Tanta Scientific Nursing Journal

1

Tanta Scientific Nursing Journal

Prof Dr Rahma Soliman Bahgat

Board Director

Prof Dr Rahma Soliman Bahgat

Editor in chief

Dr Manar Zaky Elwelely

Editor Secretary

Vol. 3 No. 3

2012

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Editorial Advisory Board

Prof Dr Farial Abdal Aziz : Community Health Nursing Alexandria University

Prof Dr Gamalat Elsaid Mansy : Pediatric Nursing, Alexandria University

Prof Dr Bassema Azat Goid : Community Health Nursing, Tanta University

Prof Dr Nazek Ebrahim AbdElghany: Community Health Nursing, Alexandria University

Prof Dr Fouada Shaban : Nursing Administrative Tanta University

Prof Dr Seham Hamoda : Nursing Administrative Tanta University

Prof Dr Rahma Soliman : Pediatric Nursing, Tanta University

Prof Dr Sanaa Abdal Aziz : Psychiatric and Mental Health Nursing , Alexandria University

Prof Dr Zeinab Loutfy: Psychiatric and Mental Health Nursing ,Ain shams University

Prof Dr Sanaa Ala eldeen: Medical Surgical Nursing, Alexandria University

Prof Dr Nahed Elsabahy: Medical Surgical Nursing, Alexandria University

Prof Dr Sanaa Nour: Obstetric and gynecological Nursing, Zagazig University

Prof Dr Magda Mourad : Obstetric and Gynecological Nursing , Alexandria University

3

Information to Authors

General policies

The Bulletin of Tanta Scientific Nursing Journal publishes concise, original articles

and contributions in the board field of nursing sciences. The Editor is responsible

for the view and statements of authors expressed in their articles.

The authors must transfer all copyright townships of the published manuscripts to

the Bulletin of Tanta Scientific Nursing Journal

The authors still retain the right to post, without permission, their own published

manuscript either as link to the online version of the manuscript on the website of

the journal

Table and figures are permitted to be used by authors

Provide the proper reference is made to the original published manuscripts and the

journal

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Manuscripts should not exceed two column, 12 pages, and inclusive

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the name of the authors(s) professional 5itle and institution affiliation

Abstract: not exceeding 200 words, should be included , ti should state the

aim of the study , subjects and methods and important findings and

conclusion

Below the abstract provide and identify 3 to 10 key words or short phrases

for indexing according to the contemporary subject headings

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Introduction: It should include relevant literature related to the problem

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of abbreviations should be spelled out the first time they are used. Symbols, others

than standard statistical symbols, should be identified the first time used

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Should include setting where the study was done subjects of the study and

criteria for selection, tools for data collection and study design and procured.

Results:

Tables, figures or graphs should be typed or drawn on one page and relative

placement should be noted in the text

Discussion:

The findings with other relevant studies in the field of studies in the field of

study

Conclusion

Recommendations

References: are numbered according to order of appearance in the text and should

follow the style of the uniform requirements for manuscripts submitted to the

journals. The Vancouver style should be followed

Procedures

All papers will be reviewed by three .The final decision to publish or reject

the manuscript remains in the hand of the editor. All manuscripts will be sent

to a statistical reviewer. Proof reading of manuscripts for linguistic and

typographic sounds will be done by the editors will be returned .The initial

review process is expected to take 2 weeks time. Accepted manuscripts

become the property of the Tanta nursing scientific journal. The journal

reserves the rights to edit all manuscripts for its style and space requirements

and for the purpose of the clarity of Tanta journal of nursing will determine

in which volume and issue accepted manuscripts will appear.

Faculty of Nursing, Tanta University

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Address:

Email: Tanta nursing [email protected]

Email: [email protected]

Three copies of the manuscripts and CD that should be sent to Tanta

Scientific Nursing Journal

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Contents

Subject Page

1-Quality of Nursing Interventions Provided to Infants Receiving

Mechanical Ventilation 7

2-Infection among Women using Intrauterine Devices and Oral

Contraceptives

22

3-Whiff Test and Vaginal pH >4.5 as Rapid and Accurate Bed-side

Screening Test for Vaginal Infection 50

4-Effects of Topical Honey Dressing on Infected Wounds after

Gynecological and Obstetrical Abdominal Surgery 57

5-Effect of Nursing Intervention on the Supportive Role Played by

Peers on Glycemic Control Among Diabetic School Students in

Tanta City.

77

6-Application of Designed Orientation Program for Nurse Interns

Based on Learning Needs Assessment

7-Life Style Profile of School Age Children Suffering From

Pathological Stuttering

8- Establishing Basic Standards of Nursing care protocol at

Neonatal Intensive care unit.

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Quality of Nursing Interventions Provided to Infants

Receiving Mechanical Ventilation

Rahma Soliman Bahgat Profssor of pediatric Nursing

Faculty of Nursing, Tanta University

Ebtisam Mohmed El-Sayed

Assistant professor of Pediatric Nursing , Tanta university

Ahmed AbdEl Basset, Assistant professor of pediatric Medicine

Faculty of Medicine , Tanta University

Shimaa Ramadan Ahmed Abd El- Sattar .B.SC.N

Faculty of nursing tanta university

Abstract

Mechanical ventilation is a complex supportive and life saving therapy for many children

with respiratory failure. Optimal outcomes for these children are achieved through the skilled

delivery of standardized nursing care include management of the airway and ventilator, physical

care, emotional support, pain and anxiety control and prevention of complications. The present

study aimed to assess the quality of nursing interventions provided to infants receiving

mechanical ventilation. The study was conducted at Pediatric Intensive Care Unit of Tanta

University Hospital. It included thirty nurses working in the previously mentioned setting and

sixty infants who received mechanical ventilation. Two tools were used for data collection: a

structure questionnaire sheet and an observational checklist. The results revealed that, more than

half of studied nurses had fair knowledge in relation to their educational level. The majority of

them had poor practice in relation to the educational level and years of experience in afternoon

shift comparing with morning shift. The study recommended that, in-service training programs

and workshops should be conducted for those nurses to improve their knowledge and

performance about standard nursing care of mechanically ventilated infants with constructive

supervision and follow up by head nurses.

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Introduction

Advances in respiratory care have become

an integral part in the care of critically ill

patients. Support of oxygenation and/or

ventilation is an integral to the practice of

pediatric critical care nursing because the

majority of critically ill infants and

children need interventions to stabilize the

pulmonary system.(1)

Mechanical ventilation is the foundation of

resuscitation, intensive care medicine, and

anesthesia.(2)

It is an invasive life support

procedure with many effects on the

cardiopulmonary system to mechanically

assist or replace spontaneous breathing. (3,4)

Mechanical ventilators are devices that can

create a flow of gas into and out of the

lungs by the manipulation of airway

pressures. The main goal of the ventilator

may be achieved by improving alveolar

ventilation, arterial oxygenation,

increasing lung

volume and reducing work of breathing.(5)

Mechanical ventilation is indicated when

the patient is unable to maintain safe levels

of oxygen and carbon dioxide through

spontaneous breathing.(3)

It is mainly used

for patients with acute respiratory failure.(6)

Respiratory failure is a sudden and life

threatening deterioration of function of the

lung, and inability to maintain normal

arterial blood gases.(7- 9)

The number of children who are suffering

from respiratory failure increases annually

all over the world. It is estimated that the

number of children who are suffering from

respiratory failure is about 1.5 million

children. In Egypt, the annual statistical

report of the Ministry of Health and

Population in 2004 showed that, the

mortality number of infants from

respiratory distress was 11.656 from

1.849.638 live births. Meanwhile, the

mortality number of children who are five

years or less is 2708 child.(1)

There are 79,400 hospitalizations in the

United States each year for neonates

undergoing mechanical ventilation,

8,500 of whom die. Importantly, almost

40% of deaths occur in cases that never

receive care at higher level centers. (10)

Mechanical ventilation can be noninvasive,

involving various types of face masks, or

invasive, involving endotracheal

intubation. Decision to initiate mechanical

ventilation should be based on clinical

judgment that considers the entire clinical

situation and should not be delayed until

the patient is in extremis.(11)

Traditionally

mechanical ventilation divided into

negative-pressure ventilation, where air is

essentially sucked into the lungs, or

positive pressure ventilation, where air (or

another gas mix) is pushed into the trachea.

(4)

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Mechanical ventilation is often a life-

saving intervention, but carries many

potential complications including

pneumothorax, airway injury, alveolar

damage, and ventilator-associated

pneumonia.(12)

Endotracheal suction is one

of the most common procedures carried

out in an intensive care unite. Suctioning

techniques are necessary nursing care used

to clear the airway of thick secretions. (13)

Quality of care focused on the system of

care. It is concerned with improving the

processes, so that everyone’s performance

improves. Improvement usually requires

removing the barriers in the way of the

providers who already possess the

motivation in order to established standard.

(14)

Nurses are constantly present at the

patient’s bedside, so they are the primary

healthcare for monitoring the patient’s

respiratory status. They also responsible

for notifying the respiratory therapist when

mechanical problems occur with the

ventilator, and when there are new

physician orders that call for changes in

the settings or the alarm parameters. (7, 15)

The nurse is responsible for documenting

frequent respiratory assessments. This

usually means documenting ventilator

setting and spontaneous respiratory

parameters every hour, with a full

respiratory assessment, including lung

sounds, at least every four hours. The

nurse also performs suctioning and

provides oral and site care around the

artificial airway. There is often a great deal

of teaching and reassuring that must be

done, both for the patient and their

family.(16)

Aim of the study:

This study aimed to assess the quality of

nursing interventions provided to infants

receiving mechanical ventilation.

Subject & Methods:

Research design:-

A descriptive design was used in this

study.

Setting:-

This study was conducted at Pediatric

Intensive Care Unit of Tanta University

Hospital. It contained one large room with

6 pediatric beds, 6 ventilators and 2

continuous positive airway pressure

devices.

Subjects:-

All available nurses working in the

previously mentioned setting who are

caring for mechanically ventilated infant

regardless of their years of experience,

level of education and their ages were

included in this study. The total number of

thirty nurses were classified as follows (12

nurses graduated from faculty of nursing, 5

nurses graduated from technical institute of

nursing and 13 nurses with secondary

school nursing diploma).

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60 infants who received mechanical

ventilation are included in this study

according to the following criteria:

Their age : from one month to 12 months

Both sexes ,Acute stage of respiratory

disorder, Free from any chronic disease

Tools of the study:-

Two tools were used to collect the

required data in this study. They were

developed based on the recent literature.

