,
intensive care unit (ICU) patients still
receive 50% of the prescribed nutrition,
leading to suboptimal nourishment due
to the frequent feeding cessation (Al
Kalaldeh, 2012).
Thus critical care nurses are
responsible for ascertaining the volume
and quality of a given formula, and
monitoring its effect(s) on patient‘s
outcomes (Persenius, Hall-Lord, Baath
& Larsson, 2008 ).Whatever was the
route of nutritional support; critical care
nurses are responsible for delivering the
prescribed nutrition in a safe and
effective way. As well, nurses need to
have up to date knowledge about the
negative impact of imbalanced diet on
patients‘nutritional status. They should
have the ability to assess nutritional
status of critically ill patients as a matter
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of monitoring and enhancing their
outcomes (Al Kalaldeh, 2012).
However,it has been found
through empirical observation in the
intensive care units at Minia University
Hospital that nutritional assessment was
not done for critically ill patients
especially those receiving enteral
nutrition. Nurses were mainly concerned
with patient‘s chief complain. Thus,
there is a need for such a study which
assesses
nurse‘s
knowledge
and
practices regarding nutritional status of
critically ill patient‘s receiving on enteral
nutrition.
2-Aim of the study
The aim of the present study was to
assess nurses‘ level of knowledge and
practice regarding monitoring nutritional
status of critically ill patients receiving
enteral nutrition.
3-Research questions
To fulfill the aim of this study, two
research questions were formulated:
3.1) Whatis the critical care nurses‘ level
of knowledge regarding nutritional status
of critically ill patients receiving enteral
nutrition?
3.2) Whatis the critical care nurses‘ level
of practice regarding monitoring
nutritional status of critically ill patients
receiving enteral nutrition?
4-Subjects and Methods
4.1 . Research Design:
A descriptive exploratory research
design was utilized in the current study.
4.2 . Setting:
The current study was carried out at
the surgical and medical intensive care
units of Minia University Hospital. The
surgical intensive care unit is located in
the second floor. It consists of three
I.C.U rooms; each one contains 2-3
beds. However, the medical intensive
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July 2015
care unit is located in the fourth floor. It
consists of three I.C.U rooms, and it
contains 11 beds. The nurse-patient ratio
ranged from 1:2 - 1:3.
4.3 . Sample:
A sample of convenience including (30)
male and female nurses working at the
surgical and medical ICUs at Minia
University Hospital, providing direct
patients care and willing to participate in
the study was included. They had
different
nursing
educational
backgrounds:bachelor degree, secondary
nursing school diploma and technical
nursing institute diploma.
4.4 . Tools of data collection:
Two tools were developed by the
researcher and utilized to collect data
pertinent to the current study, these
tools are:
4.4.1 .Tool 1: Nurses’ interview
questionnaire; It coveres two main
parts:
4.4.1.1 :
Nurses’
personal
and
background data:it covers data related
to age, gender, level of education, years
of experience in nursing, years of
experience in ICU, pattern of work,
work days /week, work hours/day, and
working in another place.
4.4.1.2 :
Nurses’
knowledge
assessment
regarding
nutritional
status of critically ill patients receiving
enteral nutrition:It was designed by to
assess nurses‘ knowledge regarding
monitoring nutritional status of critically
ill patients receiving enteral nutrition. It
consists of 58 multiple choice questions
classified into four main domains. The
first domain concerned with knowledge
about nutrition as a concept. The second
domain concerned withknowledge about
enteral nutrition. While, the third
domain, covers knowledge related to the
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needed calories, balanced diet, protein
and water requirements and the fourth
domain concerned with knowledge about
nutritional assessment parameters. The
total score of the questionnaire was 58.
Scores less than 75% were considered
unsatisfactory and scores equal or more
than 75% were considered satisfactory.
4.4.2 . Tool 2: Nurses’ practice
observational
checklist;It
was
developed to assess nurses‘ practices
regarding monitoring nutritional status
of critically ill patients receiving enteral
nutrition. It covers two parts:Nurses‘
practice regarding enteral nutrition
administration, and nurses‘ practice
regarding monitoring of patients‘
nutritional status.It consists of 20 items
classified into 3 main domains: nursing
practice regarding preparation and
administration of enteral nutrition;
nursing practice after administration of
enteral nutrition; and the nursing practice
regarding monitoring of patients‘
nutritional
status.
Each
nurse's
performed action was recorded in the
checklist
as
completely
done,
incompletely done, or not done.Two
scores were given to each completely
done pratice, one score for incompletely
done and zero score for not done. The
total scores are134. Scores less than
75% were considered unsatisfactory and
scores equal or more than 75% were
considered satisfactory.
4.5 . Validity and reliability of tools
Content validity was done to identify the
degree to which the used tools measure
what was supposed to be measured. The
developed tools were examined by a
panel of three medical and critical care
nursing experts to determine whether the
included items were clear and suitable to
achieve the aim of the current study. As
well test - re - test reliability of the data
collection tools was done using SPSS.
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July 2015
Ver. 20 and revealed aChronbach‘s Alfa
value of 0.89 indicating reliability of the
knowledge assessment questionnaire,
and a value of 0.87 indicating reliability
of the nurses‘ practice observational
checklist.
4.6 . Pilot Study
A pilot study was carried out on 3 nurses
(10%) of the total sample to test
feasibility, objectivity, and applicability
of the data collection tools. Carrying out
the pilot study gave the investigator the
experience to deal with the included
subjects, and to be familiar with the data
collection tools. Based on results of the
pilot study, needed refinements and
modifications were done and subjects
included in the pilot study were excluded
from the main study sample.
5-Protection of Human Rights
An official permission to conduct the
study was obtained from the ethical
committee and hospital directors.
Participation in this study was voluntary.
Each involved subject was informed
about the purpose, procedure, benefits,
and nature of the study, and that he/she
had the right to withdraw from the study
at any time without any rationale, then
written consents were obtained. Subjects
were informed that obtained data will
not be included at any further researches
without
a
second
consent.
Confidentiality and anonymity of each
subject were ensured through coding of
all data and protecting the obtained data.
Subjects were reported that obtained data
will not affect their annual appraisal.
6-Procedure
The current study was conducted
through two phases: preparation, and
implementation.
6.1 . Preparation phase:
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It was concerned with construction and
preparation of different data collection
tools, in addition to obtaining managerial
arrangement to carry out the study. The
investigator prepared and introduced
formal requests to the director of Minia
University Hospital. The purpose and
nature of the study were explained to
gain acceptance and support. This phase
lasted for two month s duration and
ended by carrying out the pilot study.
6.2 . Implementation phase:
This phase was concerned with starting
data collection. Data were collected over
a period of six months starting from
January 2014 to June 2014 . The
researcher visited the selected setting on
daily basis during the morning and
afternoon shifts.Nurses were submitted
by the nurses‘ interview questionnaire
(Tool 1). Nurses required about 20-30
minutes to fulfill this tool. Then the
researcher checked each questionnaire
after completing the data, to be sure that
no missing information were present.
The average number of nurses who
answered this questionnaire was 2-3
nurses per day. Later, three to four
nurses were observed in each day shift
utilizing tool (2). Each nurse was
observed on three different occasions
while performing each procedure of the
observational checklist. Each session
lasted about 3- 4 hours. Obtained data
were converted into numeric data, and
the average of the three observations‘
scores was calculated.
7-Results
Figure (1) clarifies percentage
distribution of the studied sample as
regards to gender:It shows that most
(70%)of the studied sample were
females.
Figure (2) clarifies percentage
distribution of the studied sample as
regards to age:It shows that, (83.4%) of
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July 2015
the studied sample‘s age ranged between
20 - <25 years with a mean age of 23 ±
2.349.
Table
(1)
clarifies
percentage
distribution of the studied sample as
regards
to
socio-demographic
characteristics:It showsthataround half
of the studied sample had bachelor
degree in nursing (56.7%) & work at the
surgical ICU (50%). As regards to years
of experience, around 2/3 (63.4%) of the
studied sample had less than 5 years of
experience in nursing, with a mean of
3.83 ± 3.37, and the great majority
(93.4%) had less than 5 years of
experience in ICU, with a mean of 1.6 ±
2.43. Concerning the pattern of work,
more than 2/3 (66.7%) of the studied
sample had full timework. More than
half (60%)worked 6 days/week, with a
mean of 5.13 ± 1.36, and 53.3% had 12
hours shift /day, with a mean of 9 ±
3.434.
Table
(2)
clarifies
percentage
distribution of the studied sample as
regards to total & subtotal mean
knowledge scores: It shows that,all the
studied
sample
(100%)
had
unsatisfactory total knowledge level with
a mean scores of 30.93 ± 9.56. The great
majority of the studied sample had
unsatisfactory
subtotal
knowledge
regarding enteral nutrition, the needed
caloric requirement, balanced diet,
protein and water requirements and
nutritional assessment parameters in
percentage of 96.7%, 96.7%& 93.3%,
with subtotal mean scores of 15.5 ±
4.65, 3.23 ± 1.45 & 8.8 ± 4.22,
respectively. However, 83.3% of the
studied sample had satisfactory subtotal
knowledge regarding nutrition as a
concept, with subtotal mean score of
3.41 ± 0.79. .
Table
(3)
clarifies
percentage
distribution of the studied sample as
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regards to total and subtotal mean
practice scores:It shows that the studied
sample had unsatisfactory practice level,
with a total mean practice score of 55.82
± 11.25.As well, the studied sample had
unsatisfactory practice level regarding
preparation and administration of enteral
nutrition,
nursing
care
after
administration of enteral nutrition and
monitoring patient‘s nutritional status, in
percentages of 93.3%, 100% & 100%
respectively, with subtotal mean practice
scores of 29.71 ± 6.746 , 13.72 ± 1.41
and 12.47 ± 5.06 respectively.
Table (4) clarifies comparison of mean
knowledge scores in relation to gender
of the studied sample:It reveals that
male nurses had higher total & subtotal
mean knowledge scores as compared to
females with means of 31.77 ± 10.99,
30.57 ± 9.15; 9 ± 4.94, 8.71 ± 4; 22.77
± 6.43, 21.85 ± 5.79 respectively. No
significant statistical differences were
found in the mean total and subtotal
knowledge scores in relation to gender.
Table (5) clarifies comparison of mean
practice scores in relation to gender of
the studied sample: It shows thatfemale
nurses had higher total mean practice
scores as compared to male nurses with
means of 56.61 ± 10.71 , and 55.77 ±
13.42 respectively. No significant
statistical differences were found in the
mean total and subtotal practice scores in
relation to gender.
Table (6) clarifies correlation between
sociodemographic characteristics of
the studied sample, total knowledge
and total practice scores:it reveals a
positive correlation between years of
experience in nursing and age (r = 0.522,
at p ≤ 0.003 ); years of experience in ICU
and age (r = 0.628 , at p ≤ 0.00); total
knowledge scores and total practice
scores (r = 0.455 , at p ≤ 0.011)
respectively.
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July 2015
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Figure (1): Percentage Distribution of the Studied Sample as Regards to Gender.
Figure (2): Percentage Distribution of the Studied Sample as Regards to Age.
Mean ± SD
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July 2015
23 ± 2.349
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Table (1): Percentage Distribution of the Studied Sample as Regards to Sociodemographic Characteristics (N= 30 ).
Characteristic
No
%
Frequency
Education
17
56.7
 Bachelor
8
26.7
 Technical
5
16.6
 Diploma
Department
15
50
 Surgical ICU
15
50
 Medical ICU
Years of experience in nursing
19
63.4
 <5
10
33.3
 5 - 10
1
3.3
 >10
X ± SD
3.833 ± 3.374
Years of experience in the ICU
28
93.4
 <5
1
3.3
 5 - 10
1
3.3
 >10
X ± SD
1.6 ± 2.43
Pattern of work
20
66.7
 Full time
10
33.3
 Part time
Work days / week
8
26.7
 3 days
3
10
 5 days
18
60
 6 days
1
3.3
 7 days
X ± SD
5.13 ± 1.357
Work hours / day
14
46.7
 6 hours
16
53.3
 12 hours
X ± SD
9 ± 3.434
Work in another place
24
80
 No
6
20
 Yes
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July 2015
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Table (2): Percentage Distribution of the Studied Sample as Regards to Total &
Subtotal Knowledge Scores Regarding Nutritional Status of Critically Ill Patients
Receiving Enteral Nutrition (N=30 ).
Knowledge Assessment
Domains
+SD
1.
2.
3.
4.
N=30
Subtotal &
Total mean
scores
Frequency / X Satisfactory
(≥75%)
No. %
General knowledge
about nutrition as a 25
83.3
concept.
Knowledge
about
1
3.3
enteral nutrition.
The needed caloric
requirement, balanced
1
3.3
diet, protein and
water requirements.
Nutritional
assessment
2
6.7
parameters.
Total X+SD
Unsatisfactory
(< 75%)
No.
%
N
5
16.7
30 100% 3.41 ± 0.79
29
96.7
30 100% 15.5 ± 4.65
29
96.7
30 100% 3.23 ± 1.45
28
93.3
30 100% 8.8 ± 4.22
%
X+SD
30.93 ± 9.56
Table (3): Percentage Distribution of the Studied Sample as Regards to Total &
Subtotal Practice Scores in Relation to Nutritional Status of Critically Ill Patients
Receiving Enteral Nutrition (N=30 ).
Practice Assessment
Domains
N=30
Frequency / X +SD
1. Preparation
and
administration of enteral 2
nutrition
2. Nursing
care
after
administration of enteral 0
nutrition
Total X+SD
6.7
28
93.3
0.0
30
0.0
30
%
X+SD
30
100%
29.71 ± 6.746
100
30
100%
13.72 ± 1.41
100
30
100%
12.47 ± 5.06
patient‘s
0
55.82 ± 11.25
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July 2015
N
%
Unsatisfactor
y
No. %
Satisfactory
No.
3. Monitoring
nutritional status
Subtotal & Total
mean scores
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Table (4): Comparison of Mean Knowledge Scores in Relation to Gender (N=30 ).
Variables
Male
Female
X±SD
X±SD
t
P
Gender
Enteral nutrition.
22.77
6.43
Nutritional assessment parameters.
9 ± 4.94
Total knowledge scores regarding nutritional
31.77
status of critically ill patients receiving
10.99
enteral nutrition.
NS: Not Significant
± 21.85
5.79
±
8.71 ± 4
± 30.57
9.15
0.386
0.167
±
0.312
0.70
NS
0.86
NS
0.75
NS
Table (5): Comparison of Mean Practices Scores in Relation to Gender (N=30 ).
Variables
Male
Female
t
P
X±SD
X±SD
Gender
1- Preparation and administration of enteral 27.29
± 30.61
± 0.21
nutrition
6.66
6.57
1.26 NS
2- Nursing care after administration of 14.40
± 13.42
±
0.08
1.8
enteral nutrition
1.56
1.26
NS
13.59
±
0.44
3- Monitoring patients‘ nutritional status
12 ± 4.33
0.78
6.65
NS
55.77
± 56.61
± 0.85
Total mean practice scores
13.42
10.71
0.18 NS
NS: Not Significant
Table (6): Correlation between Sociodemographic Characteristics of the Studied Sample,
Total Knowledge and Total Practice Scores (N=30 ).
Variable
age
Years
of Years
of Total
experience
in experience in knowledge
nursing
ICU
score
r
Age
p
0.522*
Years
of r
0.003
experience
in p
nursing
0.628**
0.484**
Years
of r
0.00
0.007
experience in ICU p
0.244
0.089
0.083
Total knowledge r
p
0.194
0.639
0.661
score
NS
NS
NS
0.112
0.046
-0.046
0.455*
Total
mean r
p
0.554
0.808
0.809
0.011
practice score
NS
NS
NS
NS: Not significant.
*: Significant statistical difference.
