RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES



RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

Ms. RENCY VARGHESE

I year M.Sc Nursing

Child Health Nursing

Year 2008-2009

PADMASHREE INSTITUTE OF NURSING

NAGARBHAVI,

BANGALORE-560 072.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES.

BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

|1. |NAME OF THE CANDIDATE AND ADDRESS |Ms. RENCY VARGHESE |

| | |I Year M.Sc Nursing, |

| | |Padmashree Institute of Nursing, |

| | |Nagarbhavi, |

| | |Bangalore-560 072. |

|2. |NAME OF THE INSTITUTION |Padmashree Institute of Nursing, |

| | |Bangalore. |

|3. |COUSE OF THE STUDY AND SUBJECT |I year M.Sc Nursing, |

| | |Child Health Nursing. |

|4. |DATE OF ADMISSION TO THE COURSE | |

| | |30- 6- 2008. |

|5. |TITLE OF THE STUDY | Assessment of effectiveness of Self Instructional Module on |

| | |knowledge regarding Pediatric Advanced Life Support among staff |

| | |nurses. |

| | | |

| | | |

| | | |

6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION  

The development of the Pediatric Advanced Life Support (PALS) course was done by the American Heart Association (AHA) which led to the incorporation of a more structured resuscitation curriculum into most North American pediatric programs. The stated purpose of this course is to aid the pediatric healthcare provider in developing the knowledge and skills necessary to efficiently and effectively manage critically ill infants and children, and it certainly is not targeted at physicians in particular. However, the comprehensiveness of the content and the highly organized structure of its delivery make the course an ideal format for fulfilling the objectives of teaching resuscitation-related content within the program of pediatric nurses. The widespread use of the PALS course for this purpose has in turn led pediatric nurses program to presume that the nurses are now adequately trained in the management of pediatric cardiopulmonary arrests.1

Pediatric Advanced Life Support refers to the assessment and support of pulmonary and circulatory function in the period before an arrest and during and after an arrest. Consistent with the Chain of Survival PALS should focus on prevention of the causes of arrest (Sudden Infant Death Syndrome, injury, and choking) and on early detection and rapid treatment of cardiopulmonary compromise and arrest in the critically ill or injured child. The components of PALS are similar in many respects to those of adult Advanced Cardiac Life Support {ACLS} and include

• Basic life support.

• Use of adjunctive equipment and special techniques to establish and maintain effective oxygenation, ventilation and perfusion.

• Establishment and maintenance of vascular access.

• Identification and treatment of reversible causes of cardiopulmonary arrest .

• Treatment of patients with trauma, shock, respiratory failure, or other prearrest conditions.2

Pediatric cardiac arrest frequently represents the terminal event of progressive shock or respiratory failure. Causes of pediatric cardiac arrest are heterogeneous, including Sudden Infant Death Syndrome (SIDS), submersion/near-drowning, trauma, and sepsis. The progression from shock or respiratory failure to cardiac arrest associated with each of these causes may vary, making research or outcome reporting difficult, since there is not a "typical" type of cardiac arrest.

In contrast to cardiac arrest in adults, cardiopulmonary arrest in infants and children is rarely a sudden event and does not often result from a primary cardiac cause. In adults, cardiopulmonary arrest is usually sudden and is primarily cardiac in origin; approximately 250 000 adults die annually of sudden cardiac arrest in the United States alone. Consequently, much of the research and training in adult cardiac resuscitation focuses on the identification and treatment of Ventricular Fibrillation in the out-of-hospital setting, since this rhythm is the most amenable to effective therapy.3

The etiologies of respiratory failure, shock, cardiopulmonary arrest and dysrhythmias in children differ from those in adults. In 1988, the American Heart Association implemented the Pediatric Advanced Life Support program. Major revisions to the program were made in 1994, with further revisions in 1997. The Pediatric Advanced Life Support

program teaches a systematic, organized approach for the evaluation and management of acutely ill or injured children. Early identification and treatment of respiratory failure and shock in children improve survival, from a dismal 10 percent to an encouraging 85 percent. Family physicians that care for acutely ill or injured children have a tremendous opportunity to save lives through implementation of the PALS information.

