Impact of in-Service Training Program for Nurses on Nursing Management for Children with Pneumonia under Mechanical Ventilation at Ahmad Gasim Hospital, Khartoum, Sudan 2013
Eiman Ahmed Saad Mohamed1, *, Hanan Mabrouk Ramadan2
1Pediatric Nursing Faculty of Nursing Sciences Sudan International University Khartoum, Sudan
2Pediatric Nursing Aljazeera University, Madani, Sudan
Pneumonia is common disease in paediatrics mainly in infancy and early child hood. Mechanical ventilation is one of the major supportive modalities of treatment in the intensive care unit but it carries a lot of risks and complications. My research aims training of nurses in hospital to give proper immediate care and proper use of mechanical ventilation to prevent complication. Respiratory infections account to majority of acute illnesses in children, cause and course of these infections are influenced by age of child, season, living condition and pre-existing medical problem. This is aqusi experimental study aiming to assess the impact of in-service training program for nurses on nursing management for children with pneumonia under mechanical ventilation at Ahmed Gasem hospital .Khartoum State. The sample (50) nurses available during the research period . extended from December 2013 to July 2014 (pre and post training program). The data collected by using a questionnaire and a observational checklist for the purpose of the study was collected by the researcher before and after the training program .The educational program is designed to study. The data were analyzed using the Statistical package for social sciences (SPSS) and the results showed that the nurses were acquired knowledge after intervention specially participant’s knowledge and practical regarding mechanical ventilation according their correct and wrong (88% ,79%and 90%). The result showed that the nurse practical skills improved after program The Relation between total knowledge and level of practice as (46%) for good (34%) fair (20%) poor. (75-100 good, 50-74 fair, less than 50 poor) The study recommended education and training programs on an ongoing basis to provide high quality nursing care and also circulating a protocol for how to handle a patient with pneumonia disease under mechanical ventilation. The study concluded that the nurses information about pneumonia in children has improved and mechanical ventilation have evolved dramatically among nurses.
Impact, in-Service Training, Program, Nurses, Children, Pneumonia, Mechanical Ventilation
Received: June 14, 2015
Accepted: July 18, 2015
Published online: July 28, 2015
@ 2015 The Authors. Published by American Institute of Science. This Open Access article is under the CC BY-NC license. http://creativecommons.org/licenses/by-nc/4.0/
A mechanical ventilator is a machine that makes it easier for patients to breathe until they are able to breathe completely on their own. Sometimes the machine is called just a ventilator, respirator or breathing machine. Usually, a patient is connected to the ventilator through a tube (called an end tracheal tube) that is placed in the windpipe. Sometimes, patients can use a machine that assists breathing through a mask or mouthpiece but this may not work with severe respiratory problems. Despite their life-saving benefits, mechanical ventilators carry many risks. Therefore, the goal is to help patients recover as quickly as possible to get them off the ventilator at the earliest possible time. (Robert L chatpun, 2003)
Respiratory infections account majority of acute illnesses in children, cause and course of these infections are influenced by age of child, season, living condition and preexisting medical problem ( MSN,Terri, 2008).
Respiratory tract infection is a frequent cause of acute illness in infant and children. Child responses to infection vary based on age of the child, causative organism: general health of child, existence of chronic medical conditions and degree of contact with other children (Nettina Sandra, 2001.)
Pneumonia is an inflammation of lung parenchyma it can be caused by a virus, bacteria mycoplasma or fungus it may also result from aspiration of foreign material into lower respiratory tract (aspiration pneumonia), pneumonia occurs more often in winter and early spring it is common in children but is seen most frequently in infants and young toddlers. Viruses are common cause of pneumonia in younger children and least common cause in older children. Viral pneumonia is usually better tolerated in children of all ages. Children with bacterial pneumonia more present with a toxic appearance but rapid recovery generally occur if appropriate antibiotic is instituted early. Pneumonia is usually a self limited disease. (Davidson Sir Stanley, 2000).
Some patients are not able to ventilate their lungs adequately, because of various disorders resulting in respiratory insufficiency or failure
Immediate interventions include:
Endotracheal tube (ETT).