Tool I: "A Structure Questionnaire

Sheet". It was constructed by the

researcher to assess nurses' knowledge

about mechanical ventilation. It consisted

of two parts:

Part (1):- Biosocial data: It was

developed to assess a- nurses' socio-

demographic data such as (age, level of

education, years of experience and

previous training). b- infant socio-

demographic data such as (age, sex,

date of admission, date of applying

mechanical ventilation, and history of

medical diagnosis).

Part (2):- Nurses' Knowledge about

mechanical ventilation. It included:-

definition, purpose, indications, types,

modes, parameters, complications, criteria

used for initiation of mechanical

ventilation and nursing management of

infants receiving mechanical ventilation

such as: (care for the tube, chest

physiotherapy, suction, hygienic care "eye,

oral, skin care", infection control strategies

and psychological support).

The questionnaire sheet contained closed

ended questions and the nurses were

asked to respond to these ones with only

one correct response for each; the nurses

who responded " correct answer" (one)

was given and the nurses who responded

"incorrect answer" or "did not give any

answer" (zero) was given. The "total

knowledge score" was 54 where it comes

from multiplying total number of

questions (54) in the correct response

score (1), and then the result is divided by

100 to be converted into percentage.

Grading of nurses' answers to

questions and checklist were converted as

follows: Total knowledge score from 50-

↓60% was graded (poor), total knowledge

score from 60-↓70% was graded (fair) and

total knowledge score from 70-100% was

graded (good).

Tool II: "An Observational Checklist":

It was developed by the researcher to

assess the quality of nursing interventions

related to the actual nursing care provided

to infants receiving mechanical ventilation.

It comprised 5 main items:

1-Provide care for the tube:

- All tubes must be secured to decrease

tube movement and accidental extubation.

- Inspect the skin, nose, and mouth for

tissue breakdown.

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- Change tracheostomy tape or

endotracheal tube tape as needed.

- Move the oral endotracheal tube to the

opposite side of the mouth every 24 hours.

- Frequently assess the tube’s position

2-Make Suction:

- When secretions are present.

- Prepare all needed equipment before the

procedure.

- Use the appropriate catheter size.

- Duration of the suctioning.

- Apply pre-oxygenation be considered for

30–60 seconds prior.

- Physical assessment such as rate and

depth of respiration, nature of breathing

sound.

3- Provide general hygienic care: -

including: Eye care, Mouth care and Skin

care.

a) Eye care:

- Instillation of ophthalmic ointment or

drops decreases corneal drying.

- The infant's eye should be swapped with

normal saline regularly.

- Apply antibiotic drops or ointment to the

eye as ordered.

- The eyelids of the infant should be

closed to prevent corneal ulceration.

b) Mouth care:

- Mouth care at least once per shift by

using oral swab.

- lubricate lips with water-soluble ointment

to prevent drying of lips.

-Reposition or rotate the endotracheal tube

from one corner of the mouth to the

opposite side every 24 hours.

c) Skin care:

- Bath the infant daily.

- Change position every 2 hours.

- keep infants clothes clean, dry and keep

bed free from any objects.

- Lubricate the back and bony prominence

and frequent massage for the back should

be done.

4- Follow infection control strategies:

- Washing hands before handling the

infant, before and after any procedure.

- Use isolation technique of infant who has

any infectious disease away from other

infants.

- Avoid exposing the infant to persons

with upper respiratory tract infection.

- Remove or empty water that

accumulates in the ventilator tubing.

-Methods and schedules of cleaning and

disinfection of ventilator circuits should be

learned and applied.

5-Psychological support:

- Provide an emotional support to the

infant by applying distraction techniques

as: allowing the infant to listen to stories &

quiet music, providing back rub & gentle

massage and offering attractive & safe toys

for conscious infants.

Different nursing activities related

to each item were listed. A scoring system

was used to check each activity whether it

was adequately done, inadequately done or

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not done. Scoring of (two points) was

given to adequate nursing activity; (one

point) was given to inadequate nursing

activity and (zero) for not done nursing

activity with a total score of (334) where

it comes from accumulating the number of

steps of all nursing care procedures (167)

multiplied in adequate nursing activity

score (2) then the result is divided by100

to be converted into percentage.

The total score of each item was (34

points for chest physiotherapy, 40 points for

care of the endotracheal tube, 36 points for

nasopharyngeal and oropharyngeal Suction,

38 points for endotracheal Suction, 98 points

for general hygienic care (28 points for eye

care, 38 points for mouth care, 32 points for

skin care), 62 points for infection control

strategies ( 24 points for application of

standard precautions and transmission based

precautions, 10 points for care of ventilator,

28 points for central venous catheter care) ,

and 26 points for Psychological support.

Grading of checklist nursing practice

were converted as follows: from 60-↓65 %

was graded "poor", 65-↓70% was graded

"fair", 70-100 % was graded "good".

Method

- An official permission was obtained

from the directors of hospital of the

selected setting (PICU at Tanta University

Hospital).

- Meeting with nurses before starting data

collection procedure was done to establish

a good relationship, check the availability

of conducting the research, and to explain

the purpose of the study.

- An oral consent was obtained from the

nurses to participate in the study after

explanation of the purpose and importance

of the study.

- Study tools were structured and

developed based on review of the related

literature.

- Ethical considerations:-

Nurses were informed of the privacy of

information obtained from them,

nature of the study, their right to withdraw

from the study at any time and the

confidentiality of their names.

- The pilot study: Pre-test of the used tools

was carried out at the above mentioned

setting before starting the data collection .It

was done on 10% of the study sample to

assess clarity, reliability, applicability of the

study tools, the time needed to fill each tool,

and to identify obstacles that might be faced

during data collection. The sample which

was included in the pilot study was a part of

the studied sample.

- A structure questionnaire sheet was

developed to assess the nurses' basic

information and knowledge related to

mechanical ventilation.

-The questionnaire sheet was distributed

on nurses; the content of the sheet was

explained to all of them and filled

individually. The nurses were reassured

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that all information will be confidential

and used only for the purpose of the study

and nurses were asked to respond in the

presence of the researcher.

- The time required for answering the

questionnaire sheet was about one hour.

- Each nurse was observed twice in the

morning and afternoon shifts by the

researcher to assess her care provided to

the infant receiving mechanical ventilation

by using observational check list.

- The time required to the researcher for

checking the observational checklist for

each nurse was about 2 intermittent hours.

-Data were collected over a period of 4

months from October 2011 to January

2012.

Statistical analysis:

The collected data were organized,

tabulated and statistically analyzed using

SPSS statistical package version 19.

Numerical variables were presented as

range, mean and standard deviation for

categorical variables, the number and

percent distribution was calculated.

Statistical analysis for factors affecting the

total score of knowledge and practice was

done using Mann-Whitney test as the

small sample size for each studied

categories was small and did not guarantee

normal distribution to use the student t-

test. Comparison of mean values for chest

physiotherapy, hygiene and infection

control was performed using paired t-test

as the total cases were treated as one

group. For comparisons of observations of

items related to knowledge or practice

between morning and afternoon shifts,

Wilocxon signed rank test. The level of

significance was adopted at p<0.05.

Limitations of the study:

- Lack of interest and cooperation of

studied nurses.

- Many of nurses were too overloaded with

their work particularly in afternoon shift.

- There were many interruptions during

answering the questionnaires.

- Small sample size to make

generalization.

Results:

Table (1) presents the percentage

distribution of the studied nurses regarding

biosocial-demographic characteristics. It

was revealed that, more than half of

nurses' ages (56.7%) were more than 30

years while 40% of them were between the

age of 20 and 30 years and the rest of them

(3.3%) were less than 20 years. In relation

to nurses' educational level, 43.3% of

studied nurses had secondary school

nursing diploma while more than one third

of them (40%) had university education

and the rest of them (16.7%) had technical

nursing institute. Regarding years of

experience in pediatric intensive care unit,

it was clear that the majority of nurses

(83.3%) had more than 3 years of

experience. In relation to nurses' previous

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training on care of mechanically ventilated

infants, it was found that the majority of

them (93.3%) had no previous training.

Table (2) shows mean and standard

deviation of total score percentage of

different items of knowledge among

studied nurses. It was observed that the

mean total knowledge score of nurses

regarding infection control was

(86.67±26.04) and ranged between zero

and 100%. Also, the mean total knowledge

score of nurses regarding endotracheal

tube care was (71.33±20.13) and ranged

between 40% and 100%. However, the

mean total knowledge score of nurses

regarding mechanical ventilation and

suctioning procedure was (36.67±23.73)

and ranged between zero and 66.67% for

each.

Table (3) illustrates percentage

distribution of studied nurses according to

total score of nurses' knowledge. Results

revealed that about one third of nurses

(30%) had poor total knowledge score (50-

↓60 %). However, more than half of

studied nurses (56.7%) had fair total

knowledge score (60- ↓70 %) and the rest

of them (13.3%) had good total knowledge

score (70- 100%).


distribution of studied nurses of total

practice score related to different items of

practice. In relation to general hygienic

care, it was found that the total practice

score percentage of general hygienic care

in the morning shift ranged between 66.3%

and 82.6% while, in the afternoon shift,

the total practice score percentage ranged

between 62.2% and 84.7%. Also, results

revealed that, the mean total practice score

percentage of general hygienic care in

morning shift (75.23±5.57) was more than

that in the afternoon shift (72.11±7.13).

However, in relation to endotracheal tube

care, it was found that the total practice

score percentage of endotracheal tube care

in the morning shift ranged between 47.5%

and 60% while in the afternoon shift, the

total practice score percentage ranged

between 42.5% and 62.5%. Also, results

revealed that the mean total practice score

percentage of endotracheal tube care in

morning shift (53.92±3.92) was more than

that in the afternoon shift (51.42±5.11).

There was a statistical significant

difference between total practice scores of

nurses in relation to "endotracheal tube

care","suctioning procedure",

"endotracheal suctioning" and "eye care"

in morning and afternoon shifts (P =

0.016, 0.011, 0.003, 0.001 respectively) .


distribution of studied nurses according to

total score of nurses' practice. In morning

shift, it was found that the majority of

studied nurses (90%) had poor total

practice score where it ranged from 60-

↓65%. Low percentage of nurses (10%)

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had fair total practice score where it

ranged from 65-↓70% and no one of them

had good practice score where it ranged

from 70-100%. In afternoon shift, it was

found that more than three quarters of

studied nurses (76.7%) had poor total

practice score. However, low percentage

of nurses (16.7%) had fair total practice

score and the rest of them (6.7%) had good

total practice score.