In 1983, the American Heart Association recommended the development of a course in Pediatric Advanced Life Support as a means of fulfilling the need for resuscitation guidelines and training specifically for children. The first edition of the Pediatric Advanced Life Support manual was published in 1988, and the first Pediatric Advanced Life Support courses began that year. The Pediatric Advanced Life Support program underwent major revisions in 1994 following recommendations from the 1992 National Conference on Cardiopulmonary Resuscitation and Emergency Cardiac Care. The most recent revisions in the Pediatric Advanced Life Support provider and instructor manuals were completed in 1997.4

The completely redesigned American Heart Association Pediatric Advanced Life Support course is based on new science evidence from the 2005 AHA Guidelines for CPR and a new teaching methodology. The goal of the Pediatric Advanced Life Support course is to aid the pediatric healthcare provider in developing the knowledge and skills necessary to efficiently and effectively manage critically ill infants and children, resulting in improved outcomes. Skills taught include recognition and treatment of infants and children at risk for cardiopulmonary arrest; the systematic approach to pediatric assessment; effective respiratory management; defibrillation; intraosseous access and fluid bolus administration; and effective resuscitation team dynamics.5

 

Pediatrics is an important and continually growing area in the specialized world of medicine today. The course will provide up-to-date and essential knowledge necessary for the assessment, treatment, and resuscitation of the pediatric patient.

6.2 NEED OF THE STUDY

In children, cardiac arrest is mostly the terminal event of progressive shock or respiratory failure. Primary cardiac arrest is less common in infants and children than adults but may occasionally in conditions like SIDS {Sudden Infant Death Syndrome}, drowning trauma and sepsis.

Basic life support is CPR {cardiopulmonary resuscitation} protocol mandatory in cases of cardiopulmonary arrest, till advanced life support is instituted. Two major objective of CPR are to:

{i} preserve organ viability during cardiac arrest; and

{ii} help return of spontaneous circulation {ROSC}

The ideal care of critically ill infant or child should demonstrate a seamless service starting with recognition of potential critical illness and initiation of early resuscitative interventions, escalating to advanced life support and skilled transfer to an appropriate location where an intensive care can be continued.6

To improve the preparedness of health care providers in pediatric resuscitation and to evaluate the effectiveness of the Pediatric Advanced Life Support course, Department of pediatrics in Taiwan followed the standard guidelines of American Heart Association to conduct the first 10-hour course of Pediatric Advanced Life Support course in our hospital and designed this study. The participants with less background knowledge had better increment scores after this course. The mean posttest scores in those working in private clinics and having 20 years of working experience are 74.0 and 72.0. They concluded that this provider course did increase the knowledge and skill pertaining to pediatric resuscitation personnel, particularly in participants with less background knowledge. The participants from private clinics or with working experience more than 20 years need a repeatedly educational PALS training course.7

The goal of the Pediatric Advanced Life Support Course is to provide the learner with:

1. Information needed to recognize infants and children at risk for cardiopulmonary arrest.

2. Information and strategies needed to prevent cardiopulmonary arrest in infants and children.

3. The cognitive and psychomotor skills needed to resuscitate and stabilize infants and children with respiratory failure, shock or cardiopulmonary arrest.6

Pediatric critical care has an important role to play in improving the child survival. The aim is to provide titrated care of each organ system dysfunction to reestablish normal physiology and to prevent multiple organ dysfunctions. Once a sick child is identified and assessed completely, appropriate investigations and interventions are performed. Child is periodically reexamined to assess the impact of intervention and also to identify any fresh problem.

The Pediatric team should consist of dedicated physician and nurses trained and well versed with the Pediatric Advanced and Basic Life Support. In order to improve the survival of ill child, it is mandatory to recognize a sick child at the earliest. Nurses are the first person to identify a critically sick child by observation, history taking and physical examination. So, nurses need the knowledge of Pediatric Advanced Life Support when caring for young lives.

6.3 STATEMENT OF THE PROBLEM

A study to assess the effectiveness of Self Instructional Module on knowledge regarding Pediatric Advanced Life Support among staff nurses working in pediatric wards in selected hospitals, Bangalore.

6.4 OBJECTIVES OF THE STUDY

1. To assess the pretest knowledge regarding Pediatric Advanced Life Support among staff nurses working in pediatric wards.

2. To assess the post test knowledge regarding Pediatric Advanced Life Support among staff nurses working in pediatric wards.

3. To assess the effectiveness of Self Instructional Module on knowledge regarding Pediatric Advanced Life Support among staff nurses.

4. To associate post test knowledge regarding Pediatric Advanced Life Support with their selected demographic variables.

6.5 OPERATIONAL DEFINITION

1. Effectiveness:

It refers to the extent to which Self Instructional Module on Pediatric Advanced Life Support may increase the knowledge of staff nurses.