Mechanical lung ventilator with positive pressure ventilation (PPV).
Mechanical ventilation is one of the major supportive modalities in the intensive care unit but it carries a lot of risks and complications, the most common one being ventilator associated pneumonia which can significantly affect the outcome of critically ill patients. The lungs are usually amongst the major organs involved in multiple organ failure and thus the challenge of delivering appropriate ventilation with as little complications as possible is extremely important .To ensure the highest standards of nursing care, nursing practice must be based on a strong body of scientific knowledge. It is characterized by a new or a progressive pulmonary infiltrate, fever, leukocytosis and purulent tracheobronchial secretions (Munro, Grap, Elswick, et al., 2006).
2.1. General Objectives
To assess the Impact of in service training Program about nursing management for children with pneumonia on mechanical ventilation
At Ahmad gasem Hospital, Khartoum, Sudan 2014
2.2. Specific Objective
1. To assesses nurse's knowledge and care for children with pneumonia on mechanical ventilation in pediatrics unit.
2. To apply in service training program for nurses about dealing with daily living care of mechanically ventilated children with pneumonia.
3. To identify if there is any relation between training as well as years of experience and knowledge of intensive care nurses for prevention of ventilator with pneumonia.
4. To evaluate the impact of in service training program on improving the nurses knowledge and practice in dealing with pneumonia patent under mechanical ventilation
3. Material and Methods
3.1. Research Design
A quasi - experimental design use in conducting of this research .
3.2. Study Area
The study area was Ahmed Gasim hospital at Khartoum bahry, Sudan, which is located north of Khartoum.
3.3. Study Population
The population of this study includes all the nurses (either diploma nurses or B.S.c of nursing graduates regardless of their year of experience) who were caring for children with pneumonia at Ahmad Gasim hospital.
3.4. Sample Size
All the nurses who were caring for children with pneumonia at Ahmed gasem hospital in ICU pediatrics and pediatrics word 50 nurses (total number of nurses).
3.5. Tools of Data Collection
Two tools was used to collect the necessary data to achieve the aim of the study, they were:
1. Structured knowledge Questionnaire
2. Observational Checklist
3.6. Structured Knowledge Questionnaire
A structured interview sheet was developed by the researcher. It was included
3.6.1. Part I
The first part was about socio-demographic characteristics of the studied subjects such as biosocial data including age, sex, educational level,
3.6.2. Part II
The second part was developed to collect data about the nurse’s knowledge about pneumonia such as definition, causes, manifestations, treatment, complications and nursing care. And nurses knowledge about mechanical ventilation definition, How to deal with it and Complication.
3.7. Observational Checklist
An observational checklist was developed by the researcher which was included chick list about: hand washing, gloving, use antiseptic solution, oxygen administration suction, vital sign, intubation and care of patent on mechanical ventilation.
3.8. Pre Intervention Phase
3.8.1. Pilot Study
A pilot study was carrying out before the development of the study and before embarking on the actual study (data collection). It was conducted in order to test applicability of the tools.
3.8.2. Field Work
Before conducting the study, nurses were assured that the data collected from the questionnaire was remained confidentiality and personal identification was not needed by any means. Nurses wear given the option to refuse to participate in the study, and withdraw from it at any time.
3.8.3. Interventional Phase
Each nurse was individually interviewed to assess his/her knowledge about mechanical ventilation and its care and prevention of pneumonia.
An educational program to study group was design by the researcher based on actual assessment of nurse's needs. Different teaching methodology such as lecture, discussion, demonstration, and re demonstration, was used. Different assisting learning methods were used as pamphlets, PowerPoint presentation, show pictures, posters, and real equipments. The intervention was implemented to nurses in small group (8-10 nurses).
A course of five days was offered for each group which included five lectures for two hours .the demonstration used for practical station for 4 hours at afternoon shift Atonal of (50) nurses was trained.
3.9. Post Interventional Phase
The questioner was distributed post of the intervention program for the nurse to assess their knowledge. Each nurse was evaluated by using and observational checklists collected by the researcher.
The researcher was assessed the nurses performance and their competency of application of mechanical ventilation protocols the nurses wear observed on time after three month post intervention data was collected by using questioner and chick list.
