RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

|1. |NAME OF THE CANDIDATE AND ADDRESS |Ms. SONIA EVELIN GEORGE |

| | |1st YEAR, M.Sc. NURSING |

| | |BAPUJI COLLEGE OF NURSING, DAVANGERE. |

|2. |NAME OF THE INSTITUTION |BAPUJI COLLEGE OF NURSING,DAVANGERE . |

|3. |COURSE OF STUDY AND SUBJECT |DEGREE OF MASTER OF NURSING |

| | |MEDICAL SURGICAL NURSING |

|4. |DATE OF ADMISSION TO COURSE |12th June 2009 |

|5. |TITLE OF THE TOPIC |“EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE|

| | |REGARDING VENTILATORS AMONG STAFF NURSES OF SELECTED |

| | |HOSPITALS, DAVANGERE ” |

BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

The more serious the illness, the more important it is for you to fight back, mobilizing all your resources – spiritual, emotional, intellectual, physical.1

-Norman Cousins

Florence Nightingale developed the concept of clustering the most acutely ill patients as far back as the 1800s. During the poliomyelitis and tuberculosis pandemics in the middle of the twentieth century, special units were established equipped with technical equipment to manage the airway and ventilate the patient and staffed by specialized care providers.1

Normal respiration begins with the contraction of diaphragm and respiratory muscle to create negative pressure in the chest.2 Some clients are not able to adequately ventilate their lungs because of various disorders resulting in respiratory insufficiency or failure. These clients require immediate intervention including establishment of an artificial airway and mechanical lung ventilation with positive pressure ventilator.3 The particular reason for using a ventilator will vary depending upon the medical condition and status of the patient. Some examples of why a patient may need the support of a ventilator include patients who have had extensive surgery, traumatic injuries (such as brain injuries), or severe lung infection or disease.4

A ventilator is a mechanical device that supplies air to the lungs when natural breathing is impaired.5 The early history of mechanical ventilation begins with various versions of what was eventually called the iron lung, a form of non invasive negative pressure ventilator widely used during the polio epidemics of the 20th century after the introduction of the “Drinker respirator” in 1928, and the subsequent improvements introduced by John Haven Emerson in 1931. In 1952, Roger Manley of the Westminster Hospital, London developed a ventilator which was entirely gas driven, and became most popular model used in Europe.6

A modular concept, meaning that the hospital has one ventilator model throughout the ICU department instead of a fleet with different models and brands for the different user needs, was introduced with SERVO-in 2001.With this modular concept the ICU departments could choose the modes and options, software and hardware needed for a particular patient category.6

6.1 NEED FOR THE STUDY

Caring for patients receiving mechanical ventilation may be new, but its almost certain that we’ll be seeing them more often in the future. The modes of ventilation and assessment parameters will help to meet the special needs of these challenging patients. The ability to deliver quality care to your patients on ventilators will promote efficient use of hospital resources and positive patient outcomes.7

To quantitate and assess an increase in the use of mechanical ventilation, retrospectively analyzed the records of 1,589 patients treated with mechanical ventilation. Between 1974 and 1983, there was a 156% increase in the number of patients treated each year. . Survival was 55.3% for patients with cardiogenic pulmonary edema, 34.1 % for the adult respiratory distress syndrome, 65.7% for chronic obstructive lung disease, 90.5% for asthma, 38.7% for neuromuscular disease, 92.1% for drug overdose, 33.7% for pneumonia, and 19.1 % for cardiopulmonary arrest.8

Some interventions to help clients experiencing respiratory problems are implemented by nurses. Nurses must be skilled clinicians in assessment and in use of various devices used in airway management. A thorough understanding of these devices, their advantages and disadvantages and the requirements for nursing management is imperative in order to provide quality care. Nurses must be knowledgeable about ventilation therapy so that they can perform as well as detect equipment malfunction.3

Mechanical ventilation often functions as a supportive measure for patients during an acute illness. As the numbers of chronically ill and elderly patients who are mechanically ventilated have increased, the average length of time that patients stay ventilator dependent has also increased. Today intubated patients may require ventilator support for weeks or months. These clients on ventilators are highly dependent and need comprehensive holistic care with meticulous attention to detail.They need health care providers who are not only skillfull in managing machines but also understanding and supportive during stressful situations.4

