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EFFECT OF APPLYING GUIDELINES ON NURSES` PERFORMANCE
REGARDING FLUID AND ELECTROLYTE IMBALANCE IN
Heba Mohamed Ahmed Hassan 1 ; Prof. El-sayed Elmeghawry El-sayed 2 ; Prof. Sahar Yassien Mohammad 3 ; Dr. Dina El Tabey Sobh Sobeh^4
M.Sc., Faculty of Nursing, Port Said University^1 , Professor of Internal Medicine, Faculty of Medicine, Al-Azhar University^2 , Professor of Medical Surgical Nursing, Ain Shams University^3 , Lecturer of Medical Surgical Nursing, Faculty of Nursing, Port Said University^4
ABSTRACT
Background : The accurate monitoring of fluid balance activities is a vital part of patients‟ baseline information, which guides nursing interventions to achieve physiological stability. Inaccurate monitoring of fluid balance especially in critically ill patients can deteriorate patients‟ conditions. Aim: Evaluate the effect of applying guidelines on nurses' performance regarding fluid and electrolyte imbalances in intensive care units. Subjects and method: Design: A quasi- experimental research design was utilized. Setting: Intensive care unit in Damietta General Hospital. Subjects: A convenience sample of 72 nurses working in above mentioned setting. Tools: Two tools were used to collect the needed data; nurses' knowledge Questionnaire and nurses' observation checklist. Results: The majority of nurses had satisfactory knowledge immediately and after guidelines applications comparing to before. Regarding fluid loss, also more than two thirds of nurses had satisfactory knowledge immediately after guidelines applications and follow up comparing to before guidelines application .There were statistically significant relation regarding scores of nurses' practice regarding fluid & electrolyte imbalances monitor and management pre, immediately after and follow up after guidelines applications in area of fluid and electrolyte monitor score, fluid and electrolyte management score and total practice. Conclusion: improve nurses ' knowledge and practice after application of guidelines regarding fluid and electrolyte imbalance. Recommendations: Continues education for nurses are required to have the knowledge and competence to care for patients, which includes understanding the indications for and importance of fluid balance charts and fluid &electrolyte imbalance management. Key Words: Fluid and electrolyte imbalance, Guidelines, Intensive care unit, Nurses ' performance.
INTRODUCTION
Body fluid is primarily water and is essential for proper functioning of the body organs. It contains gases (e.g., carbon dioxide and oxygen) and solid substances, called solutes that dissolve in body fluids. Many solutes are electrolytes substances (e.g., sodium, potassium) that develop an electrical charge when dissolved in water. Other solutes are nonelectrolytes. Nonelectrolytes (e.g., glucose, urea) do not conduct electricity (American Medical Association, 2010).
Body fluid is located in two fluid compartments; the intracellular space (fluid in the cells) and the extracellular space (fluid outside the cells). Approximately two thirds of body fluid are in the intracellular fluid (ICF) compartment and are located primarily in the skeletal muscle mass. The extracellular fluid (ECF) compartment is further divided into the intravascular, interstitial, and Trans- cellular fluid spaces (Bunn, F., & Trivedi, 2012).
Electrolytes in body fluids are active chemicals (cations, which carry positive charges, and anions, which carry negative charges). The major cations in body fluid are sodium, potassium, calcium, magnesium, and hydrogen ions. The major anions are chloride, bicarbonate, phosphate, sulfate, and proteinate ions. These chemicals unite in varying combinations (Alberts, 2014).
Fluid and electrolyte disorders are among the most common clinical problems encountered in the setting of intensive care. Critical disorders such as severe burns, trauma, sepsis, brain damage, and heart failure lead to disturbances in fluid and electrolytes homeostasis. Possible mechanisms include reduced perfusion to the kidney due to hypovolemia or hypotension; activation of hormonal systems such as renin- angiotensin-aldosterone system and vasopressin; and tubular damage caused by ischemic or nephrotoxic kidney damage, including renal insult caused by a myriad of medications used in the intensive care. In addition, inappropriate administration of fluid and electrolyte should be considered in the diagnosis and treatment of fluid and electrolyte disturbance (Lee, 2010).