3.10. Statistical Design
The collect data in pre test and post test was organize, categorize, tabulate in tables using numbers and percentage, mean percentage and standard deviation. Test was use the statistical package for social sciences (SPSS version) was use for statistical analysis.
3.11. Inclusion and Exclusion Criteria
3.11.1. Inclusion Criteria
1 Certified diploma, bachelor, and master nurses working in pediatric ICU and pediatric word.
2 Collaborators in critical care units and pediatric word nurses who spend more than six month
3.11.2. Exclusion Criteria
• Nurses who refuse
• Nurse who does not finished the study
|Percentage Post tested||Frequency Post tested||Percentage Pre tested||Frequency Pre tested||early nursing evaluation of pneumonia patient|
|10%||5||14%||7||Check O2 saturation|
|Percentage Post tested||Frequency Post tested||Percentage Pre tested||Frequency Pre tested||What are the types of pneumonia according to causative agent?|
|Percentage Post tested||Frequency Post tested||Percentage Pre tested||Frequency Pre tested||nursing management of pneumonia:|
|80%||40||44%||22||All of them|
|Items||pretest Correct answer||Post test correct answer||Posttest Wrong answer|
|1||Route for endotracial intubation||30||60.0%||39||78%||11||22%|
|2||Frequency of ventilator circuit changes||32||64.0%||37||74%||14||28%|
|3||Type of humidifier||26||52.0 %||41||82%||24||48%|
|4||Frequency of humidifiers changes?||29||58.0%||37||74%||21||42%|
|5||Methods of suctioning closed systems?||36||72.0%||36||72%||14||28%|
|6||Frequency of change in suction systems||24||48.0%||32||62%||26||52%|
|7||Endotracheal tubes with extra lumen for drainage of subglottic secretions||31||62.0%||39||78%||11||22%|
|Statement||Pretest YES||Pretest no||posttest Yes||Posttest No|
|a||Lack of knowledge||29||58.0%||21||42.0 %||45||90%||5||10%|
|b||Unavailability of material and cost constraints||31||62.0%||19||38.0%||37||74%||19||28%|
|c||Unforeseen in departmental protocol||26||52.0%||24||48.0%||36||72%||24||48%|
|d||Shortage of staff||25||50%||25||50 %||29||58%||21||42%|
|e||Training of staff members||37||74.0%||13||26.0%||39||78%||11||22%|
|Total knowledge Training course in ICU||Good||Fair||Poor||Total|
P value = 0.064
|1||1. Identifies the indications for mechanical ventilation||37||74.0%||13||26%|
|2||a. Lists the steps in preparing for intubation: a. Notifies physician and respiratory therapist. b Assembles the necessary equipment||44||88.0%||6||12.0 %|
|3||a. Determines the patient’s ventilator settings on a given ventilator and verifies against the physician’s orders: a. FIO2, tidal volume, rate, and mode. b. Identifies additional settings according to patient orders.||26||52.0%||24||48.0%|
|4||Describes the various modes of ventilation and their implication||29||58.0%||21||42.0%|
|5||Describes at least two complications associated with patient’s response to mechanical ventilation and their signs and symptoms||45||90.0%||10||10.0%|
|6||Describe the causes of given ventilator alarms and nursing measures taken to trouble shoot given alarm||22||44.0%||28||56.0%|
|7||Describe some preventative measures taken aimed at prevention of ventilator- associated complications.||33||66.0%||17||24.0%|
|8||Given a nursing intervention in the care plan of the ventilated patient, be able to explain the rationale.||30||60.0%||20||40.0%|
|9||Verbalizes the standards of care according to care plan and documents pertinent information including the following: type of airway, position and size; type of ventilator and settings; breath sounds and pulmonary assessment; interprets ABG results; weaning attempts and patient tolerance.||38||76.0%||12||24.0%|
|10||Verbalizes ventilator standards IAW Infection Control Manual Guidelines and Respiratory Therapy in Intensive Care Units SOP.||27||54.0%||23||46.0%|
|11||Emergency equipment available in patient room: ambubag, mask, appropriate size suction catheter and no outdated equipment.||27||54.0%||23||46.0%|
P value= 0.003 t=0.5
|2||Using gloves||42||84.0%||8||16.0 %|
|3||Semi setting position||46||92.0%||4||8.0%|