Table (6) illustrates correlation between

total knowledge and practice scores. It was

found that there was no statistical

significant difference between total nurses´

knowledge score and total nurses´ practice

score in morning shift (P = 0.162 and r =

0.262) . Also, results revealed that there

was a statistical significant difference with

positive correlation between total nurses´

knowledge score and total nurses´ practice

score in afternoon shift (P = 0.044 and r =

0.370). It was found that there was a

statistical significant difference with weak

positive correlation between total practice

scores at morning and afternoon shift (P =

0.015 and r = 0.439)

Table (1): Percentage distribution of the studied nurses regarding

Biosocial-demographic characteristics

Biosocial-demographic characteristics (n = 30)

Age in years: No %

Less than 20 years 1 3.3

20-30 12 40.0

More than 30 17 56.7

Educational level:

Secondary school nursing diploma 13 43.3

Technical nursing institute 5 16.7

Bachelor degree 12 40

Years of experience in PICU:

<1 2 6.7

1-3 3 10.0

> 3 25 83.3

Previous training on care of

mechanically ventilated infants:

Yes 2 6.7

No 28 93.3

Table (2) Mean and standard deviation of total score percentage of

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different items of knowledge among studied nurses

Items of knowledge Range Mean SD

Mechanical

ventilation 0-66.67 36.67 23.73

Endotracheal tube

care 40-100 71.33 20.13

Suctionning

procedure 0-66.67 36.67 14.66

Chest physiotherapy 0-100 55.00 35.60

General hygiene 25-87.5 63.33 14.66

Infection control 0-100 86.67 26.04

Table (3): Percentage distribution of studied nurses according to

total score of nurses' knowledge

Table (4): Percentage distribution of studied nurses of total practice

score related to different items of practice

Total practice score

percentage related to:

Morning

shift

(n = 30)

Afternoon shift

(n = 30)

t P

Endotracheal tube care: 2.567 0.016*

Range 47.5-60.0 42.5-62.5

Mean 53.92 51.42

SD 3.92 5.11

Suctioning procedure: 2.708 0.011*

Range 56.8-78.4 54.0-78.4

Mean 68.51 65.99

SD 6.04 5.999

Nasopharyngeal and

oropharyngeal

Suction:

1.786 0.085

Range 55.56-80.56 50.0-83.3

Mean 67.96 65.28

SD 6.83 7.61

Endotracheal suctioning: 3.203 0.003*

Range 55.3-78.9 55.3-76.3

Total knowledge score percentage (n = 30)

No. %

(Poor) 50- ↓ 60 9 30.0

(Fair) 60- ↓ 70 17 56.7

(Good) 70- 100 4 13.3

17

Mean 69.03 66.67

SD 6.62 6.12

General Hygienic care : 0.872 0.412

Range 66.3-82.6 62.2-84.7

Mean 75.23 72.11

SD 5.57 7.13

Eye care: 3.947 0.001*

Range 82.1-100 67.9-96.4

Mean 90.95 85.12

SD 5.03 8.44

Mouth care: 1.349 0.188

Range 57.9-92.1 47.4-92.1

Mean 75.09 75.54

SD 10.13 11.01

Skin care: 0.116 0.911

Range 59.4-87.5 53.1-87.5

Mean 67.01 66.25

SD 7.67 10.04

Chest physiotherapy: 0.215 0.803

Range 44.1-85.3 17.7-85.3

Mean 64.51 63.92

SD 12.36 13.44

Percussion: 0.230 0.819

Range 50.0-88.5 0-88.5

Mean 72.05 71.25

SD 9.99 16.18

Vibration: 0.000 1.000

Range 0-60 0-60

Mean 32.00 32.00

SD 28.70 28.70

Infection control: 0.440 0.665

Range 45.3-73.4 45.3-71.9

Mean 62.50 61.46

SD 6.46 6.56

Standard and transmission

based precautions:

0.133 0.895

Range 29.2-54.2 37.5-50.0

Mean 45.42 45.56

SD 6.03 4.67

Care of ventilator: 1.613 0.118

Range 50-80 50-80

Mean 73.3 69.67

SD 7.58 8.90

Central venous catheter 0.052 0.959

18

care:

Range 57.1-92.9 50.0-92.9

Mean 77.47 77.53

SD 11.55 12.35

Psychological care : 1.214 0.235

Range 26.9-73.1 34.6-88.5

Mean 59.36 62.56

SD 11.85 13.88

* Level of significance p< 0.05

Table (5): Percentage distribution of studied nurses according to

total score of nurses' practice

Total practice score

percentage

Morning shift

(n = 30)

Afternoon shift

(n = 30)

N % n %

(Poor) 60-↓65 27 90.0 23 76.7

(Fair) 65-↓70 3 10.0 5 16.7

(Good) 70-100 0 0.0 2 6.7

Table (6): Correlation between total knowledge and practice scores

Total practice score Total knowledge score

R P

Morning shift 0.262 0.162

Afternoon shift 0.370 0.044*

Correlation between practice at morning and afternoon shift: r = 0.439, P =0.015


Vol. 2 No. 2 May 2012 19

Discussion:

Critically ill infants in most modern PICU

require a period of mechanical ventilation.

Mechanical ventilation is an important

supportive mode in the care of acutely and

critically ill infants in general. (17- 19)

Nursing

care is one of the essential components of

quality of care given to the infants in

PICU.(20)

Therefore, pediatric nurse must

have keen observation skills, highly trained

and qualified especially when caring for

children who are critically ill. Nurses should

also be educated in the art of recognizing

any changes in children behavior,

interpreting the observation of other and

timing intervention appropriately.(21)

This

study focused on the assessment of nurses'

knowledge about mechanical ventilation and

the quality of nursing interventions related

to the actual nursing care provided to infants

receiving mechanical ventilation which

comprised 5 main items "providing care for

the tube, making suction and chest

physiotherapy, providing general hygienic

care, following infection

control strategies and psychological

support".

The present study revealed that more than

half of nurses' ages were more than 30 years.

40% of nurses had university education. It is

considered a large percentage. So, they were

able to carry out their responsibilities, had a

heightened awareness of resource allocation,

working up on evidence-based practice and

providing advanced quality of care.

Although the majority of nurses had more

than three years of experience in PICU, only

few of them had previous training in

mechanical ventilation. This rendered them

inexperienced in pediatric critical care

practice. Meanwhile, it is stated that, there is

a clear relationship between trained

intensive care staff and quality of patient

management (22)

. Also, it is indicated that,

the agency of Health Care Research Quality

identified that in order to achieve quality of

care; nurses should keep learning and

conducting research rather than being

stagnated in their educational background.

(23)


Vol. 2 No. 2 May 2012 20

Regarding nurses' knowledge in relation to

mechanical ventilation, the present study

indicated that, the mean total knowledge

score of nurses regarding to infection control

was the highest one. While, the mean total

knowledge score of nurses regarding to

mechanical ventilation and suctioning

procedure were the least. This may be

attributed to lack of their basic knowledge

and education programs regarding to

mechanical ventilation and ideal care

provided to mechanically ventilated infants.

These findings contradicted with Carson

(2000) who stated that about three quarters

of nurses had correct knowledge mechanical

ventilation. This could be related to the

difference in educational preparation,

continuous renewal of their license to

practice nursing, and their continuous

exposure to results of most recent researches

related to management of patient on

mechanical ventilation. (24)

Meanwhile,

these findings were consistent with

Mohumed (2005) who mentioned that there

was a gap between the rapid development in

scientific information and slow development

of knowledge of health care providers. (25)

Regarding chest physiotherapy which is

composed of two basic procedures

“percussion and vibration”. It was observed

that some nurses obtained zero the total

practice score in relation to percussion and

vibration procedures. This could be related

to those nurses thought that chest

physiotherapy was composed of percussion

or vibration only, so they provided one of

the two procedures and not both procedures.

Also may be due to unavailability of training

programs regarding to the ideal chest

physiotherapy procedure.

Concerning general hygienic care, the

results of the present study illustrated that

general hygienic care was adequately done

by about three quarters of the study nurses.

This finding was consistent with study

demonstrated by Zahran (1991) who

observed that the general care to the eye,

ear, nose, mouth and skin of the infant was

adequately done by about three quarters of

nurses in NICU of Tanta University

Hospital.(26)

Concerning following of infection control

strategies and specifically universal and

transmission based precautions for infection


Vol. 2 No. 2 May 2012 21

control; it was revealed that these

precautions were adequately done by only

less than half of nurses. These findings of

the present study may be due to insufficient

supplies as masks and gowns in PICU and

lack of supervision and guidance by head

nurses of the unit to nurses to strictly apply

infection control strategies. Also, this could

owe to lack of in-service training programs

related to infection control strategies.

Psychological and emotional support is very

important especially in Pediatric Intensive

Care Unit during stressful situations. The

results of the present work found that more

than one third of the study nurses neglected

or did not offer emotional care to

mechanically ventilated infants. This may be

attributed to increased and continuous

workload that negatively affects the

emotional status of nurses and make

thepsychologically upset as the majority of

them spent long years of work at PICU

without psychological or financial support,

so, they will not be able to give

psychological support adequately to the

infants in Pediatric Intensive Care Unit.

Also, lack of time of the nursing staff and

overlapping of nursing activities in intensive

care unit, would make them focus mainly on

major patient issues and would not be able

to attend to minor issues as emotional

support. Furthermore, the majority of infants

were sedated most of the time to prevent

fighting the ventilator.

This finding was consistent with the finding

of Martensson et al (2004) who stated that

the majority of nurses in intensive care unit

neglect the patient’s verbal and non-verbal

communication, so the critically ill patient

may experience feeling of anger, sadness,

negative emotion and depression. It was

stated that the role of the critical care nurse

is to consider the patient's verbal and non-

verbal communication ability. It is necessary

for critical care nurse to help the patient to

feel trust and be secure when receiving

mechanical ventilation. (27)

Although more than half of studied nurses

had fair total knowledge score, the majority

of studied nurses had poor total practice

score. This finding means that the nurses did

not apply their knowledge in providing

adequate nursing care to critically ill infants.

These findings may be attributed to that all


Vol. 2 No. 2 May 2012 22

nurses follow the hospital policy in

providing nursing care to mechanically

ventilated infants and not to follow the

standardized nursing care plan. Also, the

newly recruited nurses ask the old nurse in

the unit when they cannot perform any

procedure instead of returning to the ideal

nursing care, or may be due to lack of

resources, equipments and supplies needed

to provide standardized nursing care.

As regards of nursing performance, the

present study revealed that the nursing care

provided to infants receiving mechanical

ventilation was poor and below the accepted

level of what should have been done. This

may be due to lack of motivation, hospital

facilities, resources and lack of training

courses that enable nurses to perform

standardized nursing care. It was indicated

that the agency of Health Care Research

Quality identified that in order to achieve

quality of care; nurses should keep learning,

training and conducting research rather than

being stagnated in their educational

background (23)

.