2. Knowledge:

It refers to level of understanding regarding Pediatric Advanced Life Support among staff nurses.

3. Self Instructional Module:

In this study, it refers to an independent learning material that enhances the knowledge of staff nurses regarding Pediatric Advanced Life Support.

4. Pediatric advanced life support:

An educational course for advanced health care providers. It includes recognition and treatment of infants and children requiring basic life support and defibrillation.

6.6 ASSUMPTIONS

1. Self Instructional Module may improve the knowledge of staff nurses

regarding Pediatric Advanced Life Support.

2. Staff nurses knowledge regarding Pediatric Advanced Life Support may vary with their selected demographic variables.

6.7 RESEARCH HYPOTHESIS

H1- There is a significant difference between the mean pretest and post test knowledge regarding Pediatric Advanced Life Support among staff nurses receiving Self Instructional Module.

H2- There is a significant association between post test knowledge regarding Pediatric Advanced Life Support among staff nurses with their selected demographic variables.

6.8 REVIEW OF LITERATURE

Review of literature is defined as broad, comprehensive in depth systematic and critical review of scholarly publication, unpublished scholarly print materials, audiovisual materials and personal communications. Review of literature is a key step in research process. Review of literature refers to an extensive, exhaustive and systemic examination of publication relevant to research project. One of the most satisfying aspects of the literature review is the contribution it makes to the new knowledge, insight, and general scholarship of the researchers.8

A study was done regarding A forgotten need: Pediatric Resuscitation Training. This is a thoroughly inadequate situation as the relatively infrequent occurrence and different etiology of pediatric arrests necessitates specific training, based on standard guidelines, and adapted to meet the needs of the various groups who have contact with children. In addition to Basic Life Support, healthcare personnel need to be trained in appropriate use of airway adjuncts. Pediatric Advanced Life Support (PALS) is also essential for all medical, nursing and paramedical staff that comes into contact with acutely-ill children. Adapted from the American PALS course, it aims to provide appropriate personnel with a systematic, research-based approach to acutely-ill children in emergency situations.9

A study was done regarding simulation in resuscitation training: The quality of education. Increasing concerns about patient safety have focused attention on the methods used to train and prepare doctors for clinical practice. Reductions in clinical exposure at both undergraduate and postgraduate level have been implicated in junior doctor’s inability to recognize and manage critically ill patients. Simulation is used as a central training tool in contemporary advanced life support teaching. Simulation provides a learning opportunity for controlled clinical practice without putting patients or others at risk.10

A study was done regarding Does resuscitation training affect outcome from cardiac arrest? It is established that Basic Life Support (BLS) is performed inadequately by both nursing and medical staff and that the ability to retain these skills, once trained, is low. In addition, the initial success rate from cardiopulmonary arrest is poor. By implementing the Advanced Life Support (ALS) course and providing frequent updates on resuscitation skills and management, it is expected that cardiac arrest outcome results should improve. Initial success was defined as return of spontaneous circulation (ROSC). This was achieved in 75.0% of all resuscitation attempts. These results suggest that BLS and ALS training may only have an impact on initial survival from cardiac arrest.11

A study was done regarding curricula in pediatric resuscitation must be based on adult learning principles. The Pediatric Basic and Advanced Life Support Courses (PBLS, PALS) should use educational strategies fostering positive interactions between the instructor and learners and should take into consideration the learner's motivation for taking the course. Pediatric Basic Life Support is targeted toward caretakers of children. All aspects of the Pediatric Basic Life Support and Pediatric Advanced Life Support educational programs must be evaluated continually to determine whether learning objectives have been met and whether the teaching format is appropriate. 12

A study was done to review the resuscitation training of senior and middle grade pediatricians. And concluded that most pediatricians have attended an Advanced Life Support courses at some point during their training. Consultants are poor at maintaining/recertifying their advanced resuscitation skills. Few pediatric consultants and residents instruct on Advanced Life Support courses.13

A study was done regarding Improving emergency medical services for children with special health care needs. This study evaluated the impact of a paramedic training program on emergency medical services (EMS) responses for children with special health care needs. There was significantly more advanced life support[pic] treatment for responses with paramedics completing the training program compared with other responses. This finding suggests that existing EMS protocols may play a more important role in emergency treatment and transport of children with special health care needs than specialized training of already certified paramedics.14