Fluid and electrolyte imbalance is an important everyday performance in the intensive care unit, it’s an integrate part of everyday care of the patients (Johnson, 2010). Patients are admitted to intensive care units because a physiological crisis threatens one or more bodily systems, and their life. Critically ill patients are at great risk for fluid and certain electrolyte imbalances. Proper fluid therapy and treatment of electrolyte
AIM OF STUDY:
Evaluate the effect of applying guidelines on nurses' performance regarding fluid and electrolyte imbalances in intensive care units.
Research Hypotheses: H1- After fluid and electrolytes imbalance guidelines application, the nurses will have higher knowledge score than pre applying guidelines. H2- The nurses will have higher practice score after application of guidelines compared to pre.
SUBJECTS AND METHOD
Research design: I- Technical design: The technical design includes; setting, subjects and tools for data collection. Design: A quasi- experimental research design was applied in this study. Study Setting: This study has conducted in Intensive Care units in Damietta general hospital at Damietta city. Study sample. Convenient sample of available nurses (72 nurses) working in the previous mentioned clinical setting were included in this study. Tools for data collection: Tool 1: nurses' knowledge Questionnaire: This tool developed by the researcher after reviewing the most recent and relevant literature (McCance & Huether 2010) to assess nurses' knowledge in relation to fluid and electrolyte balance and imbalance. It was consisted of two parts:
Part 1: Demographic Data: Demographic data includes data related to (age, level of education, critical care experience, etc….).
Part 2: Nurses 'Knowledge questions: Nurses’ knowledge assessment to assess nurses' knowledge in relation to fluid and electrolyte balance and imbalance including function of electrolyte, forms of fluids and
electrolyte imbalance and the clinical features of each one, the underlying causes of imbalance and its management, complications and nurse’s responsibilities). It composed of (58) MCQ questions and (1) table matching.
Scoring system: Nurses' knowledge assessment consisted of (59 MCQ questions) and the answer was evaluated using model key answer prepared by the researcher, the score (2) for complete correct answer, the score (1) for incomplete correct answer and the score (0) for incorrect answer. Total knowledge score was (118). Total knowledge was considered as:
- Satisfactory if score ≥ 75 % of the maximum score.
- Unsatisfactory if score < 75% of maximum score.
Tool II: Nurses' observational checklist: Developed by the researcher after reviewing the most recent and relevant literature McCance and Huether (2010), to assess nurses' practice regarding fluid and electrolyte imbalance through the following: 1 - Fluid &electrolytes monitoring: assess nurses' practice in relation to fluid and electrolyte balance and imbalance including the clinical features of each one consisted of (12 items). 1- Fluid &electrolytes imbalance management: Including nurse’s responsibilities for managing of fluid and electrolyte imbalance consisted of (39 items). Scoring system: Practice observational checklist consisted of (51 questions) and the answer was evaluated using model key answer prepared by the researcher, and the score (2) for completely done, the score (1) for partially done and the score (0) for not done. Total practice score was (102). Total practice was considered as: Satisfactory if score ≥ 75 % of the maximum score. Unsatisfactory if score < 75% of maximum score. Proposed guideline: This guideline developed for nurses to enrich them with information and practice related to fluid and electrolyte imbalances in intensive care units. The educational program was presented into lectures in 3 sessions for nurses by using power point, group discussions and giving them booklets after lecture. Every session takes about 45minutes in groups of (5-10) nurses.
3 days per week (Sunday, Monday, Tuesday) during day and night shifts by rotation at all ICU wards of Damietta General Hospital.
The study consisted of seven sessions: The 1 st^ session included interviewing the nurses regarding to collect demographic characteristics, explaining study aims (Time allowed: from 20- 30 minutes for each nurse). The 2 nd^ session included assessment of nurses’ knowledge regarding fluids and electrolyte imbalance. (Time allowed: from 30- 45 minutes). The 3 nd^ session included assessment of nurses’ practice regarding fluids and electrolyte imbalance through participant observation methods. (Time allowed: from 30- 45 minutes). From 4 th^ to 6th^ session (the educational sessions): The guideline was presented in theoretical and practical sessions which aided by using data show and booklets. The theoretical part was conducted through lectures and group discussions where the practical part was conducted through demonstration and re-demonstration. This guideline consisted of 3 sessions including the immediate test. Each session lasted about 45minutes and was followed by feedbacks. These educational sessions were done in groups (5-10) nurses each time. The 7th^ session (posttest): This session included reassessment of nurses' knowledge& practice after applying the guideline and evaluated the impact of it on the studied nurses’ knowledge and practices were implemented by using posttest (three months after pretest) by using the same tools.