P value= 0.007, t= 0.6
|Level of practice Years of experience||Good||Fair||Poor||Total|
P value = 0 .041 t = 0.2
|Level of practice Training course in ICU pediatrics||Good||Fair||Poor||Total|
P value =0.085 t= 0.8
"An ounce of prevention is worth a pound of cure"
(Nancy M. Valentine)
Mechanical ventilation is a process by which gases are moved into and out of the lungs by means of a ventilator, a machine that delivers a flow of gas to a patient’s airway. The indications for mechanical ventilation include respiratory arrest, acute lung injury, critical illness and respiratory support following surgery.(Withers J. 2009)
A critically ill patient presents a major challenge and consequent reward to nursing. The nurse should provide essential individualized care directed towards the survival of the patient. Each individual nurse is accountable to take appropriate measures to save the life of the patient under her care. The number of patients on mechanical ventilator is rapidly increasing. These patients may be conscious or unconscious. The nursing staffs have to assist or perform the various activities of living until the patient fully regains consciousness.(Joseph C, Vijayakumar C, Augustine J, Dr. John G 2004)
A quasi-experimental design was used in the conduction of this study in Ahmed gasem hospital (50) nurses wear included in this study in the period extending from December 2013 to July 2014. It involved total coverage from pediatric ICU and pediatric word.
According to nurses knowledge among pneumonia the pre test result showed nurse had in adequate knowledge .but post evaluation revealed high level of knowledge among nurses toward children with pneumonia.
Regarding nursing management of pneumonia (92%) of nurses answer correctly pneumonia management post test. The main findings of this study showed that: (26.0%) was poor, (30%) fair, (44%) was good knowledge’s of participants’. Regarding mechanical ventilation in pediatric pneumonia. The fair knowledge and practice of nurses will reflect the patient care and affect morbidity and mortality.
Related to participants, availability of resources, training of staff members, staff motivation and compliance, team work, updated protocols and more nursing staff would contribute in the implementing the proper and scientific nursing care for mechanical ventilation . Unavailability of resources as well as cost represents a barrier to the implementation of proper and scientific nursing care for patent under mechanical ventilation the above findings have implications for patient safety and quality of care as well as on nursing education and training of ICU nurses. The majority of nurses' pre and post test reported training of staff member is very important (78%) (90%).
The results strongly disagree with Response rate was 61%. In most units, nurse managers reported that physicians and nurses usually collaborated in making decisions about initializing (63%) and adjusting (94%) ventilator settings and for determining weaning readiness (88%), weaning method (59%), extubation readiness (82%), and weaning failure (100%). Protocols for mechanical ventilation were available in 35% of units, some specific to weaning (18%) and others for noninvasive ventilation (35%). Automated closed loop systems were used in 18% of units. Competency training was required before nurses could adjust ventilator settings in 35% of responding units; in the remaining units, settings were adjusted by nurses who had no specific competency training(Bronagh Blackwood, Carol Junk , Jeremy David Morrell Lyons, Danny F. McAuley and lourise Rose2008)
Nurses’ knowledge levels for prevention complication of mechanical ventilation for pneumonia patient. Oral vs. nasal route for endotracheal intubation According to the evidence based guidelines (EBG’s) for applying mechanical ventilator the oral route is the recommended one
Amongst all participants, 30 (6.0%) answered correctly and 20 (40.0%) answered incorrectly, showing that nurses know that the oral route is preferred for endotracheal intubation.