**: High significant statistical difference.
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July 2015
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Discussion
The current study revealed that most of
the studied sample was females. This
finding is in agreement with that of
Shahin, (2012) who conducted a study
about nurses‘ knowledge and practices
regarding enteral nutrition at the Critical
Care Department of Al- Manial
University Hospital, and revealed that
three quarters of the studied sample was
female nurses. As well, Eskander,
(2013 ) conducted a study over 77 nurses
at a selected Egyptian Cancer Hospital,
and revealed that more than half of the
studied sample was females. As regards
to age, the majority of the studied
sample is young adults (their ages are
less than 25 years old). This finding is
agreement with that of Al Kalaldeh
(2012 ),
who
studied
nursing
responsibility and teamwork regarding
enteral nutrition in the critically ill
patients, and revealed that the majority
of nurses‘ ages were less than 25
years.According to Erikson's stages of
human development; a young adult is
generally a person in the age group
ranges from 20 to 40. Young adulthood
can be considered as the healthiest time
of life. Biological function and physical
performance reach their peak from 20–
35 years of age. Young adulthood is
filled with avid quests for intimate
relationships
and
other
major
commitments involving career and life
goals. This refers to the ability of the
studied sample to learn and modify their
practice through training and continuous
education (Karen, Zastrow, & Ashman,
2009).
In relation to qualifications, the current
study revealed that more than half of the
studied sample had bachelor degree of
nursing. This finding is in agreement
with that of Al Kalaldeh (2012) who
revealed that the majority of the studied
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July 2015
sample had bachelor degree in nursing.
As well; Eskander (2013 ) revealed that
most of the studied nurses had bachelor
degree of nursing. However, this finding
is contradicted with that of Shahin
(2012 ) who revealed that more than half
of the studied nurses had diploma
degree. These differences "from the
researcher‘s point of view" may be
related to different types of nursing
recruitment programs and variation of
patient acuity level in the selected ICUs.
Concerning years of experience, the
current study revealed that around two
thirds of the studied sample had less than
5 years of experience in nursing. This
finding is in concordance with that of
Chan (2012 ), who carried out a survey
study about Nasogastric feeding practice
and revealed that, around two thirds of
the studied sample had less than 5 years
of experience in nursing. As well,
Eskander (2013) found that more than
half of the studied sample had less than 5
years of experience in nursing.
As regards to answering the first
research question which states "what is
the critical care nurses‘ level of
knowledge regarding nutritional status of
critically ill patients receiving enteral
nutrition?‖. The current study revealed
that,all the studied sample had
unsatisfactory total knowledge scores.
As well, the great majorityhad
unsatisfactory subtotal knowledge scores
regarding enteral nutrition, the needed
caloric requirement, balanced diet,
protein and water requirements and
nutritional
assessment
parameters.
However, the great majority had
satisfactory
subtotal
knowledge
regarding nutrition as a concept.These
findings are in agreement with that of Al
Kalaldeh (2012) who found that
nurses‘knowledge scoresabout enteral
nutrition were less than 60%among the
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great majority of subjects. As well,
Shahin (2012) revealed that the
baselines total & subtotal mean
knowledge scores were low regarding
enteral nutrition before an instructional
program application as compared to post
program scores. As well, Yun, (2012)
studied
healthcare
professional's
knowledge, perception and performance
on early enteral nutrition for critically ill
patients in Seoul St Mary's Hospital, and
revealed a low knowledge level among
critical care nurses.
As well, Mula (2014 ) conducted a
study about nurses‘ competency and
challenges in enteral feeding in the
Intensive Care Unit (ICU) and High
Dependency Units (HDU) in Malawi
referral hospital over 53 nurses, and
revealed inadequate knowledge in areas
of aspirating gastric residual volume,
daily inspection of nostrils in a patient
with a nasogastric tube, documentation
of nutritional care, assessment of
nutritional status. However, Ahamed
(2014 ) had a contradictory finding
where she studied assessment of
knowledge and practice of staff nurses
regarding Ryle‘s tube feeding in a
selected Hospital of Kolkata, over 42
staff nurses working in the intensive
therapeutic unit and revealed that the
great majority of participants had
adequate knowledge.
Low nurses' level of knowledge from the
researcher‘s point of view, may be
related to lack of training sessions,
absence of continuous supervision and
evaluation. Also, it may be due to
unavailability of hospital policy or
standard guidelines for enteral nutrition
and nutritional assessment, and absence
of multidisciplinary team (NursesPhysician- dietitian) cooperation when
dealing with critically ill patients
receiving enteral nutrition. Other reasons
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July 2015
may be related to work overload, lack of
nurses‘ incentives to improve their
knowledge and lack of desire to update
knowledge especially among those who
are working in ICUs and emergency
units for several years.Nurses‘ mean
knowledge scores in the current study
did not differ significantly in relation to
educational levels, working department,
years of experience in nursing and in the
ICU. In the same line with these findings
was that of Shahin (2012) who reported
no significant statistical correlation
between age, work setting and total
knowledge scores, however, the mean
total
knowledge
scores
differed
significantly in relation to years of
experience, educational level and marital
status. A contradicting finding was
reported by Ahamed (2014) who found a
significant association of knowledge
about Ryle‘s tube feeding with the
professional qualification and years of
experience.
In relation to the second research
question, it states, "what is the critical
care nurses‘ level of practice regarding
monitoring nutritional status of critically
ill patients receiving enteral nutrition?".
The current study revealed that, all the
studied sample had unsatisfactory
practice level regarding care for
critically ill patients receiving enteral
nutrition. This low practice level from
the researcher‘s point of view may be
related to low knowledge level,
increased frequency of patients and work
load.Findings of the present study arein
agreement with that of Al Kalaldeh
(2012 ) who revealed that nurses‘
practices regarding enteral nutrition were
not safe enough. As well, Yun (2012 )
revealed that levels of performance of
critical care nurses were relatively low.
Also Shahin (2012 ) revealed that the
baselines mean scores for total &
Nutritional status of critically.
enj@nursing.cu.edu.eg
subtotal practices regarding enteral
nutrition
were
low
before
an
instructional program application. In
addition Mula (2014 ) revealed that poor
practice has been shown by the majority
of studied sample, especially in checking
gastric residual volume, daily inspection
of nostrils, documentation, and in
performing
nutritional
assessment.
However, Ahamed (2014) had a
contradicting finding where she revealed
that all subjects had average practice
level regarding Ryle‘s tube feeding.
Nurses‘ mean practice scores in
the current study differed significantly in
relation to educational levels, the
working department and working in
another place in the current study. This
finding is in agreement with that of
Shahin (2012 ) who founda significant
statistical difference in the mean total
practice scores of nurses in relation to
educational level, and marital status.
However, Ahamed (2014) had a
contradicting finding where there was no
significant association between staff
nurses‘practice
scores
and
the
professional qualification regarding
Ryle‘s tube feeding. In addition, the
current study revealedthat the mean
practices
scores
didn‘t
differ
significantly in relation to years of
experience in nursing and in the ICU.
However, Shahin (2012 ) had a
contradicting finding, where the mean
total
practice
scores
differed
significantly in relation to years of
experience.
9-Conclusion
Based on findings of the current study, it
can be concluded that, critical care
nurses have unsatisfactory knowledge
and practice levels regarding monitoring
nutritional status of critically ill patients
receiving enteral nutrition. These
336
July 2015
findings are challenging to the practice
of nurses in the area of monitoring
nutritional status of critically ill
patients.Nurses are required to have
evidence based knowledge and practice
which enable them to provide the needed
interventions to prevent complications
associated with enteral nutrition. So,
there is a need to improve nurses‘
knowledge and practices considering
their baseline levels.
10 -Recommendation
 Strict observation of nurses‘ practice
in relation to nutritional status of
critically ill patients‘ receiving
enteral nutrition.
 Conducting
periodic
training
sessions about assessing nutritional
status of critically ill patients‘
receiving different modalities of
nutritional support.
 Establishment
of
continuing
educational programs including
evidence based guidelines to
improve nurses‘ knowledge and
practice
regarding
monitoring
nutritional status of critically ill
patients‘ receiving enteral nutrition.
 Availability of written guidelines,
booklets,
and
posters
about
nutritional assessment.
 Availability of log book to
document nurses‘ monitoring of
nutritional status of critically ill
patients‘ receiving enteral nutrition.
Acknowledgment
The researchers would like to
acknowledge the contribution of all
participants who kindly agreed to take
part in the study. They generously gave
their time and attention to conduct this
study. This study would have been
impossible without their generosity.
Nutritional status of critically.
enj@nursing.cu.edu.eg
References
1. Ahamed, N. (2014 ). Assessment of
Knowledge and Practice of Staff
Nurses Regarding Ryle‘s Tube
Feeding in a Selected Hospital of
Kolkata, West Bengal. SMU
medical journal. 1(2): 294-302 .
2. Al kalaldeh, M. (2012). A review of
current nursing practice and
evidence-based guidelines in enteral
nutrition in the critically ill patient.
European Scientific Journal. 8 (30):
66-86 .
3. Bozzetti, F., (2011 ). Quality of life
and enteral nutrition. American
Society for Parenteral and Enteral
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(A.S.P.E.N.)
https://www.nutritioncare.
org/wcontent.aspx?id=266.
4. Chakravarty, C. (2013 ). Prevalence
of malnutrition in a tertiary care
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Nasogastric
feeding practices: A survey using
clinical scenarios. International
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310–319.
6. Eskander, H. G. (2013 ). Intensive
Care Nurses‘ Knowledge &
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regarding
Infection
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K. (2009 ). Understanding Human
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Medicine
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e_update_2012 /critical_care_05.pdf
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9. McClave, S. A., Martindale, R.G.,
Vanek, V. W., McCarthy, M.,
Roberts, P., Taylor, B. Ochoa, J. B.,
Napolitano, L. & Cresci, G. (2009 ).
Guidelines for the provision and
assessment of nutrition support
therapy in the adult critically ill
patient: Society of Critical Care
Medicine (SCCM) and American
Society for Parenteral and Enteral
Nutrition (ASPEN). J Parenter
Enteral Nutrition; 33:277-316 .
10. Mula, C. (2014). Nurses‘
Competency and Challenges in
Enteral feeding in the Intensive Care
Unit (ICU) and High Dependency
Units (HDU) of a referral hospital,
Malawi. Malawi Medical Journal;
26 (3): 55-59 .
11. Myrie, D. W. (2013 ). Nutrition
in critical illness: Critical care
nurses‘ knowledge and skills in the
nutritional management of adults
requiring intensive care – A review
of the literature. Caribbean Journal
of Nursing. 1(1): 49-55 .
12. Persenius, M. W., Hall-Lord, M.,
Baath, C. & Larsson, B. W. (2008).
Assessment and Documentation of
Patients
Nutritional
Status:
Perception of Registered Nurses and
their Chief Nurses. Journal of
Clinical Nursing, 17, 2125-2136 .
13. Quenot, J. P., Plantiefeve, J. &
Baudel, J.
L. (2010). Bedside
adherence to clinical practice
guidelines for enteral nutrition in
critically ill patients receiving
mechanical ventilation, critical care
nursing journal, 3 (2):34-61.
14. Seron, C., (2013 ). Enteral
Nutrition in Critical Care. Journal of
Clinical Medicine Research. 5(1):
1–11.
15. Shahin, M. A. (2012 ). Nurses‘
Knowledge and Practices regarding
Nutritional status of critically.
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Enteral Nutrition at the Critical Care
Department
of
AlManial
University Hospital in Egypt:
Impact of a Designed Instructional
Program. Journal of American
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16. Stewart,
M.
L.
(2014).
Interruptions in Enteral Nutrition
Delivery in Critically Ill Patients
and Recommendations for Clinical
Practice.
Critical
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Nurse;34[4]:14-22.
17. Sungurtekin, H., Oner, O. &
Okke,
D.
(2010).
Nutrition
assessment in critically ill patients.
Nutr Clin Pract; 23:635-64 L.
18. Yun, S. H. (2012 ). Healthcare
Professional's
Knowledge,
Perception and Performance on
Early Enteral Nutrition for Critically
Ill Patients. Korean Journal of
Critical Care Medicine. 27(1):3644.
19. Ziegler, T. R. (2009 ). Parenteral
nutrition in the critically ill patient.
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338
July 2015
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enj@nursing.cu.edu.eg
Relationship between the development of Sepsis, Systemic Inflammatory Response
Syndrome and Body Mass Index among Adult Trauma Patients at University
Hospital in Cairo
Mohamed Hendawy Mousa1*, Warda Youssef Mohamed Morsy2,
YousriaAbd El-Salam Seloma3, Ibrahim Mohamed Attia4,
1. Clinical Instructor of Critical Care and Emergency Nursing, Faculty of Nursing, Cairo University
2. Prof. of Critical care and Emergency Nursing, Dean of the Faculty of Nursing,Cairo University
3. Lecturer of Critical Care and Emergency Nursing, Faculty of Nursing, Cairo University
4. Lecturer of Critical Care Medicine Faculty of Medicine, Cairo University
Abstract:
Background: Sepsis is a major cause of mortality and morbidity in the trauma patients. There are many
factors affecting trauma outcome and incidence of its complications such as the nutritional status. The
malnutrition has negative consequences on critically ill injured patients. Critical care nurses are responsible
for close monitoring of traumatized patients which are essentials for detection of early signs of systemic
inflammatory response syndrome (SIRS) and early intervention. Aim: the aim of this study was to
investigate the relationship development of sepsis, systemic inflammatory response syndrome (SIRS) and
body mass index (BMI) among adult trauma patients at The Emergency Hospital-Cairo University.
Research questions: Q1. What is BMI profile of a selected group of the adult trauma patients admitted to
Emergency Hospital - Cairo University over a period of 6 months?, Q2. What is the frequency of SIRS and
sepsis among a selected group of the adult trauma patients admitted to The Emergency Hospital - Cairo
University over a period of 6 months?, and Q3. What is the relationship between the development of sepsis,
SIRS and BMI among a selected group of the adult trauma patients admitted to The Emergency Hospital Cairo University over a period of 6 months?.Sample:A purposive sample of52 adult male and female
trauma patients with revised trauma score (RTS) 10 to 12. Setting:The Emergency Hospital affiliated to
Cairo University. Tools: Four tools were utilized to collect data pertinent to the study: Socio demographic
and medical data tool, Systemic inflammatory response syndrome assessment tool, Revised Trauma Score
tool, and Sequential organ failure assessment tool. Results: The current study revealed that, (61.5 %) of the
studied subjects had normal BMI, (25 %) were overweight, and (13.5 %) were underweight. 84.6% of the
studied subjects had SIRS. No significant statistical correlation was found between BMI, SIRS and sepsis.
The mean initial SOFA scores of the underweight group was (4.4 + 1.6) indicating mild degree of sepsis related organ failure, as compared to the last assessment mean SOFA scores which was (8.3 + 5.3)
indicating moderate degree of sepsis - related organ failure. Conclusion: Underweight trauma patients
showed significantly higher rate of developing sepsis as compared to patients with normal body weight and
obese. Recommendations: based on finding of thisstudy the following are recommended: replication of the
study on a larger probability sample from different geographical locations in Egypt; Establishment of
specific nursing intervention protocol for underweight trauma patient for monitoring, early detection, and
management of signs & symptoms of SIRS, as well as sepsis; and carrying out further studies to assess the
other risk factors that influence trauma patients‘ outcome.
Key wards: Body Mass Index, Sepsis, Systemic Inflammatory Response Syndrome, Trauma, Sequential
organ failure assessment, revised trauma score, Nursing Intervention.
1- Introduction:
Nurses have long been challenged by the
complexity of the health care needs of
seriously injured patients and their
family. Nurses play an essential role in
the care of the trauma patient, from
prevention to resuscitation through
rehabilitation. The incidence of trauma is
predicted to increase worldwide in the
twenty
–first
century(Mcquillan,
Makic, & Whalen. 2009 ). The national
339
July 2015
safety council reported that unintentional
injury or trauma continues to be the fifth
leading cause of death for all ages.