II- Administrative Design: An official letter has issued from the Faculty of Nursing, Port-said University to the directors of intensive care units of selected hospitals to obtain their permission to conduct the study. Ethical considerations: All ethical issues have been taken into consideration during all phases of the study. The ethical research considerations in this study will include the following: The research approval has been obtained orally from the nurses before program implementation .The aim and objectives of the study was explained to the participants.
The researcher has ensured that the maintenance of anonymity and confidentiality of participants. Participants has been allowed to choose to participate or not and they have the right to withdrawal from the study at any time without penalty. IV- Statistical Design: The data obtained has organized, categorized, tabulated and analyzed by using SPSS (Statistical Package for Social Sciences), soft- ware program with suitable version, which will be applied to answer the research objectives and hypotheses.
RESULTS:
Table (1): Illustrate that 56.9% of studied nurses were in age group between 20-<30, with mean age of 27.7±6.5, and 43.1% of them had secondary school diploma. In addition to 70.8% received training in critical care. 65.3% of studied nurses displayed no need for training.
Table (2) : Illustrates that, for general knowledge, 80.6% of nurses had satisfactory knowledge immediately after guidelines applications comparing to 6.9% before guidelines application and to 75% follow up after with statistical significant increase (P<0.0001). Regarding hypovolemia , 97.2% of nurses had satisfactory knowledge immediately after guidelines applications and 72% of them follow up comparing to 27.8% before guidelines application with statistical significant increase (P<0.0001). Concerning hypervolemia, 100% of nurses had satisfactory knowledge immediately and follow up after guidelines applications compared to 4% before guidelines application with statistical significant increase (P<0.0001).
Table (3) : Represents that, there were statistically significant difference between satisfactory levels of nurses' knowledge about different serum electrolyte imbalances and management among the studied nurses at different timings of the study except knowledge about Phosphorus. There is significant difference between before and immediately after and between before and follow up.
Table (4): Clarifies that, there were statistically significant differences of scores of nurses' practice regarding fluid & electrolyte imbalances monitor and management pre, immediately after and follow up after guidelines applications in area of Fluid and electrolyte monitor score, Fluid and electrolyte management score and Total practice score with P<0.0001.
Table (2): Satisfactory scores of general nurses' knowledge, hypo and hypervolemia pre, immediately after and follow up after guidelines applications (n=72).
Knowledge Scores (%) Before^
Immediately after Follow up^
Sig 1 (before/ immediately after)
Sig 2 (immediately after/ follow up)
Sig 3 (before/ No. % No. % No. %^ follow up)
General knowledge Unsatisfactory (<75%) 67 93.1^14 19.4^18 25. Satisfactory (≥75%) 5 6.9^58 80.6^54 75. Min-Max 0.0-83.3 50.0-100.0 41.7-100.0 t=13.394 t=2.699 t=11. Mean±SD 47.2±19.8 83.4±14.4 80.2±13.2 P<0.0001* P=0.009* P<0.0001* Hypovolemia Unsatisfactory (<75%) 52 72.2^2 2.8^0 0. Satisfactory (≥75%) 20 27.8^70 97.2^72 100. Min-Max 0.0-91.7 58.3-100.0 41.7-100.0 t=13.487 t=4.768 t=9. Mean±SD 53.7±19.9 87.9±8.4 81.9±12.8 P<0.0001* P<0.0001* P<0.0001* Hypervolemia Unsatisfactory (<75%) 69 95.8^0 0.0^0 0. Satisfactory (≥75%) 3 4.2^72 100.0^72 100. Min-Max 0.0-83.3 75.0-100.0 25.0-91.7 t=24.159 t=6.469 t=14. Mean±SD 35.2±18.6 89.6±6.5 76.6±17.6 (^) P<0.0001 P<0.0001 P<0.0001***
Table (3): Distribution of satisfactory of nurses' knowledge level of different electrolyte imbalances management among the studied nurses at different timings of the study [n=72]
Knowledge Scores (%)
Before Immediat ely after
Follow up (^) (before/Sig 1 immediately after)
Sig 2 (immediately after/ follow up)
Sig 3 (before/ follow up) No % No. % No %
Knowledge about Na and Cl Unsatisfactory (<75%) 72 100.0 41 56.9 57 79. Satisfactory (75%≤) 0 0.0 31 43.1 15 20. Min-Max 0.0-72.2 38.9-100.0 33.3-94.4 t=19.858 t=7.520 t=18. Mean±SD 23.1±14.7 72.8±14.1 65.6±13.3 P<0.0001* P<0.0001* P<0.0001* Knowledge about potassium Unsatisfactory (<75%) 72 100.0 0 0.0 22 30.