A prospective study on Videoconferencing technology which may be useful for providing [pic]Pediatric Advanced Life Support[pic](PALS) re-training to geographically isolated providers. This study assess whether Pediatric Advanced Life Support re-training provided via [pic]live,[pic] interactive videoconferencing was as effective as the same instruction provided in a face-to-face format on Pediatric Advanced Life Support knowledge, psychomotor skills, and confidence in performing resuscitation skills. No significant differences were detected among delivery methods for knowledge, psychomotor skill performance, or confidence at the conclusion of the course. 15

A study was done regarding Resuscitation of the newly born infant. The basic principles are (i) A minority (fewer than 10%) of newly born infants require active resuscitative interventions to establish a vigorous cry and regular respirations, maintain a heart rate greater than 100 beats per minute, and maintain good color and tone. (ii) When meconium is present in the amniotic fluid, it should be suctioned from the hypopharynx on delivery of the head. (ii) Attention to ventilation should be of primary concern.(iv) Chest compressions should be provided if the heart rate is absent or remains less than 60 bpm. Chest compressions should be coordinated with ventilations at a ratio of 3:1 and a rate of 120 ‘events’ per minute to achieve approximately 90 compressions and 30 rescue breaths per minute. (v) Epinephrine should be administered intravenously or intratracheally if the heart rate remains less than 60 bpm despite 30 bpm of effective assisted ventilation and chest compression circulation. 16

A study was done regarding The European Resuscitation Council's Pediatric Life Support[pic] Course “Advanced Pediatric Life Support”.

The poor outcome for resuscitation from cardiopulmonary arrest in childhood is widely recognised. The European Resuscitation Council has adopted the [pic]Advanced Paediatric Life Support[pic] course for providing care for children. This paper outlines the course content and explains its remit, which is to reduce avoidable deaths in childhood by not only resuscitation from cardiac arrest but, more effectively, by recognising and treating in a timely and effective fashion [pic]life[pic]-threatening illness and injury in infants and children.17

A study was done regarding Retention of Pediatric Advanced Life Support[pic] (PALS) course concepts to measure, in a population of experienced state-certified paramedics, the decline of [pic]Pediatric Advanced Life Support[pic] (PALS) course concepts during the 2-year recertification cycle recommended by the American Heart Association. Results revealed that 25 (25%) of the 99 providers achieved a minimum passing score of 84% or greater on the PALS retest. Another 40 (40%) scored within one standard deviation below the minimum passing score. Retest score was unaffected by years of Advanced Life Support experience, number of [pic]pediatric[pic] patients seen per month, or by Pediatric Advanced Life Support Instructor status.18

7. MATERIALS AND METHODS

7.1 SOURCES OF DATA

Staff nurses working in pediatric wards in selected hospitals.

7.2 METHODS OF DATA COLLECTION

i Research Design

Quasi Experimental - one group pretest post test design.

ii. Variables

Dependent variable- level of knowledge regarding Pediatric Advanced Life Support among staff nurses.

Independent variable- Self Instructional Module administered to staff nurses regarding Pediatric Advanced Life Support.

iii. Setting

Pediatric wards in selected hospitals, Bangalore.

iv. Population

All staff nurses working in pediatric wards.

v. Sample

Staff nurses working in pediatric wards who fulfill the inclusive criteria will be considered as the samples. The sample size will be 60.

vi. Criteria for sample selection

Inclusive Criteria: The study includes

1. Male and female staff nurses working in pediatric wards.

2. Staff nurses who are willing to participate in the study.

Exclusive Criteria: The study excludes

1. Staff nurses who are not available at the time of data collection.

vii Sampling technique

Non probability convenience sampling technique.

viii. Tool for data collection

Tool consists of two sections:

Section A: Demographic Profile of staff nurses including on age, gender, religion, marital status, education, monthly income, year of experience, attended in-service education on pediatric advanced life support.

Section B: Structured questionnaire regarding Pediatric Advanced Life Support.

ix. Method of data collection

After getting formal administrative approval from concerning authorities and informed consent from the samples the investigator personally collects the data. After which data will be collected in following three phases:

Phase I:  Assess the existing knowledge regarding Pediatric Advanced Life Support among staff nurses working in pediatric wards with the help of structured questionnaire.

 

Phase II: The investigator will administer Self Instructional Module regarding Pediatric Advanced Life Support to staff nurses.

 

Phase III: After a period of one week post test level of knowledge regarding Pediatric Advanced Life Support will be assessed using same questionnaire.