Trauma is frequently referred to as the
disease of the young because the
majority of injured person's age ranged
from 16 to 24 years. Major
complications of trauma include sepsis,
hypovolemia,
pneumonia,
acute
respiratory distress syndrome and
pulmonary embolism, neurogenic shock,
Relationship between the development.
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and renal failure. SIRS is a systemic
response to a clinical insult such as
trauma (Sole, Klein &Moseley, 2012 ).
SIRS is the presence of two or more of
the following clinical manifestations:1Fever of more than 38°C (100.4° F) or
less than 36°C (96.8°F) 2- Heart rate of
more than 90 beats per minute, 3Respiratory rate of more than 20 breaths
per minute or arterial carbon dioxide
tension (PaCO2) of less than 32mm Hg,
4- Abnormal white blood cell count
(>12,000 /µL or < 4,000/µL or>10%
immature
[band]
forms)
(Chulay&Burns, 2010 ).
Sepsis is a complex condition that is
often life threatening. It is characterized
by hematological derangements and a
profound inflammatory response to an
infection or injury. Sepsis is a major
cause of mortality and morbidity in the
trauma patient. Sepsis following
traumatic injury is related to the type of
injury, together with the extent of injury
and the anatomical location There are
many factors influencing trauma
outcome
and
incidence
of
its
complications such as age, mechanism
of injury, associated patient factors (e.g.
medical conditions), severity of injury,
nutritional status of the patient,
involvement of body parts, prehospital
care and gender of the patients (Nair,
2009).One of the risk factors for the
development of sepsis is malnutrition
(Picard,
O’Donoghue,
YoungKershaw&Russell, 2006 ).
The negative consequences of
malnutrition have been known for
centuries and there is substantial
evidence that malnourished hospitalized
patients have increased morbidity,
compromised outcomes and increased
mortality rates (Chulay &Burns,
2010 ).WHO (2005 ) define malnutrition
as generally refers both to undernutrition
340
July 2015
and overnutrition. To monitor nutritional
status many parameters are useful to do
that such as: Body Mass Index (BMI),
laboratory, physical and historical data
(Stanfield, Hui, 2010 ). Body Mass
Index (BMI) is a person‘s weight in
kilograms divided by the square of their
height in meters. It is one of the most
commonly used ways of estimating
whether a person is overweight and
hence more likely to experience health
problems than someone with a healthy
weight. Obese patients have multiple
physiological changes that alter their
response to injury such as increased risk
of infection and increased cardiac output
due to increased blood volume to the
adipose tissue (Nayduch, 2009 ). On the
other hand,underweight can also cause
health problem which include fighting
off infection, osteoporosis, decreased
muscle strength, trouble regulating body
temperature and even increased risk of
death (Rochester, 2005 )
Early detection of sepsis is the key
element in its management and the nurse
should detect it and assess the traumatic
patient frequently. Critical care nurses
are the health care providers most
closely involved in daily care of
critically ill patients and so, have
opportunity to identify patients at risk
for sepsis (Beasley, 2010 ).Critical care
nurse is responsible for close monitoring
and assessment which are essentials for
detection of early signs of SIRS and
early intervention to ensure good
outcome
in
these
patients
(Chulay&Burns, 2010 ). Therefore, the
aim of this study was to investigate the
relationship between the development of
sepsis, systemic inflammatory response
syndrome and body mass index among
adult trauma patients at Cairo university
hospital.
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1. Significance of the study
Recent
studies
reported
an
incidence of sepsis between 5% and
25% among trauma patients admitted to
the intensive care unit (ICU)(lausevic, et
al 2008 ). Also it has been observed over
a period of 3 years of experience as a
clinical instructor in The Emergency
Hospital of Cairo University that, trauma
patients develop some health problems
and complications,these complications
are prominent to some extent among
those who are either over or underweight
which include sepsis, pneumonia,
hypovolemia…etc. These complications
increase length of ICU stay, increase
mortality rate, worsen the patient
outcomes, delayingpatient‘s recovery
and increase hospital costs. Therefore,
this study was designed in an attempt to
provide healthcare professionals with an
in-depth
information
aboutthe
relationship between the development of
sepsis, systemic inflammatory response
syndrome and body mass index among
adult trauma patients, which hopefully
will be reflected positively on the quality
of patients' care and prevent suspected
complications.
Furthermore, this data could be
beneficial in maintaining a costeffective patient care especially in such
critical care units as it might shorten
hospital stay and safeguard patients
against any of life threatening
complications. Also, it provides data
base that can be utilized by health care
professionals in the provision of the
future care for such group of patients and
it is hoped that, this effort will generate
an attention andmotivation for further
investigations into this area.
2. Aim of the study
The aim of this study was to investigate
the
relationship
between
the
development of sepsis, systemic
341
July 2015
inflammatory response syndrome and
body mass index among adult trauma
patients at The Emergency Hospital Cairo University.
3. Research Questions:
To fulfill the aim of this study, the
following research questions were
formulated:
Q1: What is the body mass index
profile of adult trauma patients admitted
to The Emergency Hospital - Cairo
University over a period of 6 months?
Q2: What is the frequency of
systemic
inflammatory
response
syndrome and sepsis among adult trauma
patients admitted to The Emergency
Hospital - Cairo University over a period
of 6 months?
Q3: What is the relationship
between the development of sepsis,
systemic
inflammatory
response
syndrome and body mass index among
adult trauma patients admitted to The
Emergency
Hospital
Cairo
Universityover a period of 6 months?
4. Subjects and Methods:
4.1 . Research Design
A descriptive correlational research
design was utilized in the current
study.Descriptive correlational research
is to describe relationships among
variables rather than to support
inferences of causality (Polit& Beck,
2012 )
4.2 . Setting
The study was conducted in The
Emergency
Hospital;
Cairo
University.The Emergency Hospital
consisted of ICU of department (5) one
room containing 8 beds Separated by
curtainsreceiving
approximate
56
patients every year. ICU of the 7th floor
containing two rooms, each room
contains 6 beds receiving approximate
95 patients every year.
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enj@nursing.cu.edu.eg
two or more of the pervious criteria will
indicate SIRS
4.3 . Subject
A purposive sample of 52 adult male and
female trauma patients who were
hospitalized over a period of 6 months
from a total of 151 patients who were
admitted to ICU of department (5) and
ICU of the 7th floor at The Emergency
Hospital (According to the Statistical &
Medical Records Department – Cairo
University Hospitals - 2012) and were
willing to participate in this study with a
revised trauma score of 10 or more was
included in this study.
5.4 Tools
Four tools were utilized for data
collection; one of these tools was
designed
by
the
investigator
(sociodemograghic and medical data
tool), and the other one was adapted
(SIRS assessment tool) then reviewed by
a panel of three experts.The other two
tools were adopted(Revised trauma
score, and Sequential organ failure
assessment tool (SOFA score). These
tools were:
5.4.1
Socio demographic and
medical data tool: This included the
patient‘s age, gender, diagnosis, BMI,
mid arm circumference….etc.
5.4.2 . Systemic inflammatory
response syndrome assessment tool: to
detect the incidence of SIRS. The criteria
of presence of SIRS include the
following clinical manifestations:
A. Fever of more than 38°C or less
than 36°C
B. Heart rate of more than 90 beats
per minute
C. Respiratory rate of more than 20
breaths per minute or arterial carbon
dioxide tension (PaCO2) of less than
32mm Hg
D. Abnormal white blood cell count
(>12,000 /µL or < 4,000 /µL or >10%
immature [band] forms). Presence of
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July 2015
5.4.3. Revised trauma score:
this tool was adopted from Champion
(1989 ). It is a scoring system to evaluate
the severity of trauma and used
internationally in both the pre hospital
and hospital environment primarily as an
instrument to predict the likelihood of
serious injury and mortality. RTS record
three areas1- Respiratory rate (RR)
contains 5 elements (RR= 0 take score 0,
RR= 1-5 br/min take score 1, RR= 6-9
br/min take score 2, RR > 29 br/min take
score 3, and RR= 10-26 br/min take
score 4.2- Systolic blood pressure(SBP)
contains 5 elements (SBP = 0 mm/hg
take score 0, SBP = 1-49 mm/hg take
score 1, SBP = 50-75 mm/hg take score
2, SBP = 76 – 89 mm/hg take score 3,
and SBP > 89 mm/hg take score 4. 3Glasgow coma scale (GCS) contains 5
elements ( GCS = 3 take score 0, GCS =
4-5 take score 1, GCS = 6-8 take score
2, GCS = 9-12 take score 3, GCS = 1315 take score 4). The RTS score is
reliable, valid, and effective method to
predict outcome and prognosis of trauma
patient. RTS scoresare ranging from 012 points. Lower values indicate poor
prognosis and higher values indicate
good prognosis.
5.4.4. Sequential organ failure
assessment tool: This tool was adopted
from Vincent (1996 ). It is a scoring
system used to determine the extent of
organ dysfunction or rate of failure
during stay in the intensive care unit. It
was designed to provide simple score
that indicates how the status of the
patient evolves over time. The
assessment is based on six different
scores, one for the respiratory,
cardiovascular, hepatic, coagulation,
renal and neurological systems. The
SOFA score is reliable, valid, and
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effective method to describe organ
dysfunction/failure in critically ill
patients. Regular and repeated soring
help in monitoring patients‘ condition
and disease development.Each organ is
graded from 0 (normal) to 4 (the most
abnormal), providing score of 0 to 24
points.
5.5 . Ethical consideration
An official permission to conduct
the proposed study was obtained from
the research ethical committee and from
hospital administrators to conduct the
study. Participation in this study was
entirely voluntary; each patient /relative
had the right to accept participation in
the study or not. Informed consent was
obtained from trauma patient or their
relatives. Anonymity and confidentiality
were assured through coding the data,
every participant had the right to
withdraw from the study at any time;
subjects were assured that the data will
not be reused in another research without
second /other new permission
5.6 . Procedure:
The study was conducted through two
phases:
Preparatory
phase
and
Implementation phase.
1Preparatory phase:
This phase was concerned with the
managerial arrangements to carry out the
study in addition to the construction,
preparation of two data collection tools
by an extensive review of relevant
literature
either
from
textbooks,
scientific research articles or web
sitessearches as well as seeking experts'
advice. After obtaining the primary
approval from the research ethical
committee of the Faculty of NursingCairo University, the investigator
prepared formal requests to the head of
the
EmergencyDepartments.
The
purpose and the nature of the study were
explained to the physician and nurses to
343
July 2015
gain their assistance, sharing and support
to carry out the current study.A pilot
study was carried out on eight patients
admitted to emergency department (over
a period of 18 days) and diagnosed as
trauma patients who fulfilled the
inclusion criteria to test the feasibility,
objectivity, and applicability of the study
tools and the 8 patients of pilot study
were included in the current study.
2. Implementation phase:
Data of the current study were
collected from January 2014 to July
2014, once official permissions were
granted. A total number of 52 patients
who fulfilled the criteria of inclusion
were recruited into the present study.
The first step in the implementation
phase was classifying patients by using
the revised trauma score to decide either
they can be included (if RTS 10 or
more) or excluded (if RTS is less than
10) from the study, it consumed about 5
minutes for each patients covering three
parameters of the revised trauma score
from the patient admission data. The
patients/relatives (in case of unconscious
patient) who were agreed to participate
in the study were interviewed
individually by the investigator to
explain the nature and purpose of the
current study. A written consent was
obtained and this step took about 15
minutes. Then, Socio demographic and
medical data sheet was filled out and
body mass index profile was obtained
which and took about 10 minutes. And
the last step of implementation phase
was using SOFA and SIRS assessment
tools to assess for development of sepsis
and systemic inflammatory response
syndrome from admission to discharge
(on daily basis). This required about 15
minutes for each assessment time.
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5.7 . Statistical data analysis
The collected data were scored,
tabulated and analyzed by personal
computer using statistical package for
the social science (SPSS) program
version 20. Descriptive as well as
inferential statistics will be utilized to
analyze data pertinent to the study. Level
of significant will be set at p≤0.05
6. Results
Statistical findings of the current study
are presented in three main sections:
firstsection describes the studied sample
as regards to their socio-demographic
and medical data (figures 1-3) (tables 1
and 2). The second section answering
the research questions (figure 4and5)
tables (3-10) and the third section is
devoted to additional findings table (11).
Section 1:
Figure (1) shows that, 85 % of the
studied subjects were males. Figure (2),
shows that, (36.5 %) of studied subjects
stayed in the hospital for more than one
week and (36.5 %) stayed more than two
weeks.Table (1) reveals that the mean
age of all studied subjects is (34.15 +
10.6) years, and (51.5%) were none
smokers, (96.2%) had no past medical
history and (53.8 %) were admitted with
head trauma. Table (2) shows that (38.5
%) were admitted withdisturbed
conscious level as a main reason of
admission.
Section 2:
Figure (3) reveals that, (61.5 %)
had normal body mass index. Figure (4)
illustrates that, 84.6% had systemic
inflammatory response syndrome. Table
(3) reveals that, 90% had Heart rate of
more than 90 beats per minute followed
by 73% hadabnormal white blood cell
count (>12,000 /µL or < 4,000 /µL or
>10% immature [band] forms).
Table (4) reveals that 100 % of
underweight patients had SIRS on
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July 2015
admission (71.4 % had SIRS with three
criteria, 14.3 % had SIRS with two
criteria, and the same percentage had
SIRS with 4 criteria). 100 % of
underweight patients had SIRS during
hospitalization (28.5 % had SIRS with
two criteria, 57.2 % had SIRS with 3
criteria, 14.3 % had SIRS with four
criteria). 57.2 % of underweight patients
had SIRS on discharge (42.9 % had
SIRS with three criteria, and 14.3 % had
SIRS with two criteria). Table (5)
reveals that 77 % of obese patients of the
studied subject had SIRS on admission,
92.3 % had SIRS during hospitalization,
and 76.7 % hadn‘t SIRS on discharge.
Table (6) reveals that 90.6 % of
normal weight patients had SIRS on
admission, 78.1% had SIRS during
hospitalization, and 84.4 % hadn‘t SIRS
on discharge. Table (7) illustrates that
100 % of underweight trauma patients
had mild sepsis –related organ failure on
admission, 100 % had sepsis during
hospitalization (57.1 % had mild sepsis related organ failure, and 42.9 % had
moderate sepsis - related organ failure),
and 100 % had sepsis - related organ
failure (57.1 % had moderate sepsis related organ failure, and 42.9 % had
mild sepsis - related organ failure) on
discharge. Table (8) illustratesthat 84.6
% of obese traumapatients had mild
sepsis - related organ failure on
admission, 100 % had mild sepsis related
organ
failure
during
hospitalization, and 84.6 % had mild
sepsis - related organ failure on
discharge.
Table (9) illustrates that 100 % of
normal weight patients had mild sepsis related organ failure on admission,
during hospitalization and on discharge.
Figure (5) shows that, mean initial
SOFA score of underweight adult trauma
patients was (4.4 + 1.6) indicated mild
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sepsis - related organ failure and mean
last SOFA score of them was (8.3 + 5.3)
indicated moderate sepsis - related organ
failure and No statistical significant
relationship between BMI and SOFA
scores (p = 0.073 and chi - square =
5.23).Table (10) shows that mean of
length of hospital stay of the
underweight trauma patients is 20 + 6.7
day, mean of length of hospital stay of
the normal weight patients is 14 + 4.8
day, and mean of length of hospital stay
of the obese patients is 18.5 + 6.2 day.
Section3:
Table (11) concludes that, there are not
significant statistical correlation between
BMI, age, gender, past medical
problems, marital status, place of
residence, type of trauma, occupation,
smoking habits, and length of hospital
stay, and SIRS.