Satisfactory (75%≤) 0 0.0 72 100. 0 50 69.
Min-Max 0.0-46.2 76.9-100.0 53.8-96.2 t=50.366 t=9.726 t=42. Mean±SD 12.7±10.9 91.1±6.3 80.7±9.6 P<0.0001* P<0.0001* P<0.0001* Knowledge about Calcium Unsatisfactory (<75%) 72 100.0 13 18.1 48 66. Satisfactory (75%≤) 0 0.0 59 81.9 24 33. Min-Max 0.0-50.0 56.3-100.0 25.0-93.8 t=32.912 t=9.731 t=17. Mean±SD 19.2±11.8 85.8±10.2 65.7±16.3 P<0.0001* P<0.0001* P<0.0001* Knowledge about Magnesium Unsatisfactory (<75%) 72 100.0 22 30.6 45 62. Satisfactory (75%≤) 0 0.0 50 69.4 27 37. Min-Max 0.0-50.0 50.0-91.7 25.0-91.7 t=25.200 t=5.937 t=16. Mean±SD 23.5±13.9 77.2±10.6 66.5±16.0 P<0.0001* P<0.0001* P<0.0001*
*Sig: P-value for paired t- test of significance significant at P<0.
Table (5): Relation between nurses 'total knowledge score and their demographic characteristics at different timings of the study (n=72) Demographic characteristics N
total knowledge score Before program Immediately after Follow up Mean±S D S ignificance Mean±S D S ignificance Mean±S D S ignificance Age (years) Less than 20 7 27.5±4.7 F=0.063 81.6±5.0 F=0.601 72.4±6.0 F=0. 20 - <30 41 26.7±6.2 P=0.939 83.2±3.6 P=0.551 73.1±4.3 P=0. 30 or more 24 26.9±4.8 82.5±45 74.4±6. Educational level Nursing diploma 31 26.5±4.7 F=1.388 82.5±4.1 F=0.796 74.8±5.1 F=1. Nursing institute 16 28.8±6.7 P=0.269 82.2±3.7 P=0.455 72.1±4.7 P=0. Faculty of nursing or higher 25 25.9±5.8^ 83.6±4.2^ 72.7±5. Received training No 21 27.0±5.2 t=0.527 82.7±3.9 t=0.178 73.2±4.9 t=0. Yes 51 26.3±6.5 P=0.600 82.9±4.5 P=0.859 74.1±5.5 P=0. Duration of nursing experience (years) 1 - <5 41 26.8±5.6 F=0.103 83.2±3.7 F=0.472 73.1±4.6 F=0. 5 - <10 16 26.4±6.5 P=0.903 82.5±5.1 P=0.626 73.1±6.5 P=0. 10 - or more 15 27.3±4.7 82.1±3.8 74.9±4. *t: Student t-test F: ANOVA test significant at P<0. Table (6): Relation between nurses' total practice scores and their demographic characteristics at different timings of the study (n=72) Demographic characteristics N
Total practice score Before program Immediately after Follow up Mean±SD Significance Mean±SD Significance Mean±SD Significance Age (years) Less than 20 7 56.1±6.4 F=1.176 61.6±4.7 F=2.171 61.2±4.5 F=1. 20-<30 41 56.4±7.6 P=0.315 62.2±6.9 P=0.122 61.1±6.6 P=0. 30 or more 24 59.2±7.6 65.6±6.9 64.1±6. Educational level Nursing diploma 31 58.4±7.4 F=1.492 65.9±6.8 F=6.832 64.7±6.4 F=6. Nursing institute 16 58.4±7.8 P=0.232 63.8±5.8 P=0.002* 62.5±5.6 P=0.002* Faculty of nursing or higher 25 55.2±7.3^ 59.6±6.1^ (D,F)^ 58.6±5.9^ (D,F) Received training No 21 56.8±7.1 t=0.380 64.9±6.3 t=1.317 63.8±6.1 t=1. Yes 51 57.5±7.7 P=0.705 62.6±6.9 P=0.192 61.4±6.6 P=0. Duration of nursing experience (years) 1-<5 41 56.4±7.6 F=0.753 62.4±6.5 F=0.854 61.6±6.3 F=0. 5-<10 16 57.7±6.6 P=0.473 63.7±8.2 P=0.430 62.1±8.1 P=0. 10- or more 15 59.2±8.2 65.1±6.3 63.4±5. **t: Student t-test F: ANOVA test significant at P<0. (D, F) : Significant difference between nurses with diploma and faculty graduates using Bonferroni Post Hoc test
Table (7): Correlation between total knowledge and practice scores among the studied nurses at different timings of the study (n=72)
Knowledge scores