Conclusion

Based up on the results of this study, it

could be concluded that nurses' knowledge

and practice were inadequate to provide

ideal care for mechanically ventilated

infants. It was found that more than half of

the studied nurses had fair knowledge in

relation to their educational level and the

majority of them had poor practice in

relation to the their educational level and

years of experience. This may be attributed

to lack of supervision, and lack of

motivation, resources and facilities that

affect nurses' knowledge and performance.

Recommendations

Based on the findings of the present study,

the following can be recommended:

In-service training programs and

workshops should be conducted

periodically and regularly for nurses

working in Pediatric Intensive Care

Unit to improve the nurses' knowledge

and performance about nursing care of

mechanically ventilated infants.

Protocol of care should be started on the

admission of the infant to the unit.

Newly recruited nurses in Pediatric

Intensive Care Unit are better exposed

to a sort of orientation period. During


Vol. 2 No. 2 May 2012 23

this period new nurses have to:

Know about their expected roles.

Learn about the common infant's

problems and needs.

Complement for any deficiencies in

basic knowledge and skills.

- Provision of handouts of up- to- date

guidelines regarding standardized nursing

care of mechanically ventilated infants.

- Standardized nursing care for mechanically

ventilated infants should be prepared by

professional specialized adept nursing

staff and kept in the unit.

References

1. Hanaa A. Quality of Nursing Interventions

While Managing Children Receiving

Mechanical Ventilation, Unpublished

Master Thesis in Faculty of Nursing.

Menouphiya University 2008; 1-4

2. Anna U , Jolanta S , Ivelisse G.

Mechanical Ventilation , 3rd

ed, New

York: Raven Press Co, 2010; 11-12

3. John P, Eric C , Ann R. Manual of

Neonatal Care, 6th

ed, Philadelphia:

Lippincott Co, 2004; 331

4. Genel L. Historical Perspective on the

Development of Mechanical Ventilation,

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5. Marvin K. Mechanical ventilation of

infants, Journal of American Science 2011;

7(12): 531-541

6. Witta K. New techniques for weaning

difficult patient from mechanical

ventilation. Clinical issue & critical care

nursing Journal, 1995; 1(2): 260.

7. Gehan A. Assessment of Nurses

Knowledge and Performance in Relation

to Weaning and Extubation of Patient with

Mechanical Ventilation, Unpublished

Master Thesis in Faculty of Nursing. Tanta

University 2005; 1-2

8. Clochesy J, Breu C, Cardin S, Whillaker A

, Rudy E. Critical Care Nursing, 2nd

ed,

Philadelphia: WB Saunders Co, 1996; 630-

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9. Smeltzer S, Bare B. Text Book of Medical

Surgical Nursing, 9th

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10. Angus D, Griffin M, Clermont G, Clark R.

Epidemiology of neonatal respiratory

failure in the USA: projections from


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California and New York. Am Journal

Respir Crit Care Med 2001; 164(7):1154–

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11. Merck S, Dohme C. Overview of

mechanical ventilation: Respiratory failure

and mechanical ventilation, 2009- 2010;

available at

http://www.merckmanuals.com

12. Tanıl K, Aslı K, Zahide Y, Emel D , Erdal

E. Mechanical ventilation in children,

Turkish Journal of Pediatrics

2006;48(4):323-327

13. Akgul S and Akyoluc N. Effect of normal

saline on endotracheal suctioning, Journal

clinical nurse, 2004; 11(6): 826-30

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chasm: A new health system For the 21 St

Centuries Washing DC: The National

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Lippincott Co 2004; 200-222.

16. Walls R, Murphy M , Luten R. Manual of

Emergency Airway Management, 3rd

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Philadelphia: Lippincott Williams and

Wilkins Co, 2008; 552-565

17. Palmeri J. Developing a comprehensive

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AORN J, 2005; 44(18):77.

18. Ingersoll G. Measurement in mechanical

ventilation weaning research, The Online J

Known Synthesis Nurs, 1995; 2(12), 51.

19. Chase S. The research basis for weaning

from mechanical ventilation, The Online J

Know Synthesis Nurs, 1994; 1(7) 1-10.

20. Meade M, Guyatt G,Cook D. Weaning

from mechanical ventilation: The evidence

from clinical research, Respir Care J, 2001;

46(12): 1408-15.

21. Chinn P and Leitch C. Child Health

Maintenance, A guide to Clinical

Assessment, 6th ed., London, C.V. Mosby

Co., 2000; 28-32.

22. Wong D , Hockenberry M. Wong's

Nursing Care of Infants, 7th

ed, London,

Mosby Co., 2003.

23. Backmann U, Gillies D. Factors associated

with re-intubation in intensive care: An

analysis of causes and outcomes, Chest J,

2001; 120(2): 538-42.

24. Carson S, Ely E, Govert J, Garrett J, Hall

J. Effectiveness of medical residents,

Education in mechanical ventilation,

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AHRCCM Articles in Press, 2000;(24)13,

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parents of children with hereditary diseases,

published thesis, Faculty of Nursing,

Menoufiya University, 2005; 98.

26. Zahran S. Study of the organization and

utilization of the neonatal intensive care unit

in Tanta University Hospital, Unpublished

Master Thesis in Faculty of Nursing,

Alexandria University, 1991

27. Martensson I, Fridlund B. Patient's reports

of health care practitioner interventions that

are related to communication during

mechanical ventilation, Heart& Lung J,

2004; 33(5): 308-20.


Vol. 2 No. 2 May 2012 26

Infection among Women using Intrauterine Devices and Oral Contraceptives

Aida abd El-Razek,

Assistant Professor of Maternal and newborn Health Nursing

Faculty of Nursing, Menoufyia University

Abstract

The study was to evaluate the relationship between vaginal douching practices and

genitourinary infection in women, aged 18-49, who use an intrauterine contraceptive device

(IUCD) or oral contraceptives (OCP). This study was planned and applied as a descriptive cross-

sectional study. The study was conducted at Mother and Child Health and Family Planning

Center of El-Basher Hospital Amman Jordon. The study was conducted with 185 consenting

women (90 using OCP, 90 using IUCD). Since the number of women using condoms was

minimal, these were excluded from the study. 10 months at 2009 over the period of the study. No

inclusion criteria were taken into consideration aside from age, having used the same method in

the last 4 years, and not menstruating at the time samples were to be taken. It was found that

women taking OCP who practiced vaginal douching (VD) had higher ratios of bacteria growth in

the urine compared to women with IUCD. While there was a significant relationship seen

between the method used and the urine culture results (Χ2=5.045 df =1 p=0.01), no relationship

was observed in terms of the vaginal culture (Χ2=0.631 df=1 p=0.264). The conclusion of the

study was that the development of genitourinary infection during the use of OCP or IUCD was

associated more with lack of proper hygiene rather than with the practice of vaginal douching.

Keywords: Genitourinary infection, Intrauterine contraceptive device, Oral

contraceptive, Vaginal douching


Vol. 2 No. 2 May 2012 27

Introduction

Vaginal douching (VD) is an old and

traditional practice that is carried out for

intra-vaginal cleansing or treatment, using

the fingers and/or substances to clean and

rinse out the vagina [1, 2]

. VD is a

widespread practice among women. Woman

practice VD generally for vaginal

cleanliness after menstruation or sex, as a

contraceptive measure, or because of

hygienic beliefs [3]

. According to hygienic

belief, body secretions flowing from or

remaining in the vagina preclude the

observance of hygienic beliefs.

Menstruating women, for example, cannot

perform the ritual prayer or read the Koran

[4]. Most women will clean the vaginal area

after sexual intercourse, either using their

fingers or by douching, removing seminal

fluid from the vagina as an act of

purification [4,5]

. Women use many different

substances when practicing VD. Among the

most frequently encountered of these are

soap, perfumes, and vinegar [6, 8]

. In

addition, some studies have reported that

women are not aware of the harmful effects

of VD [7, 8, 9]

. When the habit of washing out

the genital area with water after going to the

toilet is added to the practice of VD, the risk

of infection becomes more alarming [5]

. It

has been found that one-fifth of women

practicing VD do so after going to the

toilet.10 Women who wash the anal area

after defecation are likely to perform VD

with their contaminated hands. This causes

the transmission of many pathogenic

microorganisms into the vagina, making the

area susceptible to the development of many

health issues [11, 12]

. VD disrupts the balance

of the normal vaginal flora and prepares a

foundation for infection [10]

. The risk of

genitourinary infection increases when

women's poor hygienic habits are added to

this picture. It has been determined in

research that methods of contraception can

be trigger factors for infection. It is

recognized that among the different

contraceptive methods, the IUCD is the

method that is more likely to increase

susceptibility to genitourinary infections [13,

14]. IUCDs may change the nature of the

http://www.reproductive-health-journal.com/content/4/1/5#B5








Vol. 2 No. 2 May 2012 28

vaginal flora and cause an increase of

anaerobic bacteria [15, 16]

. Besides this

shortcoming, it has also been reported that a

lack of hygienic conditions during the

insertion of the IUCD and deficiencies in

information concerning its use are also

infection-triggering factors [17, 18]

.

Significant of the study

According to the reports of Jordon

Population and Health Research (JNSA), a

significant increase was seen in the use of

IUCDs as an effective method of

contraception between the years 2003-2008,

and it is striking to note that women with

IUCDs are more educated than those that

take OCPs [21]

. study reported that IUCD's

were the primary and preferred effective

method; condoms were the second

preference while taking OCPs was third [21]

.

The results of the present study are

consistent with this finding.

Studies have shown that deficiencies

in hygiene when using the various

contraceptive methods are more likely to

bring about genitourinary infection [15]

.

There is no study in the literature, however,

that examines the association between the

use of OCP and genitourinary infection.

Some studies have been reported that the

effect of OCP use on the vaginal flora is

minimal [14, 17]

. It has been reported, on the

other hand, that the estrogen contained in

OCP facilitates the population of

uropathogens in the vaginal and urogenital

cells, preparing a suitable environment for

the growth of microorganisms [15]

. In

addition to these factors, personal habits of

the individual during the use of OCPs (anal

sex, poor hygiene, low water consumption,

etc.) also trigger genitourinary infection [16]

.

The aim of the study

Evaluate the relationship between

vaginal douching practices and

genitourinary infection in women, aged 18-

49, who use an intrauterine contraceptive

device (IUCD) or oral contraceptives (OCP).

MATERIALS AND METHOD

Research design:

This study was planned and applied

as a descriptive cross-sectional study

Research Setting:

The study was conducted at Mother

and Child Health and Family Planning








Vol. 2 No. 2 May 2012 29

Center of El-Basher Hospital Amman

Jordon.

Subjects of the study

Sample size

El-Basher Hospitals, Family

planning services in Jordon are provided by

three separate groups of institutions. These

are private and state hospitals, family

physicians, and the Child Health and Family

Planning Centers (CHFPC).