(A). Figures:
Figure (1): Percentage Distribution as
regards to Gender (N=52)
Figure (2): Percentage Distribution as regards to
Length of Hospital Stay (N= 52)
Figure (3): Percentage Distribution of the
Studied Subjects as regards to Body Mass Index
(N=52)
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July 2015
Table (4) Frequency of Systemic Inflammatory
Response Syndrome (SIRS) (N =52)
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Figure (5): Relation betweenSequential Organ Failure Assessment Scores (SOFA)and
Body Mass Index (N=52).
(B) Tables:
Table (1): Percentage Distribution of the Studied Subjects as regards to socio-demographics
characteristic and medical data (N=52 ).
Frequency
Frequency
Percent
(No)
(%)
Variables


Age:
frequency
Mean+ SD
Smoking habits
None smokers
Smokers


34.15+ 10.6
Past medical history
No medical problems
Hypertension
Type of traumas :
Head trauma
Chest trauma
Abdominal trauma
Fracture
Multiple traumas
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27
25
51.1
49.1
50
2
96.2
3.8
28
6
6
2
10
53.8
11.5
11.5
3.8
19.2
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Table (2): Percentage Distribution of the Studied Subjects as Regards to Main Reason of Admission (N=52 ).
Frequency
(No)
Percent
(%)
Disturbed Conscious Level (DCL )
20
38.5
DCL & Abdominal trauma
6
11.5
Hemodynamic instability
1
1.9
Brain edema
2
3.8
Intra-abdominal bleeding and fracture pelvic
2
3.8
DCL & intra cranial hemorrhage
5
9.6
Fracture pelvic , mandible fracture & compound leg
fracture
1
3.8
DCL & lung contusion
8
15.4
Fracture femur and Hemodynamic instability
3
5.7
Flail chest and pneumothorax
2
3.8
DCL & fracture pelvic & bladder tear & peritoneal
tear & sub arachnoid hemorrhage
1
1.9
Variables

frequency
Main reason of admission :
Table (3) Frequency Distribution of Systemic Inflammatory Response Syndrome criteria
(N=52 ).
Frequency
%
Criteria
1-
Fever of more than 38°C (100.4° F) or less than 36°C
(96.8°F)
33
63.3 %
2-
Heart rate of more than 90 beats per minute.
47
90 %
3-
Respiratory rate of more than 20 breaths per minute or
arterial carbon dioxide tension (PaCO2) of less than
32mm Hg
15
28%
4-
Abnormal white blood cell count (>12,000 /µL or <
4,000/µL or >10% immature [band] forms)
38
73%
Presence of two or more of the pervious criteria will indicate SIRS
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July 2015
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Table (4) Frequency of Systemic Inflammatory Response Syndrome (SIRS) among
underweight trauma patients (N=7/52 ) with mean of length of hospital stay is 20 +
6.7 day
SIRS
No. Of pts.
incidence
0 (negative)
1 (negative with one criteria)
2 (positive with two criteria)
3 (positive with three criteria)
4 (positive with four criteria)
On Admission
N
%
During
NHospitalization
%
On Discharge
N
%
0
0
1
5
1
0
0
2
4
1
1
2
1
3
0
0
0
14.3
71.4
14.3
0
0
28.5
57.2
14.3
14.3
28.5
14.3
42.9
0
Table (5) Frequency of Systemic Inflammatory Response Syndrome (SIRS) among obese trauma
patients (N=13 ) with mean of length of hospital stay is 18.5 + 6.2 day
On Admission
During Hospitalization
On Discharge
SIRS
No. Of pts.
N
%
N
%
N
%
incidence
0 (negative)
1
7.7
0
0
9
69
1 (negative with one criteria)
2
15.4
1
7.7
1
7.7
2 (positive with two criteria)
3
23.1
10
77
2
15.4
3 (positive with three criteria) 6
46.2
2
15.3
1
7.7
4 (positive with four criteria)
1
7.7
0
0
0
0
Table (6) Frequency of Systemic Inflammatory Response Syndrome (SIRS) among normal weight
trauma patients (N=32 ) with mean of length of hospital stay is 14 + 4.8 day
On admission
During hospitalization
On discharge
SIRS
No. Of pts.
n
%
N
%
N
%
incidence
0 (negative)
0
0
1
3.1
16
50
1 (negative with one criteria)
3
9.4
6
18.8
11
34.4
2 (positive with two criteria)
16
50
21
65.6
4
12.5
3 (positive with three criteria) 12
37.5
4
12.5
1
3.1
4 (positive with four criteria)
1
3.1
0
0
0
0
Table (7) Frequency of Sequential Organ Failure Assessment Scores (SOFA) among underweight
trauma patients (N=7).
On admission
During hospitalization
On discharge
SOFA
No. Of pts.
N
%
N
%
N
%
category
0 ( no sepsis related organ failure)
0
0
0
0
0
0
Mild sepsis related organ failure
7
100
4
57.1
3
42.9
Moderate sepsis related organ
0
0
3
42.9
4
57.1
failure sepsis related organ failure
Severe
0
0
0
0
0
0
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July 2015
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Table (8) Frequency of Sequential Organ Failure Assessment Scores (SOFA) among
obese trauma patients (N=13 ).
SOFA
No. Of pts.
category
0 ( no sepsis related organ failure)
Mild sepsis related organ failure
Moderate sepsis related organ
Severe sepsis related organ failure
failure
On Admission
During Hospitalization
N
%
N
0
11
2
0
0
84.6
15.4
0
0
13
0
0
On Discharge
%
N
%
0
100
0
0
0
11
2
0
0
84.6
15.4
0
Table (9) Frequency of Sequential Organ Failure Assessment Scores (SOFA) among
normal weight trauma patients (N=32 ).
On admission
SOFA
No. Of pts.
During hospitalization
On discharge
N
%
n
%
N
%
0
32
0
0
0
100
0
0
0
32
0
0
0
100
0
0
0
32
0
0
0
100
0
0
category
0 ( no sepsis related organ failure)
Mild sepsis related organ failure
Moderate sepsis related organ
Severe sepsis related organ failure
failure
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July 2015
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Table (10 ): Mean of Length of Hospital Stay in relation to Body Mass Index (N=52 ).
BMI
Normal weight
Obese
Underweight
Mean Length of Hospital Stay
14 + 4.8 day
18.5 + 6.2 day
20 + 6.7 day
Table (11 ): Correlation Coefficient Between Body mass index, Age, gender, type of
trauma, past medical history, marital status, occupation, place of residence,
educational level, smoking habits, length of hospital stay and SIRS of the studied
subjects (N=52 ).
Items
x2or r/value
1. Body mass index / SIRS
2.899
2. Age / SIRS
.162
3. Gender / SIRS
1.71
4. Type of trauma / SIRS
3.29
5. Past medical problems / SIRS
.378
6. Marital status / SIRS
1.417
7. Occupation / SIRS
7.830
8. Place of residence / SIRS
2.043
9. Educational level / SIRS
14.89
10. Smoking habits / SIRS
0.014
11. Length of hospital stay / SIRS
6.465
*Significant at the p < 0.05 probability level
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July 2015
P/value
.235
.197NS
.19NS
.510NS
.539NS
.234 NS
.098NS
.153 NS
.002*
.906NS
.167NS
NS= not statistically significant
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Discussion
The present study delineated that
the majority of the studied subjects were
male, with a mean age of all studied
subjects was (34.15 + 10.6) years. This
is in agreement with Mica, Vomela,
Keel, and Trentz (2012 ) in a study
entitled with "The impact of body mass
index on the development of systemic
inflammatory response syndrome and
sepsis in patients with polytrauma" who
mentioned that incidence of trauma is
most common between theyoungage and
male gender. Also the present study
revealed that more than half of the study
subjects were smokers, this is in
agreement with Tammy, Pamela,
Andrej, and Scott (2010 ) in a study
entitled as "Smoking in Trauma Patients:
The Effects on the Incidence of Sepsis,
Respiratory Failure, Organ Failure, and
Mortality" who mentioned that 47.8 %
of the studied subjects were smokers.
The current study results reported that
the mean of length of hospital stay
(LOS) of underweight trauma patients is
20 + 6.7 day, the mean of (LOS) of
normal body weight trauma patientsis 14
+ 4.8 day, and the mean of (LOS) of
obese trauma patients is 18.5 + 6.2 day.
These results were supported by the
results of Mica, Vomela, Keel, and
Trentz (2012 ) reported that the mean of
length of hospital stay (LOS) of
underweight trauma patients is 20 day,
the mean of (LOS) of normal body
weight traumatized patientsis 17.2 day,
and the mean of (LOS) of obese
traumatized patients is 18.5 day.
In contrast with our study, the
study
of
Hoffmann,
Lefering,
Rathmann, Rueger, and Lehmann
(2012 )in a published study entitled as
―The impact of BMI on polytrauma
outcome" reported that the mean of
351
July 2015
length of hospital stay (LOS) of
underweight trauma patients is 7.8 day,
the mean of (LOS) of normal body
weight trauma patients is 10.7 day, and
the mean of (LOS) of obese trauma
patients is 12.7 day. Also the study of
Andruszkow, et al (2013 ) reported that
the mean length of hospital stay (LOS)
of underweight trauma patients is 20.2
day, the mean (LOS) of normal body
weight trauma patients is 25.7 day, and
the mean (LOS) of obese trauma patients
is 34.4 day.
The
current
study
results
delineated,more than half of the studied
subjects had normal body mass index, on
quarter were obese, and one eighth of
them were under weight. These results
were supported by the results of
Hoffmann,
Lefering,
Rathmann,
Rueger, and Lehmann (2012 )reported
that the lowest percentage of the studied
subjects for underweight group with
percentage 4.7 % (269/5766 ) and the
largest percentage of them for normal
weight group with percentage 45.4 %
(2617/4766 ).Also these results were
supported by the results of Chae, et.al
(2013 ) in a published study entitled as "
Body Mass Index and Outcomes in
Patients with Severe Sepsis or Septic
Shock" reported that 11.2 % of studied
subjects were underweight patients
(86/770 ), 63.5 % of them had normal
body weight (489 /770), and 25.3 % of
them
were
obese
(195/770 ).In
accordance to this study, the study of
Andruszkow, et al (2013 )in a published
research article entitled as " Impact of
the Body Mass on Complications and
Outcome in Multiple Trauma Patients:
What Does the Weight Weigh?" in an
analysis of 586 of traumatized patients
which revealed that about 4.8 % of them
were underweight, 81.2 % had normal
body weight, and 14 % were obese.
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Also the current study results
reported thatmajority of the studied
subjects had (SIRS). In this regard,
Sakamoto, et.al (2010 ) in a study
entitled with "Systemic Inflammatory
Response Syndrome Score at Admission
Predicts Injury Severity, Organ Damage
and
Serum
Neutrophil
Elastase
Production
in
Trauma
Patients"
supported these result when reporting
that 86.4 % of 212 trauma patients were
having SIRS. Also of Andruszkow, et
al (2013 ) reported that 64.1 % from 660
adult trauma patients were having
SIRS.Also the current study results
reported thatthere are no significant
statistical correlation between, body
mass index, mid arm circumference and
SIRS.These results were supported by
the results ofMica, Vomela, Keel, and
Trentz (2012 ) which reported that
nosignificant differences were found
between the three study groups.
The current study results delineated
mean initial SOFA score of underweight
adult trauma patients was (4.4 + 1.6)
indicated mild sepsis and mean last
SOFA score of them was (8.3 + 5.3)
indicated moderate sepsis - related organ
failure. In relation to the normal weight
trauma patient, mean initial SOFA score
them trauma patients was (4.4+ 1.6)
indicated mild sepsis - related organ
failure and mean last SOFA score of
them was (2.2+1.1) indicated mild sepsis
– related organ failure. Finally, obese
trauma patients, mean initial SOFA
score of them was (5.4 + 1.9) indicated
mild sepsis- related organ failure and
mean last SOFA score of them was (3.2
+ 4.2) indicated mild sepsis - related
organ failure. This explains underweight
trauma patients showed significantly
higher rate of developing sepsis - related
organ failure than the normal weight
patients and obese patients.These results
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July 2015
were supported by the results ofMica,
Vomela, Keel, and Trentz (2012 )
which reported that 46.1 % of
underweight adult trauma patients were
having and Fatty tissue seems to have a
protective effect against inflammatory
reactions in the body. Inflammatory
parameters remained unaffected in the
three study groups but the outcomes
seemed to be better for higher BMI
groups, according to the SIRS and
sepsis. In contrast with our study, the
study
of
Hoffmann,
Lefering,
Rathmann, Rueger, and Lehmann
(2012 ) reported that increased multi –
organ failure and sepsis rate in obese
patients.
8. Conclusion:
Considering the results of the present
study and the available evidence, more
than half of adult trauma patients have
normal body weight. Also the majority
of the adult traumapatients had systemic
inflammatory
response
syndrome.
Underweight trauma patients showed
significantly higher rate of developing
sepsis- related organ failure than the
normal weight patients and obese
patients. Also underweight trauma
patients were sequential having longer
length of hospital stay than normal
weight and obese group.
9. Recommendation:
Based on the findings of the present
study, the following recommendations
are suggested:
Recommendations
for
furthers
researches:
1. Replication of the study on a larger
probability sample selected from
different geographical areas in Egypt is
recommended
to
obtain
more
generalizable data.
2. Further studies have to be carried
out in order to assess the other risk
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enj@nursing.cu.edu.eg
factors influencing trauma outcome and
incidence of its complications
3. Further studies have to be carried out
in order to assess nurses' knowledge and
practices regarding trauma scoring
system, dealing with trauma patient.
Recommendations related to patients:
1. Close observation and follow up for
all trauma patients to assess their health
conditions and to detect sepsis early.
2. Establishment of specific nursing
intervention protocol for underweight
trauma patient to monitor, early detect,
and manage signs & symptomsof SIRS
and sepsis.
3. Adding
body
mass
index
measurement for critically ill injured
patients as one of the nursing assessment
sheet element at Emergency department.
Acknowledgment
This research article would not have
been possible without the support of
many people. The authors wish to
express their gratitude to all people who
share or help in this research.
References:
1.
Andruszkow.
H,
Veh.
J,
Mommsen. P, Zeckey. C, Hildebrand. F,
and Frink. M (2013 ): Impact of the
Body Mass on Complications and
Outcome in Multiple Trauma Patients:
What Does the Weight Weigh?.Hindawi
Publishing Corporation. P 3. Available
athttp://www.hindawi.com/journals/mi/2
013/345702 /, retrieved on 25/11/2014 .
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Beasely,M.,B., (2010): The
pathologist‘s approach to acute lung
injury
.archives
of
pathology
&laboratory
medicine
:
vol.134,(5),pp.719.
3.
Chae.et al (2013 ): Body Mass
Index and Outcomes in Patients with
353
July 2015
Severe Sepsis or Septic Shock, Korean J
Crit Care Med, Korean, available at
http://synapse.koreamed.org/DOIx.php?i
d=10.4266 /kjccm.2013.28.4.266
,
retrieved on 30/11/2014 .
4.
Chulay.M&Burns.S.(2010 ):
Essentials of critical care nursing ,(2nd
edition)
,
Singapore, McGraw Hill , P 277, 280,
281 ,390,391 .
5.
Hoffmann. M, Lefering. R,
Rathmann. M.G, Rueger.J.M, and
Lehmann. W (2012 ): The impact of BMI
on polytrauma outcome. Injury, Int. J.
Care Injured 43. P 184-188 . Available at
http://www.injuryjournal.com/article/S0
020-1383%2811%2900226-9 /abstract,
retrieved on 25/11/2014 .
6.
June,(2009):Body Mass Index as
a measure of obesity, London .Public Of
Health
7.
McQuilian.K.A,Makic.M.B&Wh
alen.E.W .(2009 ):Trauma nursing .(4th
edition), United State Of America
.Saunders Elsevier .P 2,11,12 .
8.