Duration of data collection is four to six weeks.

x. Plan for data analysis

The data will be analyzed by using descriptive and inferential statistics.19

In descriptive statistics- frequency, percentage distribution, mean and standard deviation will be used to analyse the level of knowledge regarding Pediatric Advanced Life Support among staff nurses.

In inferential statistics- Paired T- test will be used to analyse the difference between mean pre-test and post-test knowledge regarding Pediatric Advanced Life Support among staff nurses. ‘Chi-square’ will be used to analyse the association between pre-test and post-test level of knowledge regarding Pediatric Advanced Life Support among staff nurses with their selected demographic variables.20

xi. Projected outcome

The result of the study will enable investigator to know the level of knowledge regarding Pediatric Advanced Life Support. This will help the staff nurses to improve knowledge regarding Pediatric Advanced Life Support and enable them to practice effectively and efficiently in providing care to children and have an improved outcome.

7.3 Does the study require any investigator or interventions to the patients or human beings or animals?

Yes, Self Instructional Module will be administered as intervention for staff nurses.

7.4 Has ethical clearance obtained from your institution?

Yes, permission will be obtained from the concerned authorities and informed consent from the samples. Confidentiality and privacy of data will be maintained.

8. LIST OF REFERENCES

1. Pediatric Advanced Life Support. Available from URL:.

2. Advanced Cardiac Life Support. Available from URL:.

3. Circulation. Available from URL:.

4. Pediatric Advanced Life Support: A Review of AHA Recommendation. Available from URL:.

5. Pediatric Advanced Life Support Course. Available from URL:.

6. O.P.Ghai, Piyush Gupta, V.K.Paul. Essential Pediatrics: Pediatric Advanced Life Support. Delhi: Meenakshi Art Printers; 2004. P. 655

7. Preparedness of health care workers. Available from URL:.

8. B T Basvanthappa. Nursing research: Review of Literature. New Delhi: Jaypee brothers; 2003. P.48

9. S.M.Simpson. A forgotten need: pediatric resuscitation training. Accident and Emergency Nursing. 1994/October;Volume2{4}:224-230

10. Gavin D. Perkins. Simulation in resuscitation training: The quality of education. Resuscitation. 2007/ May;Volume 73{2}: 202-211

11. A. Pottle, S. Brant. Does resuscitation training effect the outcome from cardiac arrest. Coronary Health Care. 1999/May;Volume3{2}:76-80

12. James S Seidel, Deborah Parkman Henderson, Patricia E Spencer. Curricula in pediatric resuscitation must be based on adult learning principles. Annals of Emergency Medicine. 1993/ February;Volume 22{2} Part 2: 489-494

13. A. R. Magnay. Resuscitation training of senior and middle grade pediatricians. Paediatric Respiratory Reviews. June 2001/June;Volume 2{2}:184-194

14. Daniel W. Spaite, Carol Conroy, Katherine J. Karriker, Marsha Seng Norma Battaglia. Improving Emergency Medical Services for Children with special health care needs. The American Journal of Emergency Medicine. 2001/October;

Volume 19{6}: 474-478

15. Douglas L. Weeks, Dianne M. Molsberry. Videoconferencing technology. Resuscitation. 2008/October;Volume 1{1}:109- 117

16. John Kattwinkel, Susan Niermeyer, Vinay Nadkarni, James Tibballs, Barbara Phillips etal. Resuscitation of newly borne infant. Resuscitation. 1999/March;Volume40{2}:71-88

17. Barbara M. Phillips, Kevin Mackway-Jones Fiona Jewkes. The European Resuscitation Council’s Pediatric Advanced Life Support Course. Resuscitation. 2000/December;Volume 47{3}: 329-334

18. R. Wayne Wolfram, Cecilia M. Warren, Cindy R. Doyle, Robert Kerns, Steven Frye. Retention of pediatric advanced life support course concept. Journal of Emergency Medicine. 2003/ November; Volume 25{4}:475-47

19.Denis.F.Polit, Chery Tanto Beck. Nursing Research:Review of Literature. New Delhi: Wolter’s Kluwer.2008.P.134-137

20. Barbara Hazard Munro. Statistical methods for health care research: inferential statistics.philadelphia: Lippincott;3rd edition.1997.P.73

9. Signature of the Candidate :

10. Remarks of the guide :

11.1 Name and Designation of the Guide:

11.2 Signature :

11.3 Co-guide :

11.4 Signature :

11.5 Head of the Department :

11.6 Signature :

12.1 Remarks of the Principal :

12.2 Signature :

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