The CHFPC in the city center accepts a

monthly average of 60 women for IUD

checkups, 50 women for IUCD insertion, 70

women for OCP prescriptions, and 15

women to obtain condoms. 10 months at

2009 over the period of the study, 195

women applied to the Center and of these,

15 were using condoms. The study was

conducted with 185 consenting women (90

using OCP, 90 using IUCD). Since the

number of women using condoms was

minimal, these were excluded from the

study. No inclusion criteria were taken into

consideration aside from age, having used

the same method in the last 4 years, and not

menstruating at the time samples were to be

taken.

Type of sampleA

Convenience sample of 180 using OCP, 90

using IUCD was conveniently selected to

achieve the aim of the study.

Tools for data collection:

The data was collected by using pen-

and-paper self-report forms which included

the following: a socio-demographic data

collection form, a questionnaire inquiring

into vaginal douching behavior and data on

urine culture and vaginal culture results

based on the specimens obtained from the

women.

The data collection form consisted of

15 questions prepared by the researchers to

record the socio-demographic characteristics

of the participants and the questionnaire was

based on 13 questions from the literature 12

that were developed to inquire about

descriptive characteristics related to vaginal

douching and genital hygiene. In addition,

specimens were obtained from the women

for vaginal cultures and urine cultures.

These samples were sent to the El-Basher


Vol. 2 No. 2 May 2012 30

Technical University Microbiology and

Pathology Labs within 1 hour.

Socio-demographic Questionnaire

This consisted of questions

developed by the researcher based on the

literature. The questions concerned

the women's ages, their work, educational

level, social security status, monthly income,

number of children and births, the duration

the method had been used and similar

information

Vaginal Douching and General Hygiene

Questionnaire

This consisted of questions about vaginal

douching practices, the method used, the

reason for practicing VD, from whom the

woman had heard about vaginal douching,

the material used in VD, how frequently it

was practiced, how many times the woman

has sex in a week, and whether or not she

had any knowledge about the harmful

effects of VD.

Ethical Considerations:

The study was carried out with co-operation

of different levels of authority. An official

letter was sent from the Dean of the Faculty

of Nursing in Philadelphia University to the

directors of El-Basher Hospitals These are

private and state hospitals, family

physicians, and the Child Health and Family

Planning Centers (CHFPC) explaining the

aim of the study and the time of data

collection seeking his permission for data

collection. An official permission through

written letters clarifying the purpose and

sitting of the study was obtained from the

directors of El-Basher Hospital As an

approval for data collection. A written

informed consent was obtained from the

participants after explaining the purposes of

the study, which include: no harm was

occurring to participant, do not contradict

with the cultural, traditional and religious

issues, human rights were reserved, data was

confidential and used mainly for the purpose

of the research and each subjects was free to

withdraw from the study at any time.

Method

Data collection Procedure:

Development of tools for data

collection after reviewing the related

literature the tools was revised for


Vol. 2 No. 2 May 2012 31

content validity by 5 experts in the

field.

The women's was selected by A

convenient sample was used

according to the mentioned criteria.

The data were collected through a

period of 10 months at 2009. Three

days per week starting at 9am to

2pm. The researcher introduced

herself to the women and obtained

their consent to be recruited in the

study after explaining the aim of the

study.

Each woman was interviewed

individually by the researcher.

The average time for filling each

sheet was about 15 minutes

depending on the response of the

women. Consent was obtained from

each women and the interviewing

questionnaire was explained to each

women.

After that, the researcher assessed

Procedure for Obtaining Sterile

Urine Specimens. A sterile container

(red-screw-capped culture container)

was used as a urine culture container.

- Instructions as to how the culture

should be taken were given to the

women consenting to the study, as

follows: “Thoroughly wipe the outer

part of the urinary tract with the

disinfectant/antiseptic wipe before

taking the urine sample; dry the area

with the sterile gauze that's been

given to you; after discharging the

first few drops of urine, collect the

middle of the flow in the sterile

container. Do not allow the urine

container to touch anything and do

not fill up the container to the brim.”

[20].

The lids were then placed on the

urine containers, on which the names

of the patients were written; the

specimens were taken to the

laboratory in a short time by the

researcher. The samples were

evaluated after their “S”-shaped

inoculation on to blood

EMB/McConkey agar plates [20]

.

Procedure for Obtaining Vaginal

Culture: Glass culture tubes equipped with

cotton-tipped sterile swabs used only for this


Vol. 2 No. 2 May 2012 32

purpose were employed to gather specimens.

The small-tipped sterile swab was swept

across the vaginal wall and the specimen

was placed in a closed container with the

patient's name written on it. A Nugent score

assessment of the samples was made [20]

.

Limitation of the study:

Microbiology and pathology laboratories

container is not available for sometime.

Not funded this study by the University

Research, researcher finds it difficult to test

Statistical Analysis

The Statistical Program for the Social

Sciences, version 15.0 (SPSS 15.0) was used

for data analysis. Percentages and averages

were also calculated, the Chi-square test and

t- test were performed for the statistical

analysis. The level of statistical significance

was set at p<0.05.

The logistic regression analysis model to

determine which factors affected bacterial

growth in the urine and vaginal culture. The

enter method was used in the logistic

regression analysis

RESULTS

The women's age group, their working

status, educational level, social security

status and income levels are shown in Table

1. As can be seen in Table 1, no statistical

difference was observed between the two

groups except variable of educational level.

The women taking OCPs made up 70% of

the group, and those using IUCD's, 81.1%.

In the statistical analysis, there was no

significant difference between the two

groups in terms of performing vaginal

douching (Χ2=7.716 p=0.120) (Table 2). It

was found that 63.5% of the women

practicing vaginal douching who were

taking OCPs, 68.5 %of the women using

IUDs said that they practiced VD 2-3 times

a week; 41% of the women using IUCDs

said that they had made this decision on

their own; 46 % of the women using OCPs

said they had heard about VD from their

elders; 68.3% of the women taking OCPs

said that they performed vaginal douching

with soap and water, and 65.8% of the

women with IUDs said that they performed

vaginal douching with water; of the women

using OCPs, 47.6 % said they performed

VD usually after sexual intercourse; 61.6 %


Vol. 2 No. 2 May 2012 33

of the women with IUCDs said they

performed vaginal douching after

menstruation; 60.3% of the women taking

OCPs and 65.8% of the women using

IUCDs stated that they practiced vaginal

douching regularly. Of the women taking

OCPs, 71.4%, and 68.5% of the women

using IUCDs said they didn't think VD was

harmful (Table 2). There were significant

differences between the groups in terms of

the materials used regularly, the method of

VD and the frequency of sexual intercourse

(Χ2=18.77 p=0.000; Χ

2=7.35 p=0.020;

Χ2=29.02 p=0.000; Χ

2=8.37 p=0.000,

respectively).

Among the group taking OCPs, 78.9%, and

65.6% of the IUCD group were rinsing off

their genital area from back to front. A

statistical difference was found in this factor

between the groups (Χ2=6.211 p=0.001)

(Table 3). The two groups also exhibited

significant differences in terms of the

material used for drying off, continuously

using a sanitary pad, and the existence of a

disagreeable secretion (Χ2=5.91 p=0.011;

Χ2=18.55 p=0.000; Χ

2=2.188 p=0.000,

respectively) (Table 3). It was noted that

75.6 % of the OCP group dried off their

genitals after going to the toilet while this

percentage was 86.7% in the IUCD group.

There was no significant difference found

between the two groups (Χ2=1.494

p=0.149). Looking into whether the women

wore cotton underwear, it was seen that 83.3

% of the OCP group and 77.8% of the IUCD

group wore cotton underwear; no significant

difference was found between the two

groups (Χ2=2.414 p=0.08) (Table 3). As

regards the practice of using sanitary

protection all the time, it was revealed that

74.4 % of the OCP women and 35.6% of the

IUCD group used sanitary pads daily. A

significant difference was found between the

two groups (Χ2=18.55 p=0.00) (Table 3).

Daily water consumption of less than 2 liters

was 55.6% in the OCP group and 50. % in

the IUCD group there was a significant

difference found between the two groups in

terms of this factor (Χ2=9.956 p=0.007).

Tabe 4: While bacterial growth was

observed in the urine culture results of

53.1% of the women taking COCs, bacterial

growth was found in 35.7% of the women

with IUCDs. Escherichia coli was the


Vol. 2 No. 2 May 2012 34

microorganism predominantly found in the

urine culture of women taking OCPs,while

Enterobacteria species were more

pronounced in women with IUCDs. The

results of the vaginal culture showed that

66.7% of the women using OCP and 60.7%

of the women using IUCD's did not display

any microbial growth. In the vaginal culture,

both groups of women displayed a

predominant growth of the microorganism

Candida albicans. While there was a


groups in the urine culture results (Χ2=5.045

p=0.01), no difference was discovered in the

vaginal culture (Χ22=0.631 p=0.264).

The results of the logistic regression

analysis used to determine the factors that

had an effect on the urine and vaginal

culture are shown in Tables 4 and 5. As can

be seen in Table 4, the use of OCPs (Exp:

0.12, 95% CI 0.01-0.91), wiping from back

to front (Exp: 8.66. 95% CI 1.54-48.95),

continuous use of a sanitary pad (Exp:

59.99, 95% CI 40.83-7.68), low daily water

consumption (Exp: 68.94% CI 6.21-75.98),

engaging in sexual intercourse 3-4 times a

week (Exp: 0.203, 95% CI 0.55-0.75), using

a piece of cloth hand-sewn at home as

drying material (Exp: 0.158, 95% CI 0.02-

1.22) were seen to be independent factors

that had on an effect on bacterial growth in

the urine culture, while the use of IUCDs

(Exp: 1.07, 95% CI 0.49–2.35) and

performing vaginal douching (Exp: 6.47,

95% CI 0,97-42.74) were independent

factors observed to have an effect on

bacterial growth in the vaginal culture.


Vol. 2 No. 2 May 2012 35

Table (1): Percentage distribution of identifying characteristics according to their

general characteristics and obstetrical history.