Mica. L, Vomela. J, Keel. M, and
Trentz. O (2012 ): The impact of body
mass index on the development of
systemic
inflammatory
response
syndrome and sepsis in patients with
polytrauma. Injury, Int. J. Care Injured
45,
P
253-258 .
Available
at
http://www.injuryjournal.com/article/S0
020-1383%2812%2900513 -X/abstract,
retrieved on 25/11/2014 .
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Nayduch.D, (2009 ): Nurse to
nurse trauma care. United State Of
America, McGraw –Hill, P 486.
10.
Picard.K.M, O‘Donoghue.S.C,
Young-Kershaw.D.A&Russell.K.J,
(2006 ):
Development
and
Implementation of a Multidisciplinary
Sepsis Protocol ,Columbia , critical care
nurse
,vol
26
,available
at
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http://ccn.aacnjournals.org ,retrieved on
15/6/2013 .
11.
Polit.D.F&Beck.C.T,
(2012 ):
Nursing research (9th edition), india,
WoltersKlumer, P 223-226 .
12.
Rocheste.M,(2005 ):Underweight
problems,
USA,
available
athttp://www.medicalnewstoday.com/rel
eases/24017 .php
,
retrieved
on
31/5/2013 .
13.
Sakamoto.Y,
Mashiko.K,
Matsumoto.H, Hara.Y, Kutsukata.N, and
Yokota.H
(2010 ):
Systemic
Inflammatory Response Syndrome Score
at Admission Predicts Injury Severity,
Organ Damage and Serum Neutrophil
Elastase Production in Trauma Patients,
Japan,
Available
at
http://scholar.google.com.eg/scholar?q=i
ncidence+of+SIRS+among+trauma+pati
ent+&btnG=&hl=ar&as_sdt=0%2C5&a
s_ylo=2009 , retrieved on 14/12/2014 .
14.
Sole.M.L,
Klein.D.G&Moseley.M.J,
(2012 ):
Introduction of critical care nursing.(6th
edition), china. elsevier Saunders, P256.
15.
Stanfield.P,
Hui.Y,
(2010):
th
Nutrition and Diet Therapy (5 edition).
Jones and Bartlett Publishers, LLC.
P126.
16.
Tammy.F, Pamela.G, Andrej.R,
and Scott.A (2010 ): Smoking in Trauma
Patients: The Effects on the Incidence of
Sepsis, Respiratory Failure, Organ
Failure, and Mortality, Journal of
Trauma-Injury Infection & Critical Care
(VOLUME
69).
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Patients
The_Effects_on_the.11.aspx,
retrieved on 30/11/2014 .
354
July 2015
Internet versus Library Book as a Source.
enj@nursing.cu.edu.eg
Internet versus Library Book as a Source of Academic Information among Nursing
Students
AmouraSolimanBehairy
Medical-Surgical Nursing Department, Faculty of Nursing,
Menofia University, Egypt; Unaizah Collage of Medicine and Medical Sciences, Qassim
University, KSA
Dalia Salah El-Deen El-Sedawy
Medical-Surgical Nursing Department, Faculty of Nursing
Cairo University, Egypt
Abstract:
Background: Internet is increasingly being used worldwide in imparting information and improving its
delivery especially in nursing education field. The aim of the study was to assess the internet versus library
book as a source of academic information among nursing students. Subjects and Methods: A
descriptive/comparative design was utilized. A sample of convenience of 317 nursing students from four
female nursing colleges at different educational levels was recruited. Four tools developed by the
researchers were utilized to collect data: (1) Socio-demographic data sheet, (2) The internet versus library
book utilization questionnaire, (3) The benefits of internet usage versus library book usage questionnaire,
and (4) The internet and library usage problems questionnaire. Results: The study results revealed that; the
studied sample used the internet more than library book for the educational purposes; of the internet
benefits, it had updated information, it presented the information in different forms, and easy access. On the
other hand, library book provides evident and relevant information. The results also revealed that the major
problem regarding internet usage was it stole time, while for library book use; it needed much more
assistance to search. Conclusion & Recommendation: The students prefer to use internet rather than
library book as a source of academic information, therefore, it is recommended to pay attention for the
academic staff not only to use the internet to prepare their lectures and educational media, but also to
provide reliable and evident web sites for the students as essential references.
Key words: Internet, Academic information, Nursing student, Library book.
Introduction:
The expansion and advancement of
internet
have
carried
reflective
modifications in the educational field
across the world (Demiris et al., 2008 ).
The institutions of higher learning are
one of the primary organizations which
support
learning
and
teaching
Information
Communication
Technologies (ICTs) for the university
students. The teaching and learning
processes have been improved with the
assistance of ICT. As more and more
universities
worldwide
have
implemented Internet technology and,
day-to-day, the extent of information
obtainable online rises, universities are
stressed to link this trend in order to
enter on a global level (Kirkwood,
2008). In this respect, Larsen and
Lancrin (2005) said, ICT plays a vital
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July 2015
role in access, quality and cost which are
three fundamental aspects of education.
The 21 century is the era of high
technology. It is the information age. In
the last decade, educational research
reported increasing Internet use for
academic purposes in higher education
institutes, as the internet has become
more central to students‘ experiences in
higher education (Ahmed, 2010; Lee, &
Tsai, 2011 ). Due to increasing demand
for education and training in the
information age, online learning and
teaching is becoming a necessity in their
future (Oncu, & Cakir, 2011 ).
Nursing
education
principally
concentrates on transmitting nursing
knowledge, and assisting nursing
students to acquire the necessary skills
and attitudes associated with nursing
practice. To meet the diverse needs of
Internet versus Library Book as a Source.
enj@nursing.cu.edu.eg
today‘s educational climate, nursing
educators
must
develop
an
understanding of a variety of learning
environments and skills in modern
teaching strategies (Abu Hasheesh, AlMostafa, & Obeidat, 2011 ).
Meanwhile, the internet has multi facets'
roles in the nursing educational
discipline, the internet has enabled
numerous resource services in such a
method that the students will obtain their
needed knowledge as and when wanted
from everywhere in the place of the
world through self-learning. These
advances have greatly assisted the
learning processes to become relatively
easy. It has come to be a fundamental
portion of the educational system. The
internet resources have radically
enhanced the educational environment
with the aid of hypertexts and
hypermedia. It subjects and deals out the
information in diverse designs to the
handlers based on the requests (Sriram,
2014).
Shaqour and Daher (2010) highlighted
that, the internet has become an integral
part of the modern life, and in particular,
in higher education perspectives, internet
resources are available on different types
of on line resources with respect to
educational context. Some of these
resources are databases, power points,
journals, webpages, digital libraries,
periodicals, newspapers and educational
videos. These varieties of the resources
make the internet one of the important
educational resources for the academic
students.
Moreover, various literature and studies
(Quadri, 2013 ; Okiki,& Asiru, 2011 ;
Hoskins &Hooff, 2005) found that, the
usage of internet as an educational
resource has become to be one of
essential scientific developments in the
educational field, it provides a means of
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July 2015
information, it has some features like
easiness, effectiveness, trustworthiness,
knowledge supports, familiarity and
preferences that provoke the consumers
to apply the full abilities of the
technology
and
increase
their
satisfaction to more spread. Kress
(2006 ) clarified that, the Internet offers
multiple reading paths in contrast to
printed text.
Aldebasi and Ahmed (2013), in their
study regarding computer and internet
utilization among the nursing and
medical students in Qassim University,
Saudi Arabia, concluded that, as a result
of the rapid progress of the web
production
and
improvement
in
universities, there is an increasing in the
number of university students using
internet. They also added that, for the
information retrieval, 84% of the studied
sample used the internet, followed by
journals/libraries (36%) and textbooks
(35%). Moreover, according to Yadav,
Jain, Kapila and Prasad (2005 ), the
internet has become the world‘s biggest
library, where the retrieval of scientific
resources can be done within minutes.
Additionally, the Education Council
(2006 ) reported that, during the last
decades the Internet and digital
information sources have increased and
the reading of electronic texts has
become necessary and prevalent in
society.
Significance of the study:
Education is an interactive
process; education in health cares today
both nursing staff and student education
(Bastable, 2008). Students are the target
of the education, so it is very important
to discover the approaches, opinions and
preference of this target in order to
achieve the aim of the education. The
rapid growth of the internet has great
Internet versus Library Book as a Source.
enj@nursing.cu.edu.eg
effects on education. One of the most
important effects is the use of the
internet as a source of information
especially in academic information.
Nursing is a rapidly evolving science
because it is associated with the
development of information and
technology, so the nursing students need
means to help them to find out what's
new and modern. In addition, research
findings indicate that nursing students
had positive perception of the impact of
using information technology on
teaching and learning nursing care in
Egypt (Kandeel & Ibrahim, 2009).
Yadav et al. (2005 ) mentioned that
globally the internet has become the
world‘s biggest library, where the
repossession of scientific resources can
be done within minutes. In response to
the remarkable effect of the internet on
the university students, some nursing
colleges have taken number of actions
such as included the computer studies in
their curriculum, others requested the
license of the computer as a requirement
of the student graduation. So, it is
important to perform researches in this
area to have evidence based regarding
this issue. Therefore, the aim of the
current study was to assess the internet
versus library book as a source of
academic information among nursing
students.
Aim:
The aim of the study was to assess the
internet versus library book as a source
of academic information among nursing
students.
Subjects and Methods:
Design:
A descriptive/comparative design was
used in this study to achieve the previous
stated aim.
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July 2015
Setting:
The study was conducted at four female
nursing colleges at central region of the
Kingdom of Saudi Arabia (KSA).
Sample:
A sample of convenience of 317 female
nursing college students at central region
of KSA from different educational levels
was included in the study. The inclusion
criteria were: (1) University nursing
college students, (2) Can use the
computer and internet, and (3) had an
access to the internet at home.
Tools:
Four tools were utilized to collect data;
all the tools were developed by the
researchers. To ensure content validity, 5
panel of expertise in the field of
education and medical surgical nursing
revised all the tools.
1. Socio-demographic data sheet:
Demographic data consisted of
items seeking information about
the background of the students
such as: age, educational level,
educational status of the father
and mother, occupational status
of father and mother, and family
income.
2. The internet versus library book
utilization sheet: It measures the
students' utilization of library
book versus internet as an
academic educational resource. It
consisted of 9 items, 2 out of 9
were asked about the days of
using internet versus library book
per week and usage per hours.
The rest of items were asking
about uses of the internet versus
library book. Participants were
asked to express their responses
using the Likert scale for 5
questions out of 7, a three–point
scale rated as agree, neutral and
Internet versus Library Book as a Source.
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disagree, whereas neutral means
not supporting either agree or
disagree, and the 2 remaining
items were measured by either
"Yes" or "No". The reliability of
the questionnaire was 0.72
Cronbach‘s alpha.
3. The benefit of internet usage
versus library book usage sheet:
It assessed the student's opinion
regarding the advantages of using
the internet and library book as a
source of information in the
academic education. It consisted
of 8 items, a Likert scale rated as
agree, neutral and disagree were
used. The tool had 0.81
reliability Cronbach‘s alpha
4. The internet and library usage
problem sheet: It assessed the
problems facing the students in
searching on the internet and the
library book.The participants
were asked to respond with 3point Likert scale, which were
agree, neutral, and disagree. The
Cronbach‘s alpha reliability score
of the tool was 0.76.
Procedure:
Once permission was taken from the
head of the university and ethical
committee, the researchers initiated data
collection, the researchers introduced
themselves to the participants and
explained the purpose of the study and
consent form was taken. About 650 of
the research questionnaires were
distributed and from these 317 students
completed the questionnaires. The data
collection phase started in the middle of
the 1 st term of the 2013 –2014 academic
year and the data collection was
completed nearly by the end of the
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July 2015
second term of the same academic year.
The questionnaires were distributed to
the students by the end of the study day
as the researchers arranged with the
deans of the colleges and the heads of
the
departments.The
questionnaire
needed 10 – 20 minutes to be completed
for each student.
Ethical Considerations
An official permission was taken from
the head administrator of the university
and the research committee, from which
participants were voluntarily recruited in
the study. The aim of the study was
explained to the students and they were
informed that their participation was
entirely voluntary. Students had an
opportunity
to
determine
their
willingness to participate in the study
which considered as oral informed
consent. Confidentiality was ensured
through the use of code numbers.
Pilot Study
The pilot study was carried out on 50
nursing students in the selected colleges,
and they were excluded from the main
study sample. The tools were applied in
order to assess the clarity of the items
and those who were confusing, biased or
poorly worded were omitted from the
tools.
Statistical Analysis
Data were collected, and then entered to
a database file. Statistical analysis was
performed using the statistical package
for social science (SPSS), version 16.
Frequency and percentage were used to
describe the sample and their responses
to the questionnaires and chi-square test
was used to find out the statistical
significance of the difference between
internet and library book as a source of
academic information. Data was
described by summary tables. Statistical
significance was considered at P- value
<0.05.
Internet versus Library Book as a Source.
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Results:
A sample of convenience of 317 nursing
students was included in the study. All
of them were females from different
educational levels whereas 22.1 % were
in the first year, 29.7 % in the second
year, 22.7 % in the third year and 25.5
% in the fourth year. In addition, 16.1 %
of the studied sample reported that they
use the internet since 1 to 2 years ago,
73 % of them use the internet from 3–4
years ago and 10.7 % of the students
used the internet since 5 years or more.
Table (1) shows that 92.1% of the
sample used the internet for 3–4
days/week for educational purpose,
while 74.8 % of them reported that they
use the library book for 1–2 days/week.
In addition, 82.3 % of the sample
reported that they use the internet for
about 4–6 hours/day, while 66.6 % of
the sample reported that they use library
book for 1–3 hours/day.
There were statistically significant
differences between internet versus
library book in relation to duration of
usage in both days/week and hours/day.
Table (2) Regarding the usage of the
internet versus library book, 89.3%
versus 55.5 % of the sample agreed that
they use the internet rather than library
book to obtain information related to
courses they study, while 80.4 % versus
32.8% of the study sample agreed that
they use internet for their academic
assignments versus library book, and
78.2% versus74.1% of the sample
agreed that internet and library books
were important source of information
respectively.
Moreover, 73.8% agreed that the first
place they would look for information
was internet compared with 18.9% for
library book, while 91.8% of the sample
agreed that 1 or 2 hours use for the
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July 2015
internet would be helpful for them
compared to 57.7% for library book.
There were statistically significant
differences between the usages of the
internet versus usage of library book in
all items.
Internet versus Library Book as a Source.
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Table (1): Frequency and percentage distribution and chi-square of the duration of
academic usage of internet versus library book among nursing students (n=317 )
Variables
Days of using/week
1 – 2 days
3 – 4 days
5 – 7 days
Hours of using /day
< 1 hour
1 – 3 hours
4 – 6 hours
7 hours or more
Internet
No.
%
Library Book
No.
%
2
292
23
0.6
92.1
7.3
237
51
29
74.8
16.1
9.1
3
53
261
0.0
1
16.7
82.3
0.0
106
211
0.0
0.0
33.4
66.6
0.0
0.0
p-value
.000
.000
Table (2): Frequency and percentage distribution and chi-square of the internet
versus library book usage as a source of academic information (n=317 )
Variables
Agree
Internet
Neutral
Obtain
information
related to courses I
take.
Work on academic
assignments.
An important source of
information to use.
The first place I would
look for information.
1 or 2 hours use would
be helpful.
283
(89.3)
255
(80.4)
248
(78.2)
234
(73.8)
291
(91.8)
Agree
16
(5)
26
(8.2)
6
(1.9)
52
(16.4)
26
(8.2)
36
(11.4)
63
(19.9)
31
(9.8)
0
(0)
104
(32.8)
235
(74.1)
60
(18.9)
183
(57.7)
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Library Book
Neutral Disagr
ee
176
22
119
(55.5)
(7)
(37.5)
Disagr
ee
18
(5.7)
59
(18.6)
25
(7.9)
75
(23.7)
41
(13)
154
(48.6)
57
(18)
182
(57.4)
93
(29.3)
p-value
.000
.000
.000
.000
.000
Internet versus Library Book as a Source.