Nowadays, use of continuous mechanical ventilation is an ordinary level of care for clients managed in critical care and on general care units.The client in continuous mechanical ventilation is a challenge to the nurses providing care.Therefore the nurses must be familiar with the equipment, complications and nursing management.2 Studies support that education to staff nurses on ventilators would be helpful in reducing ventilator associated complications and facilitate early recovery.Researcher’s own experience, discussion with experts and the influence of new models of ventilators, made her to realize that there is a need to educate the staff nurses regarding ventilators.

6.2 REVIEW OF LITERATURE

“Literature review is a critical summary of research on a topic of interest often prepared to put a research problem in the context or as the basis for an implementation project”

Polit and Hungler

1) A study was conducted in Sugar Land, Tex (S-YPKS) to examine critical care nurses' knowledge about the use of the ventilator bundle to prevent ventilator-associated pneumonia. Published reports were reviewed for current evidence on the use of the ventilator bundle to prevent ventilator-associated pneumonia, and education sessions were held to present the findings to 61 nurses in coronary care and surgical intensive care units. Changes in the nurses' knowledge were evaluated by using a 10-item test, given both before and after the sessions. Changes in the nurses' practices related to ventilator-associated pneumonia, including elevation of the head of the bed to 30 to 45, were observed in 99 intubated patients. After the education sessions, the nurses performed better on 8 of the 10 items tested . they concluded that Education sessions designed to inform nurses about the ventilator bundle and its use to prevent ventilator-associated pneumonia have a significant effect on participants' knowledge and subsequent clinical practice.9

2) On behalf of the executive board of the Flemish Society for Critical Care Nurses conducted a study to develop a reliable and valid questionnaire for evaluating critical care nurses' knowledge of evidence-based guidelines for preventing ventilator associated pneumonia. Ten nursing-related interventions were identified from a review of evidence-based guidelines for preventing ventilator-associated pneumonia. Selected interventions and multiple-choice questions (1 question per intervention) were subjected to face and content validation. Item difficulty, item discrimination, and the quality of the response alternatives or options for answers (possible responses) were evaluated on the test results of 638 critical care nurses. The quality of the response alternatives led to the detection of widespread misconceptions among critical care nurses. They concluded that the questionnaire is reliable and has face and content validity. Results of surveys with this questionnaire can be used to focus educational programs on preventing ventilator-associated pneumonia.10

3) As part of a needs analysis preceding the development of an e-learning platform on infection prevention, European intensive care unit (ICU) nurses were subjected to a [pic]knowledge[pic] test on evidence-based guidelines for preventing [pic]ventilator[pic]-associated pneumonia (VAP). A validated multiple-choice questionnaire was distributed to 22 European countries between October 2006 and March 2007. We collected 3329 questionnaires (response rate 69.1%). The average score was 45.1%. Fifty-five percent of respondents knew that the oral route is recommended for intubation; 35% knew that [pic]ventilator[pic] circuits should be changed for each new patient; 51% and 57%, respectively, recognised that subglottic drainage and kinetic beds reduce VAP incidence. Most (85%) knew that semi-recumbent positioning prevents VAP. Professional seniority and number of ICU beds were shown to be independently associated with better test scores. Further researches determine whether low scores are related to a lack of [pic]knowledge,[pic] deficiencies in training, differences in what is regarded as good practice, and/or a lack of consistent policy.11

4) A study to characterize the role of Australian critical care nurses in the management of mechanical ventilation. A 3-month, prospective cohort study was performed. All clinical decisions related to mechanical ventilation in a 24-bed, combined medical-surgical adult intensive care unit at the Royal Melbourne Hospital were determined. Of 474 patients admitted during the 81-day study period, 319 (67%) received mechanical ventilation. Death occurred in 12.5% (40/319) of patients. Median durations of mechanical ventilation and intensive care stay were 0.9 and 1.9 days, respectively. A total of 3986 ventilation and weaning decisions were made. Of these, 2538 decisions (64%) were made by nurses alone, 693 (17%) by medical staff, and 755 (19%) by nurses and staff in collaboration. Decisions made exclusively by nurses were less common for patients with predominantly respiratory disease or multiple organ dysfunction than for other patients. They concluded that in this unit, critical care nurses have high levels of responsibility for, and autonomy in, the management of mechanical ventilation and weaning.12