Nurses' Total practice Before program Immediately after Follow up r P r P r P General knowledge 0.152 0.202 -0.139 0.245 -0.099 0. Fluid loss 0.126 0.290 -0.210 0.077 0.052 0. Increased fluids 0.129 0.280 0.253 0.032* 0.185 0. Knowledge about Na and Cl -0.170 0.153 0.003 0.982 0.013 0. Knowledge about potassium 0.086 0.474 -0.130 0.276 0.067 0. Knowledge about Calcium 0.200 0.092 -0.131 0.274 0.007 0. Knowledge about Magnesium 0.004 0.975 -0.081 0.501 0.086 0. Knowledge about Phosphorus 0.051 0.672 0.145 0.223 0.038 0. Total knowledge score 0.180 0.130 -0.132 0.268 0.124 0. *r: Pearson correlation coefficient significant at P<0.
DISCUSSION:
Inaccurate fluid balance monitoring and recording can result in complications with respect to on-going patients‟ management. Inaccurate fluid balance data may result in inappropriate administration of diuretic therapy, resulting in fluid imbalances that affect the patients‟ hemodynamic stability. It is essential that critical care nurses implement appropriate correct recording, accurate calculation and fluid balance monitoring, to provide safe patient care (Boyd et al., 2011).
The effective management of critically ill patients requires accurate assessment of their fluid balance status. This assessment includes appropriate monitoring of fluid intake and output, as well as the accurate calculation and correct recording of this data (Shepherd, 2011). Therefore, fluid balance monitoring requires close attention to provide comprehensive data, upon which patient management decisions can be based (Diacon & Bell, 2014).
Demographic characteristics of the studied group in the current study showed that more than half of the studied nurses were at age 20-<30, less than half of them were diploma nursing, more than two third of them were received training courses, more than half of them said that they didn’t need any training courses.
Regarding to the duration of nursing experience, half of them have experience from 1<5years ago, which mean that the most of them are fresh graduated. According to the
hospital of Bangalore" stated that the overall mean percent of pretest knowledge score was unsatisfactory and posttest knowledge score was satisfactory. The data further support that posttest knowledge scores were greater than the pretest knowledge scores. So, there is an
enhancement in overall knowledge after the structured teaching program (Lee, (2010).
However, Pegram and Bloomfield (2015) study illustrated that the mean score of nurse knowledge was less than half of the satisfactory knowledge scores before starting the guidelines.
These data prove the first research hypothesis that" after fluid and electrolytes imbalance guidelines implementation, the nurses will have higher posttest knowledge score compared to pretest score".
The current study clarified that, almost all nurses were performed unsatisfactorily regarding monitoring and managing of fluid and electrolyte abnormalities. The result of the pre-test, might be related to a main cause of inaccurate fluid balance monitoring was a shortage of nursing staff and workload in ICU. Also might be because fluid balance monitoring is considered a routine nursing measure; nurses might think that they are competent in fluid balance calculation and monitoring and do not look forward updating their knowledge.