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Figure (1): Percentage distribution of the students' responses about "has the
internet usage replaced the library book usage for academic work"?
Figure (1) shows that 76.3% reported that the internet usage replaced the library book
usage for academic work.
Figure (2): Percentage distribution of the students' responses regarding "do you go
to the library less often because you can find much of information you need on the
internet"?
Figure (2) illustrated that 83.3% of the studied sample reported that they go to the library
less often because they can find much of information they need on the internet.
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July 2015
Internet versus Library Book as a Source.
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Table (3): Frequency and percentage distribution and chi-square of the advantages
of using of the internet versus library book as a source of academic information (n:
317 )
Variables
Agree
It gives more information
251
(79.2)
233
(73.5)
317
(100)
294
(92.7)
206
(64.9)
264
(83.3)
288
(90.9)
238
(75.1)
Internet
Neutral Disagr
ee
24
42
(7.6)
(13.2)
0
84
(0)
(26.5)
0
0
(0)
(0)
23
0
(7.3)
(0)
75
36
(23.7) (11.4)
25
28
(7.9)
(8.8)
9
20
(2.8)
(6.3)
32
47
(10.1) (14.8)
Library book
Agree Neutral Disagr
ee
168
27
122
(53)
(8.5)
(38.5)
53
33
231
(16.7) (10.4) (72.9)
78
113
126
(24.6) (35.6) (39.8)
54
0
263
(17)
(0)
(83)
170
44
103
(53.6) (13.9) (32.5)
304
13
0
(95.9)
(4.1)
(0)
295
12
10
(93.1)
(3.8)
(3.1)
39
54
224
(12.3)
(17)
(70.7)
p-value
.000
It is easy to access the
information I want
.000
It
has
up–to–date
information
.000
Data
presented
in
different forms
.000
It is suitable for all
educational purposes
.000
It
offers
evident
information
.000
It
offers
relevant
information
.000
Others:
You have fun during
.000
study, not boring.
Regarding the advantages of using the internet versus the library book as a source of
academic information, 79.2% agreed that they learn more from the internet than library
book, while, 73.5% reported that internet was easy to access the information they want.
In addition, the entire sample (100 %) agreed that they had updated information from
internet versus 24.6% agreed about library book.
In addition, 92.7% versus 17% agreed that data are presented in the internet in different
forms versus library book. Moreover 64.9 % said that internet was suitable for all
educational purposes versus 53.6% who agreed for library book; while, 95.9% and
93.1% of the studied sample agreed that library book provide evident and relevant
information in comparison to 83.3% and 90.9% agreed that internet offers evident and
relevant information respectively. Finally, 75.1% of the studied sample agreed that they
had fun during study on the internet compared to 12.3% for library book.
There were statistically significant differences between internet and library book in
relation to the advantages of usage.
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July 2015
Internet versus Library Book as a Source.
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Table (4): Frequency and percentage distribution and chi-square of the problems
facing the students in using the internet versus library books for study (n= 317 )
Variables
Agree
Not being able to find the
information I am looking
for.
Not being able to recognize
the reliable scientific
information.
Not being able to efficiently
organize the information I
gather.
It takes too long to search.
58
(18.3)
It needs more assistance or
training to effectively search
on.
It costs too much.
Internet
Neutral Disagr
ee
59
200
(18.6) (63.1)
Library Book
Neutral Disagr
ee
175
49
93
(55.2) (15.5) (29.3)
p-value
Agree
.000
132
(41.6)
78
(24.6)
107
(33.8)
27
(8.5)
53
(16.7)
237
(74.8)
.000
132
(41.6)
80
(25.2)
105
(33.1)
37
(11.7)
18
(5.7)
262
(82.6)
.000
43
(13.5)
121
(38.2)
140
(44.2)
68
(21.4)
134
(42.3)
128
(40.4)
131
(41.3)
177
(55.8)
66
(20.8)
0
(0)
120
(37.8)
140
(44.2)
.000
.000
85
46
186
10
12
295
.000
(26.8) (14.5) (58.7)
(3.1)
(3.8)
(93.1)
It steals (wastes) my
184
61
72
58
72
187
.000
studying time.
(58.1) (19.2) (22.7) (18.3) (22.7)
(59)
Regarding problems facing students in using internet they were in order 58.1% of the
sample agreed that internet steals their studying time, followed by an equal percentage of
41.6% agreed that they were not being able to recognize reliable scientific information
and efficiently organize information they gather, then 38.2% agreed that they need more
assistance or training for effective searching.
In relation to library book usage problems, 55.8% agreed that they need more assistance
for searching, followed by 55.2% agreed that they were not being able to find
information they were looking for, then 41.3% agreed that they took too long to search.
There were statistically significant differences between internet and library book in
relation to the problems that the students face in using.
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Discussion
The internet is one of the important
sources
of
academic
education
information and it creates an educational
delivery system. Therefore, the aim of
the current study was to assess the
internet versus library book as a source
of academic information among the
nursing students. A sample of
convenience of 317 nursing college
students was recruited for the study. The
socio-demographic profile of the sample
was as follows: the studied sample had a
mean age of 20.8 years, all of them were
females. In addition, about one third of
the fathers' studied sample had
secondary school, while more than one
third of their mothers had university
education, and more than one third of
their fathers were retired, while more
than one third of the mothers had
governmental job.
In relation to the duration of using the
internet versus library book, the study
results revealed that there was a
statistically
significant
difference
between internet and library book
regarding to duration of usage, whereas,
most of the sample used the internet for
3–4 days/week, while almost three
quarter of the sample used the library
book for 1–2 days/week. As well, the
results showed increased duration of
usage per day than library book.
Whereas the majority of the sample used
the internet 4–6 hours/day, two thirds
used library book for 1–3 hours per day.
The study results done by Rasmusson &
Eklund (2013 ) are congruent with those
of the current study, as they mentioned
in their study that the mean usage of the
internet for the students were 12.6
hours/week.
Regarding the uses of the internet and
the library book, the study results
revealed that there were statistically
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July 2015
significant differences between internet
and library book in relation to uses, as
the studied sample used the internet
more than library book for the
educational purposes, to earn courses
related information, as well as work on
their academic assignments. As well, the
majority of the studied sample reported
that internet is the first place they look
for information. Moreover, about three
quarter of the studied sample reported
that the internet usage replaced the
library book usage, so, they go to the
library less often, and they added that 1–
2 hours use may be helpful to do their
work on the internet rather than library
book. The study results come into the
same line with those of the study done
by Bashir, Mahmood, and Shafique,
(2008 ) to explore internet use among
university students. They found that
most of the students use this technology
for course related reading and research
needs.They added that ease of work and
time saving, are the reasons of internet
use
among
university
students. Moreover, regarding on how
often they used Internet, their results
revealed that daily users were 93 (31%),
while 141 users (47%) were using
Internet 2-3 days in a week, 16 users
(5.5%) were using it fortnightly, 21
users (7%) were using it once a month
and 34 (11.5%) were using it rarely.
In addition, Kafyulilo (2014) in a recent
study found that computer was the most
used learning tool for teaching perceived
by both students and teachers. Another
study done to evaluate internet access
and utilization by medical students for
academic purpose on 532 students in
Lahore concluded that the majority of
the respondents were using internet for
academic purposes rather than traditional
resources
(Jadoon,
Zahid,
Mansoorulhag, et al., 2011 ).Similarly, a
Internet versus Library Book as a Source.
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study carried out by Aldebasi and
Ahmed (2013 ) revealed that seventy
percent of the sample prefers to use the
internet as a source of information
versus use textbook.
With reference to advantage of the
internet versus library book, there were
statistically
significant
differences
regarding all items of benefit between
internet use and library use, whereas, all
the sample agreed that internet had an
updated information, as well as the
majority agreed that internet gives more
information and most of them agreed
that it presented the information in
different forms, which may be
interesting (power point, photos, graphs,
video, etc.) to learn rather than books, as
well as it is easy to access than the
library book, also to have fun while
studying as agreed by three quarter of
the sample as a benefit of using the
internet. On the other hand, most of the
sample agreed that library book provide
evident and relevant information rather
than internet.
A study done by Breitkreuz (2009), to
examine the experience of nursing
students using the internet as an
educational resource come into the same
view with the current study results as the
studied sample reported that the using of
the internet makes their learning easy,
the internet also gives more information
to learn, and also they reported that
internet gives them valuable information,
the nursing students also added that the
information presented on the internet is
live information it expands their
experiences as well as it is updated
information. Finally, they reported their
perception of how difficult it would be to
complete their studies without internet
access. As well, Aldebasi and Ahmed
(2013 ) revealed in their study regarding
the benefit of using the internet that
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July 2015
more than half of the sample reported
that it had latest knowledge, as well as it
is time saving. In addition, more than
one third of the sample reported that it
had easy accessibility.
Moreover, a study carried out by
Abdalla,
Karam,
Ahmed
and
AbdElHakeim (2013 ), on e-learning
versus traditional learning in teaching
critical care nursing: Its effect on
students'
performance
in
Egypt
concluded that e-learning as a teaching
method
has
highly
statistically
significant positive effect on students'
performance versus traditional teaching
methods.
Regarding the problems facing the
students using the internet versus library
book, the major problems regarding
internet use were that it stole the
studying time, followed by that the
students were not being able to
recognize
the
reliable
scientific
information, as well as it was difficult
for them to organize the information
they gather because it was very huge. On
the other hand, the use of library book
needs much more assistance, followed
by that students may not find the
information they are looking for and it
may take too long to search.
Alrashid (2006) found in his study that,
the most significant barrier reported by
participants in using the internet for
health information was "it takes too long
to view/download pages," followed by
"not being able to find the information in
Arabic language." The third concern had
to do with the reliability of the health
information that was provided on the
internet. As well, Barrett (2012 ) and
Emwanta & Nwalo (2013 ) added that
the complexity of online reading stems
from the ability of the readers to call
their experience and knowledge from
different knowledge sources, which may
Internet versus Library Book as a Source.
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make comprehending the internet more
difficult for some students. Another
element of searching difficulty may be
not being able to find relevant
information. Barrett also, added that they
may need more training and assistance to
use internet.
Conclusion
The study results concluded that the
nursing students may use internet rather
than library book to earn courses–related
information as well as work on their
academic
assignments.
Therefore,
students should be trained to extract
valuable information from the approved
educational web sites and they should be
encouraged to check the authenticity of
the information by relating it with the
existing evidences. This will be helpful
in promoting evidence based learning.
Besides that, the online-based learning
programs are able to replace the
conventional class lectures and the high
demand requirement of the nursing
students for the recent advances in health
field.
Recommendations
As the use of the internet is the area of
preference for the students to gain
educational knowledge and practices, so
it was recommended:
1. To enhance and reinforce the
internet as a source of
information in the academic
nursing education.
2. For faculty members within
universities, they may need to
update
their
curriculum,
materials and instructional
programs.
3. To increase the credit hours for
the college requirement courses
in computer application and for
the internet use.
4. To provide computer access
facilities for all the students.
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July 2015
5. To include the reliable and valid
internet websites in the essential
references for the students
6. Further studies may be needed to
assess
gender
differences
regarding internet utilization in
the academic field.
7. Further researches also may be
needed to assess the effect of the
internet on the academic
achievement among nursing
students.
References:
1- Abdalla, K., Karam, O., Ahmed,
N.,&AbdElHakeim, E. (2013 ). The
effect
of
e-learning
versus
traditional teaching methods on
students‘ performance regarding
critical care nursing. Journal of
Advanced Computer Science and
Technology Research, June; 3 (2),
83-98 .
2- Abu Hasheesh, M., Al-Mostafa, O.,
&Obeidat, H. (2011). Traditional
versus nontraditional methods of
teaching: The Impact on nursing
teaching effectiveness and student‘s
achievements at nursing colleges,
An-Najah University. J. Res.
Humanities; 25 (1), 255-270 .
3- Ahmed, M. (2010 ). Effectiveness
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methods of teaching biology in
junior college.
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4- Aldebasi, YH., & Ahmed, MI.
(2013 ). Computer and internet
utilization among the medical
students in Qassim University,
Saudi Arabia. Journal of Clinical
and Diagnostic Research; 7(6),
1105-1108 .
5- Alrashid, SA. (2006 ). Perceptions
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health information source among
Saudi
college
students.
A
dissertation for the degree of doctor
of philosophy; pp. 4-10.
6- Barrett, P.L. (2012 ). Informationseeking processes of fourth grade
students using the internet for a
school assignment. A dissertation
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7- Bashir, S., Khalid Mahmood, K.
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Adolescent Girls: Assessment.
enj@nursing.cu.edu.eg
Adolescent Girls: Assessment of Biological Factors
Tereza Khalifa1 , Prof. Ragaa Ali Mohamed2, Assist. Prof. Gehan Ebrahim3
1
(Maternal& Newborn Health Nursing, Faculty of Applied Medical Science / October 6
University, Egypt)
2
(Maternal& Newborn Health Nursing, Faculty of Nursing / Cairo University, Egypt)
3
(Maternal& Newborn Health Nursing, Faculty of Nursing / Cairo University, Egypt
Abstract:
Dysmenorrhea is the most common gynecological complaint and the leading cause of recurrent short-term
school absenteeism among adolescent girls. It was considered worthwhile to identify risk factors for
dysmenorrhea, since such information is useful in designing management process. Aim of the study: to
explore the biological factors that affect dysmenorrheal symptoms among adolescent girls in secondary
schools. Research design: A descriptive exploratory research design using structure interviewing
questionnaire. Sample: A purposive sample of 500 adolescent girls who had dysmenorrhea was recruited
in this study. Setting: The study was carried out at general and technical governmental secondary schools
which located at north Cairo. North Cairo is included about 24 secondary schools. These schools are listed
in a table alphabetically. The investigator selected 10% randomly from these schools to be included in the
study. Tools of data collection: Two tools were developed, tested for content validity, and then used to
collect data pertinent to the current study: (1) Structure interview questionnaire design by the researcher
to collect data pertinent to the current study: it included "Female profile, demographic data (2) Numerical
Rating Pain Scale (NRS): is used to assess the intensity of pain. Results: the result showed that the mean age
of the participant was 16.4±0.9 years and BMI (M±SD) 22.7±3.88 and mean age of menarche that was
12.46±3.88. The result showed positive correlation between body mass index , sleeping hour ,good eating
habits , practiced of exercise and severity of dysmenorrhea Conclusion: the prevalence of dysmenorrheal
was high among secondary school student , severity of pain co-related to early menarche, eating habits
,sleeping hours and exposure to passive smoking .Recommendation: this study recommended further
researches to carry out to explore the relationship between biological factors and dysmenorrhea to
determine the possible pathway of this association
Keywords - Adolescent, Biological factors, Dysmenorrhea, Menstrual pain, Primary dysmenorrhea.
Introduction
Adolescence is a time of rapid
change that can affect teenage girls
physically, emotionally and mentally.
During this time many girls will desire
to be more independent from their
families. They often develop stronger
relationships outside their families and
begin to form their own ideas about what
matters most too them (Pitts, Ferris,
Smith, Shelley & Richters, 2008).
Puberty is the phase of
adolescence when the body changes to
become sexually mature, caused by the
rapid release of female hormones into
the body. Girls when enter puberty, they
undergo a great many physical changes,
369
July 2015
not only in size and shape, but in such
things as: the growth of pubic, under
arm, and other body hair, increased body
odor , the development of breasts, the
start of menstruation ( Parker,Sneddon
&Arbon, 2009 ).