5) A study was conducted to evaluate knowledge of critical care providers (physicians, nurses, and respiratory therapists in the intensive care unit) about evidence-based guidelines for preventing ventilator-associated pneumonia. Ten physicians, 41 nurses, and 18 respiratory therapists working in the intensive care unit of a major tertiary care university hospital center completed an anonymous questionnaire on 9 nonpharmacological guidelines for prevention of ventilator-associated pneumonia. The mean (SD) total scores of physicians, nurses, and respiratory therapists were 80.2% (11.4%), 78.1% (10.6%), and 80.5% (6%), respectively, with no significant differences between them. Furthermore, within each category of health care professionals, the scores of professionals with less than 5 years of intensive care experience did not differ significantly from the scores of professionals with more than 5 years of intensive care experience. They concluded that health care delivery model that includes physicians, nurses, and respiratory therapists in the intensive care unit can result in an adequate level of knowledge on evidence-based nonpharmacological guidelines for the prevention of ventilator-associated pneumonia.13

6) The objective was to educate ICU staff and respiratory therapists (RT) regarding VAP prevention techniques and improve infection prevention practices thereby reducing the risk of developing VAP.An evidence based self study VAP educational module in booklet form with pre and post testing was distributed to ICU nurses, patient care technicians (PCT) and RTs. Head of bed (HOB) and covered Yankauer observations on ventilated patients were begun 1 month prior to distributing the module and continued for 6 months. Prior to the introduction of the module, HOB compliance was 100%. Covered Yankauer compliance was 50% although on the pretest 100% of staff correctly stated the Yankauer should be covered between uses. Six months after completion of module, HOB compliance mean was 98 % (p > .05); covered Yankauer compliance mean was 98 % (p < .05). They concluded that although staff understood the correct infection prevention practices, additional educational interventions were necessary to translate [pic]knowledge[pic] into clinical practice. Educational interventions, feedback of rates and observational data resulted in a significant increase in the compliance of covering the Yankauer and improved infection prevention practices.14

7) Ventilator[pic]-associated pneumonia (VAP) is the most common nosocomial infection in patients on mechanical ventilation and results in increases in mortality, an observational pre and post-intervention study was conducted to assess whether an educational programme focusing on preventive practices for VAP could reduce the incidence was done . Six hundred and seventy-seven adult patients, mechanically ventilated for >48 h were included in the study population. An evidence-based guideline for preventive practices at the bedside was developed and disseminated to the intensive care unit staff. VAP incidence rates before and after implementation of the educational programme were compared. VAP infection rates reduced by 51%, from a mean of 13.2±1.2 in the pre-intervention period to 6.5±1.5/1000 device days in the post-intervention period (mean difference 6.7; 95% CI: 2.9–10.4, P=0.02).They concluded that a multidisciplinary educational programme geared towards intensive care unit staff can successfully reduce the incidence rates of VAP.15

6.3 STATEMENT OF THE PROBLEM

“A study to evaluate the effectiveness of structured teaching programme on knowledge regarding ventilators among staff nurses of selected hospitals, Davangere”.

6.4 OBJECTIVES OF THE STUDY

1. Assess the knowledge of staff nurses regarding ventilator

2. Assess the effectiveness of structured teaching programme on knowledge of staff nurses regarding ventilators.

3. Compare pre and post test scores of knowledge of staff nurses.

4. Determine the association between demographic variables and pre test knowledge score.

6.5 OPERATIONAL DEFINITIONS

EVALUATE

It refers to determine amount of outcome of knowledge among staff nurses by structured teaching programme.

EFFECTIVENESS :

It refers to determining the extent to which the information in the structured teaching programme has achieved the desired effect as expressed by gain in knowledge score.

STRUCTURED TEACHING PROGRAMME :

It refers to systematically planned teaching programme designed to provide informations which is prepared by researcher.