Variables Groups

General characteristics *OCP=90 **IUDC=90 Χ2

P

No % No %

Age / year

< 20

20- 25

26- 30

31-35

18

28

20

24

20

31

22

26.7

20

30

25

15

22

33

27.8

16.7

2.349

0.503

Occupation

Hose wife

Working

25

65

27.8

72.2

15

75

16.7

83.3

5.789

0.122

Educational level

Primary

Secondary

University

15

45

30

16.7

50

33

20

55

15

22.2

61.1

16.7

15.612

0.004

Monthly Income

500-1000 (Middle-class)

1001-1500 (With means)

1501-3000 (Very wealthy)

43

33

14

47.8

36.6

15.6

23

53

14

25.5

58.9

15.6

4.160

0.125

Obstetrical history

Gravidity

1-2

≥ 3

56

34

62.2

37.8

66

24

73.3

26.7

4.267

0.167

Parity

Non

1-2

≥ 3

2

54

34

2.2

60

37.8

1

65

24

1.1

72.2

26.7

3.870

0.005


Vol. 2 No. 2 May 2012 36

Number of children

1-2

3-4

No child

50

35

5

55.6

38.9

5.5

64

22

4

71.1

24.4

4.4

3.876

0.652

*OCP: Oral Contraceptive **ICUD: Intrauterine contraceptive device

Table 2: Percentage distribution of Descriptive characteristics according to vaginal

douching

Variables

Groups

*OCP=90 **IUDC=90

Χ2

P No % No %

Practicing vaginal douching

Yes

No

63

27

70

30

73

17

81.1

18.9

7.716

0.120

Frequency of vaginal douching

Once a week

2-3 times a week

23

40

36.5

63.5

23

50

31.5

68.5

5.213

0.157

Where she found out about vaginal

douching

from family elder

on her own

from friends

29

18

16

46

28.6

25.4

27

30

16

37

41

22

5.44

0.142

Materials used in vaginal douching

water

soap and water

20

43

31.7

68.3

48

25

65.8

34.2

18.77

0.000

For what purpose?

After menstruation

After sexual intercourse

26

30

41.3

47.6

45

18

61.6

24.7

5.96

*0.460


Vol. 2 No. 2 May 2012 37

After a bath 7 11.1 10 13.7

Does she regularly rinse out the

vagina?

Yes

No

38

25

60.3

39.7

48

25

65.8

34.2

7.63

0.020

Manner in which vaginal douching is

done

Fingers + water at

high pressure

Water at high pressure

52

11

82.5

17.5

20

53

27.4

72.6

29.05

0.000

Is VD harmful?

Yes

No

18

45

28.6

71.4

23

50

31.5

68.5

2.87

0.230

Number of times a week she has sex

1 – 2

3 – 4

5 and more

43

16

4

68.3

25.4

6.3

50

18

5

68.5

24.7

6.8

8.37

0.000

*OCP: Oral Contraseptive

**ICUD: Intrauterine contraseptive device

Table 3:Perecentage Distribution of some hygienic characteristics of the women

Variables Groups

*OCP=90 **IUDC=90 Χ2

P

No % No %

Post-toilet cleansing from

back to front

Yes

71

78.9

59

65.6

6.211

0.001


Vol. 2 No. 2 May 2012 38

No 19 21.1 31 34.4

Drying after going to the

Toilet

Yes

No

68

22

75.6

24.4

78

12

86.7

13.3

1.494

0.149

Drying material

Toilet paper

Cloth hand-sewn at home

53

37

58.8

41.2

68

22

75.6

24.4

5.91

0.011

Cotton underwear?

Yes

No

75

15

83.3

16.7

70

20

77.8

22.2

2.414

0.08

Always uses a sanitary pad

Yes

No

67

23

74.4

25.6

32

58

35.6

64.4

18.55

0,000

Uncomfortable discharge

Yes

No

56

34

62.2

37.8

37

53

41.2

58.8

3.85

0.001

Daily water consumption

Less than 1 liter

2 liters

More than 2 liters

30

50

10

33.3

55.6

11.1

25

45

20

27.8

50

22.2

9.956

0.007


**ICUD: Intrauterine contraseptive device

Table 4:Logistic regression analysis of variables affecting bacterial growth in urine culture

Variables

P Exp 95%CI Lower –Upper


Vol. 2 No. 2 May 2012 39

Oral Contraceptive 0.13 0.01-0.92 0.04

Vaginal douching 15.48 0.34-71.21 0.16

Wiping from back to

front

8.67 1.54-48.69 0.01

Continuous

use of sanitary

napkin

59.99 40.83-7.68 0.00

Sexual

intercourse 3-4

times a week

0.203 0.55-0.75 0.01

Using a cloth

for drying off

0.158 0.02-1.22 0.05

Consuming

less than 2

liters of water

68.94 6.21-75-98 0.00


Table 5:

Logistic regression analysis of variables affecting bacterial growth

in the vaginal culture

Variables Exp 95%CI Lower –

Upper

P

IUCD 1.07 0.49-2.35 0.03

Vaginal douching 6.47 0.97-42.74 0.05

Performing VD 0.69 0.29-1.61 0.39


Vol. 2 No. 2 May 2012 40

with the fingers

Performing VD

2-3 times a week

1.68 0.77-3.65 0.05

Continuously using a sanitary

napkin

0.53 0.26-1.08 0.08

**ICUD: Intrauterine contraceptive device

DISCUSSION

In the present study, there was a higher

percentage (81.1%) of women using IUCDs

who were practicing VD compared to the

women who were taking OCPs (70. %).

Many studies have shown that the use of

IUCDs increases the risk of vaginal

infection [22,23,25]

. Various factors play a role

in determining whether women using

IUCDs will develop an infection. These are,

among others, the technique used in

inserting the IUCD, the duration of its use,

and the age of the woman. The IUCD

changes the nature of the vaginal flora and

leads to an increase in anaerobic bacteria [17,

26].

However, many studies have also shown

that genitourinary system infections are

reduced if general hygiene is carefully

practiced, the IUCD is carefully inserted,

and regular check-ups are performed over

the period the IUCD remains in the uterus,

provided the rules of hygiene are adhered

to[24, 26]

. As it was observed in the present

study that women using IUCDs had better

toilet hygiene behavior than the women

taking OCPs, it might be said that hygiene is

one of the factors affecting the growth of

bacteria in the urine cultures of women

taking OCPs.

Failure to clean the anal region separately

leads to the colonization of microorganisms

at the entry of the urethra and vagina [26]

.

Vaginal douching, the continuous use of

sanitary napkins, and faulty washing and

cleaning after defecation increases the risk

of infection {27, 28]

.



Vol. 2 No. 2 May 2012 41

Vaginal douching has become a part of

women's general hygiene in [14,15]

. Married

women describe themselves as being soiled

when seminal fluid remains in the vagina

after sexual intercourse. Women's beliefs

cause women to regard the vagina as

contaminated after intercourse. Women

practice vaginal douching to feel clean again

and many studies have shown that women

practice vaginal douching to restore their

sense of wellness and cleanliness [10,18]

.

Other reasons reported as to why women

perform vaginal douching have been vaginal

discharge, eliminating itching or odor,

preventing or treating sexually transmitted

diseases or vaginal infections, and using the

practice as a contraceptive measure [8,10,14,29]

.

The practice is common as it is a part of the

full ablution regimen required by the

religion after sexual intercourse. 4,10In the

present study, VD was resorted to primarily

after menstruation and sexual intercourse.

Hodoğlugil et al. reported in a study they

conducted in the Black Sea Region in 2000

that VD was practiced by 64.0% of women

using IUCDs and by 64.5% of women that

were not. In the present study, our finding

was that more women with IUCDs were

practicing VD compared to women taking

OCPs; this is consistent with the literature.

In the study, the women in the OCP

and IUCD groups said that they performed

vaginal douching 2-3 times a week. In a six-

month study conducted in the US, it was

found that 22% of women practice vaginal

douching [28]

. The detergents, soaps, acetic

acid, perfumes and other agents that may be

used in vaginal douching disturb the vaginal

flora and prepare a suitable environment for

infection [10,16,29]

. Various studies have

shown that soap and water are the

substances that are most commonly used in

vaginal douching [6,14]

.

In the present study, the use of soap

and water was more pronounced in women

taking OCPs compared with those using

IUCDs. Most of the women taking OCPs

were using their fingers to wash the vagina

with soap and water whereas most of the

women with IUCDs were practicing VD by

washing out the vagina with water at high

pressure without using the fingers. IUCDs in

particular are a potential risk factor and

although the women with IUCDs, who were


Vol. 2 No. 2 May 2012 42

using less soap than the OCP group and

refraining from using their fingers, instead

flushing out the area with water at high

pressure, exhibited more prominent bacterial

growth in the culture, both methods resulted

in the development of vaginal infection The

transport into the urinary tract of

microorganism colonies developing in the

vagina is facilitated by the fact that the

exterior one-third of the urethra, which is

short in women, is in constant contact with

intestinal flora [26]

. The regions of the body

that are conducive to the colonization of

microorganisms are the vagina, rectum, and

ureter. The type of underwear worn, the

form of cleansing, the materials used, among

other factors, are all instrumental in the

degree these three areas are protected [10]

.

Since the continuous use of a sanitary

napkin keeps the vagina moist, an

environment that allows bacteria to grow is

thus created.

In many studies it has been shown

that a large percentage of women use

sanitary pads continuously, either because of

religious beliefs or as a customary habit. It

has been proven in many studies that daily

water consumption can prevent urinary tract

infections [17,26]

. In our study, the

predominance in the OCP group of

uncomfortable vaginal discharge, cleansing

from back to front, continuous use of

sanitary napkins, daily water consumption of

under 2 liters, and the use of cloths as drying

materials after going to the toilet were the

factors that resulted in more bacterial growth

in the urine culture compared to the IUCD

group. At the same time, it is known that

estrogen facilitates the settling of

uropathogens in the vagina and urogenital

cells and that some antibiotics spoil the

vaginal flora, creating an environment where

microorganisms can grow freely [15,19]

. The

difference observed in the urine culture of

women taking OCPs in the present study

was a product of the characteristic of such

agents, a factor which was intensified by the

deficiencies in hygiene that were observed

in the study.

Conclusion and Recommendation

Women continue to practice

traditional habits that can be recognized as

VD. Changing these traditions is a difficult

task that will require time. VD is practiced,


Vol. 2 No. 2 May 2012 43

regardless of whether the hazards to the

health are known or not. When the variety of

reasons women practice VD are considered,

it is of importance to study women's

hygienic practices and educate them about

the mistakes they are making. It is important

that members of a health team offer women

the opportunity for an exchange of

information, working to prevent the

complications that faulty technique and lack

of attention to the rules of hygiene can bring

about. The early discovery of mistakes is

essential, not only in terms of preventing

potential health problems in women but also

in treating existing problems early on.