Menarche is a milestone in
female puberty that signifies the
maturation of reproductive potential and
physiological growth (Chang &Chen,
2009; Guvenc, Kilic, Akyuz &
Ustunsoz, 2012 ). It generally occurs
approximately 2-3 years after the
initiation of puberty, between the ages of
11 and 14
years in 95% of girls
depending
on
race,
ethnicity,
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socioeconomic and nutritional status
(Kaplowitz, 2006).
Menstrual cycles are irregular
during the first year of menarche due to
anovulatory cycles (Singh et al., 2008).
Height, weight and body fat content
continue to increase for 1 – 2 years
following menarche and the cycles
become regular within 2 – 3
years.
Typically a menstrual flow lasts 2 – 7
days in 70 – 80% of cases, and changing
three to six pads per day suggests normal
flow (David & Steven, 2007 ). The
duration between two menstrual cycles
ranges from 21 to 45 days in the 1 – 2
years after menarche. When ovulatory
cycles begin, 60 – 80% of the cycles are
21 – 34 days long, which some variety
of menstrual dysfunction occurs in
approximately 75% of adolescent girls
(Cakir, Mungan, Karakas, Girisken and
Okten, 2007). Although menstruation
itself is physiological , it often leads to
physical and psychological problems in
women
of
reproductive
age
(Wong&Khoo,2011 ).Conditions such as
irregular menstrual cycle, premenstrual
pain ,and excessive menstrual bleeding
may be a warning of disorders affecting
a women's reproductive health and
fertility (Wijesiri & Suresh ,2012 )
Dysmenorrhea is one of the most
common gynecologic disorders among
adolescent girls (Dikenso et al., 2009 ).
It is defined as pelvic pain directly
related to menstruation, and is associated
with symptoms ranging from headache
and back pain to nausea, vomiting and
diarrhea (Ma et al., 2015 ). It is classified
into two categories: primary when pelvic
examination and ovulatory function are
normal; and secondary when there is an
identifiable gynecological pathology
(Marzouk, El-Nemer, Hany & Baraka,
2013)
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July 2015
Primary
dysmenorrhea
characteristically
begins
when
adolescents attain their ovulatory cycles;
generally within the first year after
menarche. Dysmenorrhea can disrupt
daily activities causing significant social
disabilities (Parker, Sneddon &Arbon,
2009). Pain may inconvenience a girl
during holidays, social activities, or
sometimes when high performance is
required. Chronic recurrent pain of
dysmenorrheal causes absence from
school or work and significant costs to
the health-care system (Avasarala &
Panchangam, 2008 ).
The pathogenesis of primary
dysmenorrhea is not always understood.
Prostaglandins seem to be intimately
involved; Dysmenorrhea results from the
withdrawal of progesterone near the end
of a menstrual cycle (Parveen, Majeed,
Zahra, Rajar & Munir, 2009). This
withdrawal has been shown to increase
the synthesis of prostaglandins F2
(PGF2) and E 2 (PGE 2) (Cheng and
Lin, 2011), and stimulate the uterine
contraction as prostaglandins are known
to induce myometrial contractions,
causing menstrual cramps (Yeh , Hung ,
Chen & Wang, 2012 ).
Dysmenorrhea relates to many
risk factors. as, Lathe, Proctor,
Farquhar, Johnson & Khan (2007 ) who
reported that risk increases with heavy
menstrual flow, young age, age of
menarche,
menstrual
regularity,
menstrual cycle duration ,BMI, stress,
diet, active or passive smoking , alcohol
drinking, hormonal contraceptive use,
socioeconomic status
,emotional
problems, such as depression and
anxiety, are also associated with
dysmenorrhea (Dorn et al. ,2009 ;Grandi
et al., 2012; Nohara, Momoeda, Kubota
&
Nakabayashi
,2011 ;Yamamoto,
Okazaki, Sakamoto & Funatsu, 2009).
Adolescent Girls: Assessment.
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Dysmenorrhea is under-treated
because physicians are not fully aware of
its high prevalence and morbidity.
However, this condition is often
considered as physiological pain and
ignored by adolescents; and only few
adolescents need to consult a physician
for menstrual pain and most of them
self-medicate with over-the-counter
medicines(Cakir et al .,2007 ) .
1.1 Significant of the study:
Adolescent girls are one of the
most
groups
that
suffer
from
dysmenorrhea which is the leading cause
of
recurrent
short-term
school
absenteeism in this group ,there is 14%–
26% of adolescents miss school or work
as a result of primary dysmenorrheal
pain , but the girls which suffering from
menstrual pain they considered it is
normal and manage it with traditional
habits ( e.g. hot drinking & aspirin
tablet) that used by their mother‘s or
significant personal
in their social
relation to relive this pain , in order to
seeking no medical advice to know
what‘s the causes of their pain which
may be related to life style factors as
types of diet , pattern of sleeping , daily
activity , exercise , life event stress and
smoking .The role of women‘s health
nurse is to assess the adolescent girls
which suffering from menstrual pain and
counsel them about the importance of
seeking medical advice to discover the
causes of this pain, try to manage their
pain and reach to adult hood wellbeing.
1.2 Aim : The aim of the current study
is to:
Explore the biological factors
that affect dysmenorrhea symptoms
among adolescent girls in secondary
schools.
1.3 Research Question :
What are the biological factors that
affect adolescent girls who had primary
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July 2015
dysmenorrhea
among
Secondary
School?
II. Material and Methods
1. Material
1.1 Research Design:
A
descriptive
exploratory
research design was utilized in the
current study. This design is concerned
with description of a phenomenon of
interest and focuses on a single group or
population characteristics without trying
to make interference.
1.2 Setting:
This study will be conducted in
represented sample from general and
technical
governmental
secondary
schools which located at north Cairo.
North Cairo is included about24
secondary schools. These schools are
listed in a table alphabetically. The
investigator selected 10% randomly
from these schools to be including in the
study
1.3 Subjects:
Purposive sample of 500
adolescent girls who had primary
dysmenorrhea was recruited according to
the following criteria: Menarche for at
least one year at the time of study, none
married, willing to participate in the
study & Study in the secondary school.
The sample of 500 participants
will be calculated using a power
analysis. A Power of 0.95 (β = 1-0.95 =
0.5) and slope H1= 0.15, at alpha 0.05
(one-sided) will be used as the
significance level because these level
have been suggested for use in the most
areas of behavioral science research . In
addition, the medium effect size (0.15) is
conventional effect size in behavioral
science that will be used when the new
area of research and when instruments
have not well been tested. Although the
minimum number of 500 subjects will
be required by power analysis, the
Adolescent Girls: Assessment.
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researcher will aim to obtain 500
subjects in this study because ten percent
of non-response rate will be expected to
be lost from the subjects.
1.4 Tools of Data Collection: two tools
were used in the current study to collect
the necessary date.
1.4.1 Tool (1):
Adolescent
Structured
selfadministered questionnaire designed by
the researcher to collect pertinent data
related to demographic data which
include participant code number, age,
residence and mother educational level,
number of family member and girls
order in family, adolescent assessment
data which included data related to
physiological factors, life styles (diet,
exercise, sleeping pattern, habits such as
coffee, smoking and alcohol intake) &
menstrual profile which included data
related to girl's menarche age, presence
and absence of dysmenorrhea, its
duration, amount of blood loss,
regularity, symptoms experienced during
menstruation, how to deal with this
symptoms and quality of life related
questions.
1.4.2 Tool (2): Numerical Rating Pain
Scale (NRS):
A standardized tool was adopted
from McCaffery and Beebe (1989)
used to assess the intensity of pain .The
NRS is simple to use and is one of the
most
common
approaches
for
quantifying pain. Girls are asked to rate
the severity of their pain on a scale from
0 to 10, while zero score indicating no
pain, from 1 to 3 score indicating mild
pain , from 4 to 6 score indicating
moderate pain and from 7 to 10 score
indicating the worst pain imaginable.
The NRS can be a helpful technique for
clarifying the relationship between pain
and dysmenorrhea.
372
July 2015
McCaffery & Beebe ,(1989)
2. Methods
2.1 Ethical Considerations:
Before the conduction of this
study, a written approval from the ethics
committee –faculty of nursing and
ministry of education, from the general
director of each school. Written
informed consents obtained from
participant after clarification of the
study's purpose to collect the necessary
data. Also, girls were informed that
obtained data will not be included in any
further researches. Confidentiality and
anonymity of each subject were assured
through coding of all data.
2.2 Content Validity and Reliability:
The tools for data collection were
developed after reviewing the related
literature and examined by a panel of
experts in field of maternal & new born
health nursing then these tools were
tested for content validity.
2.3 Pilot of the study:
A pilot study was carried out on a
sample of 10% of sample excluded from
the sample to test the feasibility and
applicability of the tool.
The main purpose of the pilot study was
to Test the relevance and applicability of
data collection tools, Detect any problem
peculiar to the tools, To determine the
time needed to finish questionnaire sheet
&Find out any problem that may
interfere with the process of data
collection.
(The pilot study revealed that
statements of the questions were
relevant).
2.4 Collection of data:
The
researcher
selected
adolescent girls who had primary
dysmenorrhea who fulfilled the criteria
from previously mentioned setting. The
Adolescent Girls: Assessment.
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researcher explained the purpose of the
study to each girl, and then written
consent to participate in the study was
obtained from each girl's agreements to
be included in the study. One day per
week were specified for data collection
over a period of six months, starting
from October 2012 to the end of April
2013.
2.5 Procedure of the study:
The study proceeds as follows:
Regarding the implementation phase: It
was carried out after obtaining official
permissions from the research committee
and from the general director of each
school to proceed in the current study.
Data of the current study were collected
over a period of 6 months from October
2012 to April 2013 . The researcher
visited the selected setting on twice
weekly basis and met the adolescent
girls in the break time and free classes.
The girls were informed about the
purpose and nature of the study and the
researcher obtained Parents‘ consent
letters from those who accepted share in
this study. They answered survey
questions in the classroom and body
weight and high was measure by
researcher. The average number of
student who answered the questionnaire
was 15- 20 girls per day. Investigator
took 10 minutes to clarify any
difficulties in the tool & then answering
the questions took approximately 15
minutes from each girl. Then the
researcher checked each questionnaire
after the girls had completed it, to be
sure that no missing information were
present
2.6 Statistical Analysis Data
Upon completion of data
collection, data were analyzed using
SPSS program version 20; then
tabulated. Relevant statistical analysis
was used to test the obtained data.
373
July 2015
Descriptive and inferential statistics
were done such as mean and standard
deviations; frequency; percentage; chi
square test; and independent t test &
ANOVA analysis of variance.
III. Result
Result showed that the mean age
of the students under the study was
16.4± 0.908 years. The mean age of
menarche was (12.46± 1.269 years),
most of them had their first menstrual
period at the age of 10-12 years.
Considering the heaviness of menstrual
bleeding, table (1) shows that the
majority of girls (73%) who used two
pads per day (had moderate bleeding) &
more than half of the sample (51%) had
regular cycle. Regarding the menstrual
pain level, about half of studied girls
(49%) had experienced severe menstrual
pain while 43% of had who experienced
moderate menstrual pain and the
remaining of girls (8%) experienced
mild menstrual pain where the mean
score of menstrual pain was 6.5±2,363 .
Correlation between menstrual
characteristics
and
severity
of
dysmenorrhea Table (2) reveals that girls
who had early menarche, had less
experience of dysmenorrhea than those
who experienced late menarche, they
complain from severe dysmenorrhea
while girls who were mid-normal
menarche out of 48.8% they complain
from severe dysmenorrhea in addition to
late-normal menarche out of 50% of
them also experience dysmenorrhea. In
relation to heavy period was association
with severe pain .about two third of girls
who had heavy period experienced
severe menstrual pain. There were
statistically significant relation found (p
= 0.01), all other correlations were not
statistically significant (p > 0.05).
In relation to the BMI table (3)
shows that the mean of BMI was 22.7 ±
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3.88kg/m², the study referred to BMI
ranged between 16 - 43 kg /m², 8% of
the studied girls had BMI less than 18.5
kg/m² (were under weight), about two
third of the studied girls (69%) were
ranged between 18.5-24.9 kg/m² (were
normal weight), (18%) were ranged
between
25-29.9
kg/m²
(were
overweight), (3%) were ranged between
30-34.9 kg/m² (were obesity I )while
only 1% of them had BMI ≥ 35 kg/m².
Concerning relation between
BMI and severity of dysmenorrhea. The
study revealed that there was positive
correlation among body mass index of
girls and the severity of pain (p = 0.001),
the majority of girls who complained
from severe pain were overweight and
obese Table (4).
Table(5)
shows
that
the
correlation between number of meals per
day and severity of dysmenorrhea Chi –
square (p = 0.002 ) finding a relation
between number of meals & severity of
pain of menstrual cycle, the girls who
get one meal per day had the most
complain from severe dysmenorrhea
than those who get three meals.
Concerning relation between type
of favorite food and severity of
dysmenorrhea Chi-square (p = 0.001 )
showed that positive association between
some types of food and severity of pain
such as fruits, vegetables, carbohydrates,
meat, cereals and desert that means girls
who had high consumption of some
types of foods experience severe pain
(table6).
The relation between exposure to
passive smoking and severity of
dysmenorrhea Table (7) reveals that
more than half of studied sample
(51.4%) exposed to passive smoking,
those girls most properly complained
from severe dysmenorrhea (p = 0.001).
374
July 2015
Concerning relation between
alcohol drinker and severity of
dysmenorrhea Chi-square (p = 0.001 )
showed that positive association alcohol
drinker and severity of pain (table 8)
represents that 11% were often and
sometimes drinkers alcohol and out of
75% of them feel severe pain during
menstruation
Concerning relation between
severity of dysmenorrhea and daily
activities in general Table (9) represents
the relation between girl's menstrual pain
level and its impact on their daily
activities in general; it was found that
there was a statically significant relation
(p = 0.001 ) where more than half of girls
who severe menstrual pain had direct
impact on their daily activities.
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Table (1): distribution of studied sample according to student menstrual cycle
character (N=500):
Variable
No.
%
Age groups
 13 16 18-19
57
401
42
M± SD
Menstrual cycle
Age of menarche
 early normal (10-12 yrs)
 mid-normal (13-14 yrs)
 late-normal (15-17 yrs)
M± SD
Rhythm of menstruation ( Regularity of menstruation )
 Irregular
 Regular
Interval of menstruation : (days)
 short menses (less than 21 days)
 regular (21-35 days)
 Longer menses (more than 35days)
M± SD
Amount of menstrual blood flow
 Light
 Medium
 Heavy
Level of menstrual pain
 Mild
 Moderate
 Severe
M± SD
375
July 2015
11.4%
80.2%
8.4%
16.4± 0.908
290
58%
172
34.4%
38
7.6%
12.46± 1.269
243
257
48.6%
51.4%
6
251
0
2.4%
97.6%
0%
28.7± 2.741
24
363
113
4.8%
72.6%
22.6%
41
216
243
8.2%
43.2%
48.6%
6.5± 2.363
Adolescent Girls: Assessment.
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Table (2): relation between characteristics of menstrual cycle and severity of
dysmenorrhea (N=500 ):
Variable
Age of menarche
early normal (1012yrs) (n=290 )
mid-normal (13-14
yrs) (n=172 )
late-normal ( 15 17yrs) (n=38 )
Amount of
menstrual blood
Light(n=24 )
Medium(n=363 )
Dysmenorrhea severity
Mild
Moderate
Severe
N
%
N
%
N
%
22
7.6%
128
44.1%
48.3%
45.9%
14
0
84
9
5.2%
79
10
26.3%
9
23.7%
19
50.0%
7
29
29.2%
8.0%
9
175
37.5%
48.2%
8
15
9
76
33.3%
43.8%
Heavy(n=113 )
Rhythm of
menstruation
Irregular(n=243 )
5
4.4%
32
28.3%
23
9.5%
104
42.8%
Regular(n=257 )
18
7.0%
112
43.6%
0
0%
10
90.9%
Interval of
menstruation :
days(n=257 )
short menses
(less than 21 days)
(n=6)
Regular(n=251 )
(21-35 days)
longer menses
(more than 35days)
(n=0)
Health education
about menstrual
cycle
No(n=86)
Yes(n=414)
11
6
12
7
47.7%
1
9.1%
102
41.5%
126
51.2%
0
0%
0
0%
0
0%
3.5%
38
9.2%
41
175
376
47.7%
42.3%
42
201
49.1
92a
.000
33.8
96a
.000
1.01
3a
.603
10.49
3a
.005
3.29
4a
.193
49.4%
7.3%
3
P
67.3%
18
* Significant level at p < 0.05
July 2015
48.8%
X2
48.8%
48.6%
Adolescent Girls: Assessment.