KNOWLEDGE:

It refers to information collected by the researcher from the subjects by administering structured questionnaire.

VENTILATOR :

It is a machine which mechanically assist patients in the exchange of oxygen and carbondioxide.

STAFF NURSE :

A person who has completed a programme of basic nursing education and is qualified and authorized in her country to supply the most responsible service of nursing , nature for the promotion of health , prevention of illness and care of the sick.

6.6 ASSUMPTION

The study assume that

1. Staff nurses may have some knowledge regarding ventilator.

2. Structured teaching programme will be an effective intervention among staff nurses in imparting knowledge on ventilator.

3. Staff nurses level of knowledge is influenced by demographic variables.

6.7 RESEARCH HYPOTHESIS

H1 – The mean post test of subjects exposed to structured teaching programme will be greater than their mean pretest scores as measured by planned knowledge questionnaire at 0.05 level of significance.

H2 - There will be significant association between selected demographic variables and the level of knowledge of staff nurses.

6.8 LIMITATIONS

The study is limited to

• The nurses who are willing to participate in the study.

• The nurses who are present at the time of data collection.

7. MATERIALS AND METHODS OF THE STUDY

7.1 SOURCE OF DATA

Nurses who are available in the hospital at the time of data collection..

1. RESEARCH DESIGN

Pre- experimental research design with one group pretest post test.

2. VARIABLES OF THE STUDY

i. DEPENDENT VARIABLE

Knowledge gained by the staff nurses.

ii. INDEPENDENT VARIABLE

Structured teaching programme on knowledge on ventilator.

3. STUDY SETTINGS

The study will be conducted in Bapuji hospital and S.S Institute of medical science and research centre. Davangere .

4. POPULATION

The population of the present study will be comprised of nurses who are working in Bapuji hospital and S.S Institute of medical science and research centre.

1. THE METHOD OF DATA COLLECTION

Data will be collected by using self administered questionnaire after obtaining prior permission from the hospital.

1. SAMPLING TECHNIQUE

Purposive sampling technique is used to select the sample of

staff nurses.

7.2.2 SAMPLE SIZE

In this study, the sample size will be 50 staff nurses.

3. CRITERIA FOR SELECTION OF THE SAMPLE

INCLUSION CRITERIA

1. Nurses those who are willing to participate in the study.

2. Both male and female staffs are included.

EXCLUSION CRITERIA

1. Nurses who are not responding to questionnaire.

2. Nurses who are not available at the time of data collection.

4. INSTRUMENT

A structured questionnaire will be prepared in such a way it will consists of two parts.

I The demographic data of the staff nurses.

II The knowledge of staff nurses regarding ventilator.

5. METHOD OF DATA ANALYSIS AND PRESENTATION

The data being collected through structured questionnaire will be carefully analysed through the following statistical technique.

I Descriptive statistics

i) Frequency and percentage used to describe demographic characteristics of staff nurses being studied under research.

ii) Mean and standard deviation will be used to assess knowledge of ventilators among staff nurses.

II Inferential statistics

i) Paired ‘t’ test will be used to compare pretest and post test knowledge scores.

ii) Chi square test will be used to find out the association between demographic variables with the level of knowledge of staff nurses about ventilators.

2. DOES THE STUDY REQUIRE ANY INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMAN ANIMALS?

Yes, structured teaching programme will be administered to the staff nurses in increasing their knowledge regarding ventilators.

3. HAS ETHICAL CLEARENCE BEEN OBTAINED FROM YOUR INSTITUTION?

Ethical clearance will be obtained from the institutions ethical committee (IEC).The purposes and details of the study will be explained to the study subject and informed consent will be obtained from them. Assurance will be given to the study subject on the confidentiality of the data collected from them. Permission will be obtained from the hospital for data collection.

8. REFERENCES

1. Lewis SL, Heitkemper MM, Dirksen SR, O’Brien PG, Butcher L: Medical surgical nursing: assessment and management of clinical problems. 7th ed. Missouri, India: Elsevier; 2007. p. 21-35.

2. Black JM, Hawks JH. Medical surgical nursing: clinical management for positive outcomes. 7th ed. Missouri, India: Elsevier; 2005. p. (vol 1).