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21. Turkish Population and Health Research

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Vol. 2 No. 2 May 2012 88

Whiff Test and Vaginal pH >4.5 as Rapid and Accurate Bed-side Screening Test for

Vaginal Infection

Sahar Fahmy Gawad

Lecturer of Obstetric & Gynecology Nursing,

Faculty of Nursing, South Valley University (Kena), Egypt

Abstract

Bacterial vaginosis and Trichomonas virginals infection have been associated with adverse

pregnancy and health outcomesAims of the study : To evaluate the diagnostic yield of

determination of vaginal pH considering pH>4.5 as diagnostic for vaginal infection and positive

Whiff test as rapid bed-side diagnostic tests and their applicability as screening tests for vaginal

infection in women apparently free of symptoms Materials & method: The current study

included 120 women; 60 women were complaining of vaginal discharge (Patient group) and

another 60 women have no complaint of vaginal discharge (Screening group). An un-lubricated

Cusco’s vaginal speculum was inserted into the vagina and characteristics of the discharge with

respect to amount, odor and type of discharge were evaluated. Two samples of the vaginal

discharge collected on dry sterile cotton wool tipped swabs. Secretions from the second swab

were placed on pH indicator strips with a pH range of 3.5 to 6 to determine vaginal pH. Two

drops of 10% KOH solution were added to the second and release of fishy amine odor signified a

positive whiff test.Results: Thirty-three patients (55%) complained of vaginal discharge, 5

patients (8.3%) had itching and 14 patients (23.3%) had history of recurrent discharge and past

history of treatment. Thirty-nine patients 39 (65%) had positive whiff test and 43 swabs (71.7%)

had pH>4.5. Twenty-seven patients were missed on reliance on clinical data only, while 21

patients were missed in case of whiff test and only 17 patients in case of pH>4.5. Thus, both tests

improved the diagnosis of vaginal infection with sensitivity rate of 85% and accuracy rate of 65%

compared to sensitivity rate of 58.9% and accuracy rate of 46.7% for clinical alone. Conclusion:

Determination of vaginal pH >4.5 and positive Whiff test are rapid, simple and easy to perform

as bed-side diagnostic tests and could be used as screening tests for vaginal infection in women

apparently free of symptoms.


Vol. 2 No. 2 May 2012 88

Introduction

Bacterial vaginosis and Trichomonas

virginals infection have been associated with

adverse pregnancy and health outcomes.

Being the most common vaginal infections

among women. BV and TV increase risk for

acquisition of other sexually transmitted

infections. In obstetrics, BV has been

implicated in causing higher rates of late

miscarriage, preterm premature rupture of

membrane, chorio-amnionitis, spontaneous

preterm labor, preterm birth, and postpartum

endometritis (1, 2, 3)

.The high prevalence of

BV and TV and the large burden of

associated disease, there is a compelling

public health need for simple and

inexpensive point-of-care diagnostic tests for

expanded screening of women especially in

poor settings (4)

.In many parts of the

developing world, laboratory diagnosis of

vaginal infections is not available outside

urban areas. Even simple and inexpensive

methods such as Gram stain of vaginal

smears or microscopic examination for

motile trichomonads are generally beyond

the reach of most primary healthcare settings

(5)Healthcare workers typically manage

vaginal infections using a syndromic

approach which bases treatment on

symptoms and signs. Unfortunately, studies

have shown low sensitivity and low

predictive values for diagnoses of

reproductive tract infections (RTI) using a

syndromic approach among women. Such an

approach not only misses asymptomatic

infections but also results in substantial

under-diagnosis and over-treatment of BV

and TV (6-9)

.The present study aimed to

evaluate the diagnostic yield of

determination of vaginal pH considering

pH>4.5 as diagnostic for vaginal infection

and positive Whiff test as rapid bed-side

diagnostic tests and their applicability as

screening tests for vaginal infection in

women apparently free of symptom

Materials & method

Research design:

The research was prospective study

Setting:

The study was conducted at the outpatient

clinic of Department of Obstetrics &

Gynecology, South Valley University

Hospital at Kena


Vol. 2 No. 2 May 2012 89

Subject:

The subject was composed of 120 women

were enrolled in the study. Sixty women

were collected from those attending the

gynecology outpatient clinic complaining

from vaginal discharge (Patient group)

-Another 60 women collected from those

attending Family Planning Clinic requesting

for appropriate contraceptive modality and

have no complaint of vaginal discharge

(Screening group).

Tools of data collection

Structure questioner sheet was developed by

the researcher to collect the necessary data

which includes the following:

Part I: Socio demographic data: which

includes as age, marital status, educational

level, occupation, and parity were recorde

Part II

Participants were asked about their

symptoms, the nature of their complaints

concerning presence and amount of

discharge, presence of itching, past illness,

and history of treatment before enrollment.

Pregnant and menstruating women or those

who had used antibiotics and/or topical

vaginal creams within seven days prior to

the date of examination were excluded from

the study.

Tool II

An un-lubricated Cusco’s vaginal

speculum was inserted into the vagina and

characteristics of the discharge with respect

to amount, odor and type of discharge were

evaluated.

Two samples of the vaginal discharge

collected on dry sterile cotton wool tipped

swabs. Secretions from the second swab

were placed on pH indicator strips with a pH

range of 3.5 to 6 to determine vaginal pH.

Two drops of 10% KOH solution were

added to the second and release of fishy

amine odor signified a positive whiff test.

Results

As regarding sociodemogrphic data, the

study included 120 women with mean age of

34.9±3.4; ranged from 23-41 years. The

majority of studies sample were age group

of 30-40 years. Eighty-nine women were

currently married while 9 women were

single while 11 were widow and 11 were


Vol. 2 No. 2 May 2012 90

divorced. Twenty-three women were

university graduate, As regarding

educational level , it was noticed that 41

women were high school graduate while 35

%of them were not graduated and 21% of

them were illiterate. Only 11 women were

nullipara, 21 women were primpara, 40

women were para-two, 32 women were

para-three and 16 women were para-four.

There was non-significant difference

between both groups as regards enrollment

data, (Table 1).

Thirty-three patients (55%) complained of

vaginal discharge which was profuse in 11

patients (18.3%), minimal in 15 patients

(25%) and scanty in 7 patients (11.7%). Five

patients (8.3%) had itching and 14 pa tients

(23.3%) had history of recurrent discharge

and past history of treatment.

Among studied patients 39 women (65%)

had positive whiff test and 43 swabs (71.7%)

had pH>4.5, while both tests were positive

in 22 patients. Only 10 patients had

discharge gave positive pH test, 11 patients

had discharge gave positive whiff test and

12 patients had discharge gave positive both

tests, (Table 2, Fig. 1). Considering presence

of vaginal discharge as the frequent clinical

symptom and the main complaint, 27

patients will be missed on reliance on

clinical data only. On contrary 21 patients

will be missed on reliance on whiff test and

only 17 patients in case of pH>4.5. Thus,

both tests improved the diagnosis of vaginal

infection with sensitivity rate of 85% and

accuracy rate of 65% compared to sensitivity

rate of 58.9% and accuracy rate of 46.7% for

clinical alone.Application of both tests to

screen the apparently healthy group allowed

detection of 28 cases with vaginal infection

despite the absence of complaints or clinical

findings. Fifteen women (25%) had vaginal

pH>4.5, while 13 women gave a swab

giving positive Whiff test and 5 of these

women gave both tests positive (Table 3,

Fig. 3).


Vol. 2 No. 2 May 2012 88

Table (1): Percentage distribution of the Study participants as regarding socio

demographic data enrollment data

Total Patients

group

Screening

group

Statistical

difference

Age (years) Strata 20-25 2 (1.7%) 1 (1.7%) 1 (1.7%) p>0.05

>25-30 11 (9.2%) 6 (10%) 5 (8.3%)

>30-35 51 (42.5%) 26 (43.3%) 25 (41.7%)

>35-40 52 (43.3%) 23 (38.3%) 29 (48.3%)

>40 4 (3.3%) 4 (7.7%) 0

Total 34.9±3.4

(23-41)

34.8±3.7

(23-41)

35±3.2

(25-40)

p>0.05

Marital

status

Single 9 (7,5%) 5 (8.3%) 4 (6.7%) p>0.05

Currently married 89 (74.1%) 42 (70%) 47 (78.3%)

Divorced 11 (9.2%) 6 (10%) 5 (8.3%)

Widow 11 (9.2%) 7 (11.7%) 4 (6.7%)

Educational

status

Illiterate 21 (17.4%) 11 (18.2%) 10 (16.7%) p>0.05

Educated but not

graduated 35 (29.2%)

18 (30%) 17 (28.4%)

High school 41 (34.2%) 19 (31.8%) 22 (36.7%)

University graduate 23 (19.2%) 12 (20%) 11 (18.3%)

Parity 0 11 (9.2%) 6 (10%) 5 (8.3%) p>0.05

1 21 (17.5%) 10 (16.7%) 11 (18.3%)

2 40 (33.3%) 22 (36.7%) 18 (30%)

3 32 (26.7%) 15 (25%) 17 (28.4%)

4 16 (13.3%) 7 (11.6%) 9 (15%)


Vol. 2 No. 2 May 2012 89

Data are presented as mean±SD & numbers; ranges & percentages are in parenthesis

Table (2): Percentage distribution of Patients groups regarding Clinical and swab

examination

Data Number Percentage

Clinical

data

Discharge Profuse 11 18.3

Minimal 15 25%

Scanty 7 11.7

Total 33 55

Itching 5 8.3

Recurrent complaint 14 23.3

Swab

examination

pH>4.5 Positive 43 71.7

Negative 17 28.3

Whiff test Positive 39 65

Negative 21 35

Both Positive 22 36.7

Negative 38 63.3

Table (3): Percentage distribution of screening groups regarding Clinical and swab

examination

Test Result Number Percentage

pH>4.5 Positive 15 25

Negative 45 75

Whiff test Positive 13 21.7

Negative 47 78.3

Both Positive 5 6.3


Vol. 2 No. 2 May 2012 90

Negative 55 93.7

Fig. (1): Frequency of clinical data and swab findings in

patients group

0

5

10

15

20

25

30

35

40

45

50

Pati

en

t

ClinicalpH>4.5Positive Whiff test

Fig. (2): Test validity rates of clinical and/or swabing

for diagnosis of vaginal infection

0

10

20

30

40

50

60

70

80

90

Clinical only Clinicl & Swabbing

(%)

Senstivity

Accuracy


Vol. 2 No. 2 May 2012 91

Fig. (3): Frequency of positive swab result among

women screened for infection

0

2

4

6

8

10

12

14

16

18

20

pH>4.5 Positive Whiff test

Sw

ab


Vol. 2 No. 2 May 2012 88

Discussion

The frequency of vaginal discharge varied

between various populations and among

certain population; in developing countries

the frequency of vaginal infection varied

between 20 to 50% of non-pregnant women

and bacterial vaginosis was found to affect

about 70% of women (10, 11)

.