The current study clarified that, there were statistically significant difference regarding scores of nurses' practice regarding fluid & electrolyte imbalances monitor and management pre, immediately after and follow up after guidelines applications in area of fluid and electrolyte monitor score, fluid and electrolyte management score and Total practice, which mean that the guidelines have a positive effect on the nurse’s performance.
Complete a fluid balance chart accurately, recognizing when fluid intake or urine output is abnormal, and formulate a plan to resolve this. Reflect on nurses' practice, identifying areas for development in relation to fluid balance documentation and demonstrating insight into the professional importance of fluid balance records (Shahin et al., 2012).
The results of the current study are in the same line with Vincent and Mahendiran, (2015) used e-Learning and verbal presentation in their study to raise nurses‟ awareness around fluid balance, after intervention, the researchers found that to improve nursing
practice, adequate knowledge is needed.
Also the Nursing and Midwifery Council (NMC) has issued clear guidance on the importance of record keeping and states that:’ Nurses are required to have the knowledge and competence to care for patients, which includes understanding the indications for and importance of fluid balance charts. Fluid management should be accorded the same status as a drug prescription (McGloin, 2015).
These data prove the second research hypothesis that "The nurses will have higher posttest performance score compared to pre implementation of the guidelines".
The current study illustrated that, there was no statistically significant relation between nurses 'total knowledge score and their demographic characteristics at different timings of the study, which mean that there was no significant relation between their age, level of education, training courses or duration of experience and total knowledge score.
These findings might be due to there are no specific training courses about fluid and electrolyte imbalance management in the hospital for the nurses or due to shortage of nurses and lack of nurses' perception about the importance of training courses or importance of upgrading their knowledge regarding such subject.
The current study findings were inconsistent with study findings of Pancorbo- Hidalgo, et al (2007) who reported a negative relationship between years of experience, nurses with more years of working experience (21-30 years) had lower levels of knowledge than those with less years of working experience (1-10 years) and explained these result due to nurses with more years of working experiences may have had less chance to gain access to up-to-date information. So finally there was a negative relation between nurse’s work experience and their knowledge.
On the other hand, this finding is in disagreed with Hammed, (2009) who reported that the female Bachelor degree nurses scores were significantly better than diploma nurses possibly because of the basic knowledge received during academic years, which is different than that received by diploma nurses, which is not proved by the current study findings as their mean scenes were always lower than diploma nurses through a three phases of the study.
The current study illustrated that, there were no statistically significant relation
CONCLUSION:
Based on the results of the present study, there was significant improvement in nurse's knowledge and practice related to fluid and electrolyte imbalance.
RECOMMENDATIONS:
I- Recommendations for improving nursing science: Hospital should provide the ICUS with high qualified nurses who holed a bachelor degree in nursing. A guideline handout for fluid and electrolyte imbalance intervention should be placed in a clear and reachable site for all nurses. Hospital and ICU administrators should pay more attention for staff competency through regular staff evaluation to determine their knowledge level and performance to improve it. Hospital and ICU administrators should pay more attention for covering the unit with the suitable number of competent nurses to ensure high quality of patient care. A fundamental standard of practice for every nurse practicing in an ICU. Fluid balance chart should be updated and a system for monitoring continuous infusions and a more accurate tool should be established. II- Recommendations for improving nursing education: Continues education for nurses are required to have the knowledge and competence to care for patients, which includes understanding the indications for and importance of fluid balance charts and Fluid &electrolyte imbalance management. In-service education should be conducted for all nurses in the ICUS regarding assessment and monitoring of fluid balance. Novice nurses should be trained adequately regarding assessment and monitoring of fluid balance. III- Recommendations for improving nursing research: Encourage nurses for upgrading themselves by having more degrees after bachelor degree such as master degree. Encourage nurses to use technology in searching for the new researches, new books, and also the new guidelines in nursing. Further Studies:
Further research studies should be emphasizing on the shortage of staff nurses in the critical areas such as ICUs, its effect on the quality of patient care and how to solve this shortage. Further studies may assist in refining the particular challenges of accurate fluid balance monitoring accuracy in Intensive Care Units Further research studies on how to prepare a good clinical instructors or educators in the hospital to help staff to be competent and more qualified.
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