3. Black JM, Jacobs EM. Luckmann &Sorensen’s medical surgical nursing: a psychosocial approach. 4th ed. Philadelphia: W.B Saunders company; 1993. p. 997-990.

4. Dossey BM, Guzetta CE, Kenner CV. Critical care nursing: Body-mind-spirit. 3rd ed. Philadelphia: JB Lippincott company; 1992. p. 223.

5. .

6. .

7. Bolton PJ, Kline KA.Understanding modes of mechanical ventilation. AJN 1994 Jun; 94(6):36-43.

8. Fedullo AJ, Shayne DS. Mechanical ventilation:Analysis of increasing use and patient survival. J Int care Med [abstract]1983 [cited 1988]; 3(6):315-320.Available from: URL: http//.

9. Tolentino AF, Ruppert SD, Yun S, Shiao PK. Evidenced based practice: Knowledge about the use of ventilator bundle to prevent ventilator associated pneumonia. AJ crit care [abstract]2007 [cited 2007]; 16(1). Available from: URL: http//.

10. Labeau S, Vandijck DM, Claes B, Aken PV, Blot SI. Decisions Made By Critical Care Nurses During Mechanical Ventilation and Weaning in an Australian Intensive Care Unit. J Int care med [abstract]2007 [cited 2007]; 33(8): 1463-1467.Available from: URL: http//content/98r816q76p23m1u7.

11. Labeau S, Vandijck DM, Rello J, Adam S, Rosa A, Welnisch C,et al. Evidence-based guidelines for the prevention of ventilator[pic]-associated pneumonia: results of a [pic]knowledge[pic] test among European intensive care nurses. J hosp Infec [abstract]2008 [cited 2008]; 70(2): 180-185.Available from: URL: http//.

12. Rose l, Nelson S, Johnston L, Presneill JJ, Decisions Made By Critical Care Nurses During Mechanical Ventilation and Weaning in an Australian Intensive Care Unit. AENJ [abstract]2007 [cited 2009]; 12(4): 38-43. Available from: URL: http//.

13. El-Khatib MF, Zeineldine S, Ayoub C, Husari A, Bou-Khalil PK, Clinicians’ Knowledge of Evidence-Based Guidelines for Preventing Ventilator-Associated Pneumonia. AJCC [abstract] 2009 [cited 2009]; 9(6): 412-418. Available from: URL: http//ajcc..

14. Mangles CJ, Recktenwald AJ, Broyles DH, Cranston H, Woeltje KF. Educational Interventions To Reduce Ventilator Associated Pneumonia Impact Behavior Change in a Community Intensive Care Unit. AJ Infec cntrl [abstract]2006 [cited 2006]; 34(5): E80-81.Available from: URL: http//.

15. Salahuddin N, Zafar A, Sukhyani L, Rahim S, Noor MF, Hussain K,et al. Reducing ventilator-associated pneumonia rates through a staff education programme. J hosp Infec [abstract]2004 [cited 2004]; 57(3): 223-227.

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|9. |SIGNATURE OF THE CANDIDATE | | |

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ETHICAL COMMITTEE CLEARANCE

1. TITLE OF THE DISSERTATION: “EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING

VENTILATORS AMONG STAFF NURSES

OF SELECTED HOSPITALS, DAVANGERE”

2. NAME OF THE CANDIDATE: MS. SONIA EVELIN GEORGE,

1st year M.Sc Nursing,

Bapuji College Of Nursing.

3. SUBJECT: MEDICAL SURGICAL NURSING

4. NAME OF THE GUIDE : PROF. S.F. BILLALLI , M.Sc.

Principal and HOD,

Medical surgical Nursing Dept,

Bapuji college of Nursing, Davanagere-4

5. APPROVED/NOT APPROVED:

(If not approved, suggestion)

PROF. S.F.BILLALLI, MRS.LEELAVATHY.R.H

Principal and HOD, Head of the Department of Department of Medical surgical Nursing, Obstetrics and Gynecological Nursing

Bapuji college of Nursing, Bapuji College of Nursing

Davanagere-4 Davanagere-4.

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