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Table (3): distribution of studied sample according to student BMI (N=500)
Variable
N.
%
BMI
1. Underweight (BMI < 18.5)
41
8.2%
2. Normal weight (18.5 ≤ BMI < 24.9)
344
68.8%
3. Overweight (25 ≤ BMI < 29.9)
91
18.2%
4. Obesity I (30 ≤ BMI <34.9)
17
3.4%
5. Obesity II (35 ≤ BMI <39..9)
5
1.0%
6. Extreme Obesity (BMI >40)
.4%
2
M± SD
22.7± 3.88
Table (4): Correlations among body mass index of girls and severity of dysmenorrhea
(N=500):
X2
Variable
Dysmenorrhea severity
Mild
Moderate
Severe
N
%
N
%
N
%
BMI
Underweight (BMI < 18.5) (n=41)
Normal weight
(18.5 ≤ BMI < 24.9) (n=344)
Overweight
(25 ≤ BMI < 29.9) (n=91)
Obesity I
(30 ≤ BMI <34.9) (n=17)
Obesity II
(35 ≤ BMI <39..9) (n=5)
Extreme Obesity (BMI >40) (n=2)
5
12.2%
22
53.7%
14
34.1%
31
9.0%
143
41.6%
170
49.4%
5
5.5%
42
46.2%
44
48.4%
0
0.0%
8
47.1%
9
52.9%
0
0.0%
0
0.0%
5
0
0.0%
1
50.0%
1
P
650.286a
.000
100.
0%
50.0
%
* Significant level at p < 0.05
Table (5): relation between number of meals per day and severity of dysmenorrhea (N=500):
X2
Variable
Dysmenorrhea severity
P
Mild
Moderate
Severe
N
%
N
%
N
%
Number of meals per day
one meal(n=52)
2
3.8%
17
32.7%
33
63.5%
two meals(n=109)
7
6.4%
55
50.5%
47
43.1%
.002
21.403a
three meals(n=204)
26
12.7%
94
46.1%
84
41.2%
more than three meals(n=135)
6
4.4%
50
37.0%
79
58.5%
* Significant level at p < 0.05
377
July 2015
Adolescent Girls: Assessment.
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Table (6): relation between type of favorite food and severity of dysmenorrheal (N=500):
Variable
Fruits
Vegetables
Carbohydrates
Never(n=10)
0
Rarely(n=18)
4
sometimes(n=1
50)
Often(n=322)
Never(n=7)
Rarely(n=56)
sometimes(n=1
98)
Often(n=239)
Never(n=7)
Rarely(n=74)
sometimes(n=1
68)
Often(n=251)
Milk and its products
Never(n=37)
Rarely(n=87)
sometimes(n=1
93)
Often(n=183)
Never(n=13)
Meat
Rarely(n=50)
sometimes(n=2
08)
Often(n=229)
Cereals
8
0.0%
22.2
%
14.0
%
4.9%
0.0%
7.1%
11.1
%
6.3%
14.3
%
1.4%
10.7
%
8.4%
13.5
%
9.2%
10
5.2%
81
18
0
9.8%
0.0%
14.0
%
80
1
21
16
0
4
22
15
1
1
18
21
5
7
20%
38.9%
48.7%
56
37.3%
128
4
36
39.8%
57.1%
64.3%
178
3
16
55.3%
42.9%
28.6%
64
32.3%
112
46.9%
71.4%
112
1
46.9%
14.3%
23.0%
48.8%
56
68
75.7%
40.5%
44.6%
48.6%
118
14
47.0%
37.8%
42.5%
42.0.%
42
102
48.3%
52.8%
43.7%
7.7%
48.0%
85
12
19
46.4%
92.3%
38.0%
50.0%
87
41.8%
38.0%
48.8%
125
15
54.6%
36.6%
43.8%
49
40.5%
7
73
5
17
82
112
18
37
24
17
7.4%
14.6
%
15.7
%
87
19
20
53
11
5.1%
100
5
43
13
4.1%
13.6
%
8.0%
9
6.5%
59
8
1
4
6.7%
5.0%
5.3%
11.9
%
6.2%
48
3
39
11
23
13
378
July 2015
2
7
104
Rarely(n=121)
Rarely(n=162)
sometimes(n=1
38)
often(n=119)
Deserts
Never(n=20)
rarely(n=76)
sometimes(n=1
93)
often(n=211)
* Significant level at p < 0.05
80%
38.9%
8.2%
6
Never(n=81)
8
17
Never(n=41)
sometimes(n=2
15)
Often(n=123)
Fats
Dysmenorrhea severity
Mild
Moderate
Severe
N
%
N
%
N
%
39
70
99
75
112
56.6%
46.5%
104
48.4%
35.0%
48.1%
75
31
61.0%
38.3%
43.2%
42.8%
79
70
48.8%
50.7%
40.3%
15.0%
51.3%
51.3%
63
16
33
71
52.9%
80.0%
43.4%
36.8%
35.5%
123
58.3%
X2
P
26.102a
.000
23.421a
.001
30.763a
.000
6.239a
.397
20.928a
.002
24.950a
.000
7.611a
.472
30.099a
000
Adolescent Girls: Assessment.
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Table (7): relation between exposure to passive smoking and severity of
dysmenorrhea (N=500):
Variable
Dysmenorrhea severity
Mild
Moderate
Severe
N
%
N
%
N
%
exposure Sometimes
35
16.2
84
38.9
97
44.9
to
(n=216)
passive
Often
13
6
2.1
46.5 146
51.4
smoking
2
(n=284)
* Significant level at p < 0.05
X2
P
32.411
.000
Table (8): relation between alcohol intake and severity of dysmenorrhea N=500 ):
Variable
Alcoholic
drinks
Never
(n=358 )
Rarely
(n=63 )
Sometimes
(n=28 )
Often
(n=28 )
Dysmenorrhea severity
Mild
Moderate
Severe
N
%
N
%
N
%
18
16
35
9.1
47.3
43.6
2
8
38.1
39
0
0.0
24
61.9
5
17.9
5
1
4.2
5
17.9
18
20.8
18
X2
P
27.105a
.000
64.3
75.0
Table (9): relation between severity of dysmenorrhea and daily activities in general
(N=500):
Variable
Dysmenorrhea severity
X2
Mild
Moderate
Severe
N
%
N
%
N
%
daily activities in
general
13.0
46.7
40.2
No (n=184)
13.383a
24
86
74
%
%
%
5.4
13
41.1
16
53.5
Yes (n=316)
17
%
%
%
0
9
* Significant level at p < 0.05
379
July 2015
P
.001
Adolescent Girls: Assessment.
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IV. Discussion
The aim of the current study was
to explore the biological factors that
affect dysmenorrhea symptoms among
adolescent girls in secondary schools.
This aim was achieved through study
findings and in frame of answering of
research questions.
Dysmenorrhea and age of menarche
according to the results yield by the
present study, the mean age of menarche
in the current study was (12.46±
1.26years) table (1) this result go in line
with the study done by Bahathiq &
ElAwad (2014 ) who found that age of
menarche ranged from (9-17) and the
mean age was (13.2±1.3 years) that
might be explain the two studied sample
were Egyptians female. on other hand ,
the result of this study was disagree with
Desalegn, Berihun and Abay (2009)
who reported the mean age of menarche
of studied sample was (15.8±1.0 years).
Regarding to the age of menarche
and severity of dysmenorrhea the current
study showed that a significant
association between age of menarche
and severity of dysmenorrhe, the result
revealed that girls, who had early
menarche, had less experience of
dysmenorrhea
than
those
who
experienced late menarche. While Zhu,
Proctor, Bensoussan, Smith & Wu
(2007 ) found in their study on 120
Australian women and 122 Chinese, the
Girls who had their first menstruation at
a younger age reported more severe pain
associated with their menstrual periods
.Young age has consistently been shown
to increase the risk of painful
menstruation as well as nulliparous
status and that also agree with Desalegn,
Berihun and Abay (2009 ) who reported
that there was significant difference
between the two groups under his study,
the group who had dysmenorrhea their
380
July 2015
age of menarche lower than the group
with no dysmenorrhea and reported it
might be interfered that early menarche
produces more prevalent dysmenorrheal.
In a recent study conduct in Egypt (Abd
El-Hameed, Mohamed, Ahmed &
Ahmed ,2011 ) the mean age of
menarche nearly the same of the current
study the difference between studied
done in Egypt and others countries might
be attributed to the difference in
socioeconomic status ,environment and
food habits ,while others found no
association between the age at menarche
and dysmenorrhea (Weissman ,Hartz
,Hansen &Johnson 2004 ).
Dysmenorrhea and Character of
menstruation
In relation to the character of
menstruation
and
severity
of
dysmenorrhea current study agree with
the many studies which found that
heavy period was association with severe
pain .about two third of girls who had
heavy period experienced severe
menstrual pain and all other menstrual
characteristics as regularity and length
the menstrual cycle were not statistically
significant correlation .This result go in
line with Omidvar and Begum (2012 )
who found that both length of menstrual
flow and blood loss were found to be
significantly associated to dysmenorrhea
,the same result of his study revealed
that cycle length and regularity of
menstruation did not exhibit significant
association to dysmenorrhea ,however,
fact is that relatively higher proportion
of the selected females in dysmenorrhea
.group had longer cycle length than the
non dysmenorrhea group suggesting
cycle length to exert an effect in
menstrual pain .both dysmenorrheic
females were found to experience
regular menstrual periods. It is relevant
to
mention
that
the
primary
Adolescent Girls: Assessment.
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dysmenorrheal may essentially be due to
hormonal effects causing higher levels of
circulating prostaglandins (table 2).
Dysmenorrhea and BMI
The present study revealed that
the majority of girls who complains from
severe pain within over weight and
obese table (3-4). The study done by
Nohara et al., 2011 ) & Ozerdogan ,
Sayiner , Ayranci , Unsal & Giray
(2009 ). Go in line with the result of this
study who demonstrated a strong
positive relationship between BMI and
dysmenorrhea. Obese women tend to
have higher estrogen levels. In the other
side the study done by Ju, Jones
&Mishra (2015) reported; it has been
shown that people with higher levels
BMI have higher level of prostaglandin;
both high estrogens and high
prostaglandin are probable mechanism
of dysmenorrhea While Ohde et al.
(2008 ) reported that there was no
association between being overweight
and the occurrence of menstrual cramps.
Dysmenorrhea and dietary habits
Regarding to the number and
types of meals, the current study showed
that a significant association between
number of meal/day and severity of
dysmenorrhea , that means girls who get
one meal/day had experience severe pain
adding to types of foods this finding go
in line with Gagua, Tkeshelashvili &
Gagua (2012 )who suggested that
nutrition during adolescence affects
reproductive function in young women
and dysmenorrhea as well (table 5 ).the
result of the study found also that girls
who like to eat vegetables & fruits
reported they had severe pain of menses
,this finding go in line with Fujiwara,
Sato, Awaji& Nakata,( 2007 )who
reported that vegetarians frequently have
menstrual disturbances to predict
dysfunction in the hypothalamic381
July 2015
pituitary-ovarian
axis,
irregular
menstruation is one of the positive
clinical symptoms. While Tavallaee,
Joffres , Corber , Bayanzadeh and Rad
(2011 ) reported that one important
finding of his study was association
between fruits and vegetable intake and
pain level of menstruation ,girls who had
a high consumption of fruits &
vegetables intake on daily basis
experience less dysmeorhea who showed
that vegetarians had higher levels of
serum sex-hormone binding globulin
(SHBG). Vegetarian tend to have lower
BMI which is correlated with higher
level of SHBBG. It has also been shown
that a low fat diet is associated with a
lower estrogen level, elevated SHBG or
decrease estrogen may lead to less
stimulation of the endometrium and
reduced
the
proliferation
of
endometrium and therefore a lower level
of prostaglandins. The result of the study
found also those girls who like to eat
cereals & food contained high
carbohydrates reported they had severe
pain of menses this finding go in line
with Fujiwara et al.
(2007 ) who
suggested that excessive caloric intake
tend to have higher BMI which is
considered
risk
factor
for
dysmenorrhea(table 6).
Dysmenorrhea and smoking
The current study shown that
more than half of study population (table
7) expose to passive smoking &
experienced
severe
pain
during
menstruation , some studies shown that
smokers experienced more menstrual
pain rather than non smokers (Ju,
Jones& Mishra 2014 ). In contrast of this
study showed that the exposed of
cigarette smoke to women & passive
smoking increases the risk of primary
dysmenorrhea (Amini, Raden, Hidayati,
Dewi & Indrayanto, 2011). Smoking is
Adolescent Girls: Assessment.
enj@nursing.cu.edu.eg
known to causes vasoconstriction which
reduces endome trial blood flow and can
lead to menstrual pain. It also has been
suggested that exposed to passive
smoking tend to have longer period
(Swift, 2014 ) which high been
associated with menstrual cramps.
Dysmenorrhea and Alcohol intake
Egyptian
students
in
the
secondary school alcoholic drinkers in
this study were represented 11% were
often and sometimes drinkers (table 8)
and out of 75% of them feel severe pain
during menstruation .in contrast with the
previous result study done by Tavallaee
et al.(2011).Showed that non alcohol
drinkers experienced less pain. Some
previous studies showed that people who
drink alcohol in moderate, tend to have
more severe pain compared with those
who did not drink alcohol at all, while
Okoro, Malgwi & Okoro (2013 ) who
reported that no significant associations
were established between severity of
dysmenorrhea with alcohol consumption
and cigarettes smoking.
Dysmenorrheal and quality of life
As regard the quality of life
during dysmenorrhea is comparatively
poor among adolescent girls who had
dysmenorrhea: loss of physical activity
and work satisfaction, personal relation,
confidence
and
concentration
at
school.this clearly indicates that
dysmenorrhea is distributing the quality
of life when compared with the level of
non dysmenorrhic girls(table 9) .the
study done by (Al-Jefout et al ,2015)
.Go in line with the result of this study
who reported that dysmenorrhea is
highly prevalent among young adult
Jordan female and seems to negatively
affected quality of life particularly as
related to university attendance &
performance and social relationships.
382
July 2015
V. Conclusion
Based on finding of the present
study, it can be conclude that: These
study
provided
some
important
indications
of
biological
factors
associated with dysmenorrhea it showed
that the risk of dysmenorrhea was
significantly higher in girls in the
secondary schools. The severity of pain
co-related to exposure to passive
smoking, age of menarche, heaviness of
menstrual blood flow, BMI, types of
meals ,skipped meals, alcohol drinkers,
on the other hand the results revealed
that also that, length and regularity of
menstruation
not
demonstrate
significances association with presence
of dysmenorrhea .
VI. Recommendations
Based on the finding of the present
study, the following recommendations
were suggested:
1. Further researches should be
done to explore the relationship
between
dysmenorrhea
&
biological factors on a large
sample
2. Curriculum of secondary schools
should
contain
efficient
knowledge about menstruation:
its nature, cycle disorder
especially dysmenorrhea and
management.
3. Raise awareness of adolescent
girls related to dysmenorrhea.
Acknowledge
Researchers would like to thank all the
staff in the secondary and all students
who participated in this study.
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