According to Frequency of ventilator circuit changes, Types of humidifier, Frequency of humidifiers changes, open closed suction systems, Frequency of change in suction systems, Endotracheal tubes with extra lumen for drainage of subglottic secretions
And Patient positioning According to EBG’s on mechanical ventilation the majority of nurses answered correctly after intervention 32 (64.0%), 26 (52.0%), 36 (72.0%), 30 (60.0%), 30 (60.0%)
These results are agreed with. (No association between knowledge and years of working experience (p- value 0.34), ICU training (p- value 0.64) and level of education (p- value 0.55). ICU nurses’ practice on prevention of VAP was statistically associated with education level (p- value 0.03) but not associated with ICU training (p- value 0.53) and years of work experience (p- value 0.64). On observation large (By Ally Tatu Said 2012)
According to the evidence based guidelines (EBG’s) for applying mechanical ventilator the oral route is the recommended one Amongst all participants, 30 (60.0%) answered correctly and 20 (40.0%) answered incorrectly, showing that nurses know that the oral route is preferred for endotracheal intubation this finding agree with112 qualified nurses, working in eleven different ICUs were asked to complete an anonymous questionnaire regarding endotracheal / tracheostomy tube cuffs. Results were summarized using frequencies, percentages or means or percentiles as appropriate. More than 90% of all respondents were unaware of the different types of cuffs available. 83% of respondents were felt that they were responsible for their patients cuff care management. Most respondents indicated that they were unaware of any specific protocol regarding the care of tube cuffs in their units. (Mol D. A, Villiers G. T, Classen A. J2009)
The observational check list’ is designed and the researcher observe the practice of nurses during dealing with daily living care of mechanically ventilated patients, the result showed That: (43. %) fair practice, (32, %) poor practice, and (25.0%) have good practice of participants’ regarding mechanical ventilator with pneumonia patent .the results nearly similar to study on Practice and knowledge of staff nurses regarding care of immobilized patients with a view to develop a protocol was done in Bangalore. 55 staff nurses were selected for the study. An observational checklist was used for assessing the practice and a structured knowledge questionnaire was used to assess the knowledge. The collected data was analyzed by descriptive and inferential statistics. The findings showed that overall practice mean percentage was 62.77% and knowledge score was 53.28%. no significant relationship between knowledge and practice. Majority of the immobilized patients are prone for complications. It can be prevented by comprehensive nursing care. On the basis of study findings the investigator developed a protocol for caring immobilized patients as a guide for the nursing personnel (Manju V.2009)
The main findings of this study showed: that: (26.0%) was poor, (30%) fair, (44%) was good knowledge’s of participants’ regarding mechanical ventilation in pediatric pneumonia, (42.5%) fair practice, (32,50%) poor practice, and (25.0%) have good practice of participants’ regarding applying mechanical ventilation with pneumonia. The fair knowledge and practice of nurses will reflect the patient care and affect morbidity and mortality.
Nurses' knowledge and practice are improved after intervention that is main objective of this study.
ICU trained nurses and experienced are expected to have better knowledge than those who have not undergone pediatric ICU training as they become shift leaders and supervisors of nursing care. The relation between ICU experience and knowledge levels was clinically not significant and therefore this indicates that working for longer periods in ICU does not necessarily Nurses have fair knowledge for mechanical ventilation and in order to implement measures to prevent complication, it is necessary to be aware of such measures. Without this knowledge, nursing practice and patient care are not of high standards. Nurses need knowledge on the topic so as to question measures that are being used in their units and their usefulness in mechanical ventilation.
This study was concluded for ICU trained and non ICU trained nurses working in ICUs of Ahmed Gasem pediatrics Hospital the results showed they did not have adequate knowledge for mechanical ventilation.
After this study nurses ware improvement in knowledge and practice also.
• Ongoing in-service training must be introduced into hospitals and ICUs to improve knowledge on mechanical ventilation, which is cause of a common nosocomial infection in the pediatric intensive care units.
• Orientation of new staff members in ICU’s should include education on strategies for using mechanical ventilation as management for pneumonia
• Put ICU protocols and should be reviewed regularly as updates and new evidence for best practice are constantly emerging and staff should be educated on the updated protocols.
• Further research should be conducting to test knowledge levels of nurses prior to and after educational programmes on evidence based guidelines for mechanical ventilation to assess if nurses gained knowledge after exposure to educational programmed.
• For spatial pediatric hospital must be selecting expertise nurses manly in ICU pediatrics so it serous side and give them chances for external training such as scrap nursing, nursery, neonatology….ect.