Proper diagnosis of bacterial vaginosis is

challenging. In addition to scientific

considerations, choosing a method for

laboratory diagnosis requires consideration

of complexity, cost, and the frequency of un-

interpretable specimens. Nevertheless, some

alternative diagnostic methods have been

developed, such as the polymerase chain

reaction, rapid nucleic acid hybridization

test, proline amino peptidase activity. More

recently, several point-of-care tests based on

various combinations of microbial products,

presence of RNA, or more complex

laboratory instrumentation such as sensor

arrays, have also been introduced for the

diagnosis of bacterial vaginosis. However,

most of these are expensive and their

sensitivities and specificities do not offer a

huge advantage over the classical methods

(12, 13).

Through the current study, the

dependence on clinical manifestations

allowed identification of 33 patients with

vaginal infection, while reliance on positive

Whiff test allowed detection of 39 patients

and vaginal pH>4.5 allowed detection of 43

patients. Thus, reliance on these rapid bed-

side tests raised sensitivity for presence of

vaginal infection to 89% and accuracy of

diagnosis to 65%. The diagnostic bed-side

tests were applied to non-symptomatizing

women considering themselves free of

vaginal infection and could identify 28 cases

of vaginal infection, so both tests could be

used for screening of vaginal infection

among apparently healthy women. In line

with the reliance on these both tests in

conjunction with clinical manifestations if

present; Madhivanan et al. (14)

compare the

performance of simple inexpensive point-of-

care tests; vaginal pH; and Whiff test to

laboratory diagnosis including serology for

HSV-2; cultures for TV, Candida sp., and

Neisseria gonorrhoeae; Gram stains and

found that in the absence of laboratory


Vol. 2 No. 2 May 2012 89

diagnostics, vaginal pH; and Whiff test is

not only inexpensive and practical, but also

significantly more sensitive than the

syndromic management approach, resulting

in less over-treatment.

Quan (15)

documented that vaginitis

is one of the most common ambulatory

problems to occur in women, the medical

history and examination are an important

source of clues to the underlying diagnosis;

however, making a definitive diagnosis

requires skillful performance of office

laboratory procedures, including the vaginal

pool wet mount examination, determination

of the vaginal pH, and the whiff test and

vaginal and cervical cultures, nucleic acid

tests, and point-of-care tests are available

and may be required in selected patients.

Thulkar et al. (16)

evaluated sensitivity and

specificity of pH test and Whiff test in

diagnosis of abnormal vaginal discharge,

considering microscopic diagnosis as gold

standard and found pH ≥4.5 and positive

Whiff test had sensitivity of 94.1% and

specificity 87.5% in diagnosing vaginal

infection and concluded that pH test and

Whiff test can improve diagnostic value of

speculum examination where microscope

facilities are not available.

Hainer & Gibson (17)

stated that

bacterial vaginosis, trichomoniasis, and

vulvovaginal candidiasis are the most

common infectious causes of vaginitis and

diagnosis is commonly made using the

Amsel criteria, which include vaginal pH

greater than 4.5, positive whiff test, milky

discharge, and the presence of clue cells on

microscopic examination of vaginal fluid.

The procedure as a whole was

applied by the author, a gynecologically

qualified staff nurse without the attendance

of physician, and owing to simplicity and

good yield could be applied as training

course for nurses working in healthcare units

for widespread screening program. In hand

with this assumption, multiple studies tried

self-obtained swabs for diagnosis of

vaginitis and reported applicability.

Huppert et al. (18)

compared the accuracy of

self-performed point-of-care tests with

clinician-performed tests for trichomoniasis

in adolescent women and found that young

women performing a self-point-of-care test


Vol. 2 No. 2 May 2012 90

detected as many trichomoniasis infections

as clinician- point-of-care tests or culture,

twice as many as wet mount and slightly

fewer than an amplified test. Incorporating

self-obtained or self-performed point-of-care

tests into routine practice could effectively

increase the identification and treatment of

trichomoniasis in this vulnerable

population.It could be concluded that

determination of vaginal pH >4.5 and

positive Whiff test are rapid, simple and

easy to perform as bed-side diagnostic tests

and could be used as screening tests for

vaginal infection in women apparently free

of symptoms.


Vol. 2 No. 2 May 2012 88

References

1-ElyanA, Rund N: Bacterial vaginosis and

pregnancy. ASJOG, 2004; 1: 179-84.

2-McClelland RS, Sangare L, Hassan WM:

Infection with Trichomonas vaginalis

increases the risk of HIV-1 acquisition.

Journal of Infectious Diseases, 2007; 195,

698–702.

3-Atashili J, Poole C, Ndumbe PM, Adimora

AA, Smith JS: Bacterial vaginosis and

HIV acquisition: a meta-analysis of

published studies. AIDS, 2008; 22, 1493–

501.

4-Bologno R, Díaz YM, Giraudo MC,

Fernández R, Menéndez V, Brizuela JC,

Gallardo AA, Alvarez LA, Estevao

Belchior SG: Importance of studying the

balance of vaginal content (BAVACO) in

the preventive control of sex workers.

Rev Argent Microbiol. 2011;43(4):246-

50.

5-Mullick S, Watson-Jones D, Beksinska M,

Mabey D: Sexually transmitted infections

in pregnancy, prevalence, impact on

pregnancy outcomes, and approach to

treatment in developing countries.

Sexually Transmitted Infections, 2005;

81, 294–302.

6-World Health Organization: Management

of Symptomatic STIs . RTIs Sexually

Transmitted and Other Reproductive

Tract Infections . A Guide to Essential

Practice. WHO, Geneva, 2005.

7-Tann CJ, Mpairwe H, Morison L: Lack of

effectiveness of syndromic management

in targeting vaginal infections in

pregnancy in Entebbe, Uganda. Sexually

Transmitted Infections, 2006; 82, 285–9.

8-Romoren M, Velauthapillai M, Rahman

M, Sundby J, Klouman E, Hjortdahl P:

Trichomoniasis and bacterial vaginosis in

pregnancy, inadequately managed with

the syndromic approach. Bulletin of

World Health Organisation, 2007; 85,

297–304.

9-Onyekonwu CL, Olumide YM, Oresanya

FA, Onyekonwu GC: Vaginal discharge:

aetiological agents and evaluation of

syndromic management in Lagos. Niger J

Med. 2011;20(1):155-62.


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10-Rivers CA, Adaramola OO, Schwebke

JR: Prevalence of bacterial vaginosis and

vulvovaginal candidiasis mixed infection

in a southeastern american STD clinic.

Sex Transm Dis. 2011; 38(7):672-4.

11-Sherrard J, Donders G, White D, Jensen

JS; European IUSTI: European

(IUSTI/WHO) guideline on the

management of vaginal discharge, 2011.

Int J STD AIDS. 2011; 22(8):421-9.

12-Menard JP, Mazouni C, Fenollar F,

Raoult D, Boubli L, Bretelle F:

Diagnostic accuracy of quantitative real-

time PCR assay versus clinical and Gram

stain identification of bacterial vaginosis.

Eur J Clin Microbiol Infect Dis. 2010;

29(12):1547-52.

13-Ram JL, Karim AS, Sendler ED, Kato I:

Strategy for microbiome analysis using

16S rRNA gene sequence analysis on the

Illumina sequencing platform. Syst Biol

Reprod Med. 2011;57(3):162-70.

14-adhivanan P, Krupp K, Hardin J, Karat

C, Klausner JD, Reingold AL:Simple and

inexpensive point-of-care tests improve

diagnosis of vaginal infections in

resource constrained settings. Trop Med

Int Health. 2009; 14(6):703-8.

15-Quan M: Vaginitis: diagnosis and

management. Postgrad Med. 2010;

122(6):117-27

16-Thulkar J, Kriplani A, Agarwal N: Utility

of pH test & Whiff test in syndromic

approach of abnormal vaginal discharge.

Indian J Med Res. 2010;131:445-8.

17-Hainer BL, Gibson MV: Vaginitis. Am

Fam Physician. 2011; 83(7):807-15.

18-Huppert JS, Hesse E, Kim G, Kim M,

Agreda P, Quinn N, Gaydos C:

Adolescent women can perform a point-

of-care test for trichomoniasis as

accurately as clinicians. Sex Transm

Infect. 2010;86(7):514-9.


Vol. 2 No. 2 May 2012 88

Effects of Topical Honey Dressing on Infected Wounds after Gynecological and Obstetrical

Abdominal Surgery

Mona Abd El-Haleem Ebraheem El-Agamy

Assistant lecturer Maternity and Gynecological Nursing

Faculty of Nursing, Tanta University.

Prof. Dr.Shadia Abd El-kader Hassan

Maternity and Newborn health Nursing,

Faculty of Nursing, Cairo University.

Naeim Fatoh El Far

Prof. of Microbiology,

Faculty of Medicine, Tanta University.

Iman Abd El-Azziz El-Khayat

Lecturer of Maternity and Gynecological Nursing,

Faculty of Nursing, Tanta University.

Abstract

Despite use of prophylactic antibiotics, wound infections remain common. Post operative wound

infections develop in 4% of patients following inpatient gynecologic surgery and in 5% to 7% of

patients undergoing primary cesarean section. The use of honey as a wound dressing material is

an ancient remedy that has been rediscovered. The aim of the study is to evaluate the effects of

topical honey dressing on infected wounds after obstetrical and gynecological abdominal surgery

as compared to the routine hospital wound care. This study was conducted on 60 women were

recruited from Tanta University hospitals at Obstetrical and Gynecological Department. Where

30 of them were dressed according routine wound care of the hospitals, which includes local

antiseptics, daily dressing, and antibiotic. And the others were dressed by honey (Api-care)

dressing plus the routine hospital wound care. The result of the study revealed that the mean age

of the honey group was 30.87 ± 8.41 while the other groups mean age was 35.17 ± 9.92 which

was statistically not significant (p=0.061). Results of honey dressing showed remarkable change


Vol. 2 No. 2 May 2012 89

compared to other method. After 6 days of dressing, wound appearance among those dressed by

honey was normal among 100% of cases compared to grey or white pallor appearance for the

other group. Honey dressed group showed 100% significant improvement, mild pain, non

exudates which was significantly different from other group (p=0.001). the mean duration of

management of cases with honey was found to be 11 days compared to 20 cases for other group

which was found to be significantly different at p=0.001. The researcher concluded that topical

application of sterile topical honey cream (Api-care) could eradicate organisms within short time,

reduce period of antibiotic use, accelerate the healing process in unique and economic way, result

in minimal scar formation, prevent wound dehiscence and need for re- suturing. weight, 15.8% in

overweight, and 37.5 in obese women (4)

.


Vol. 2 No. 2 May 2012 88

Introduction

Hysterectomy and cesarean section are the

most commonly performed operations

among inpatients at Egyptian Hospital (1)

.

The two most frequent complications of

these surgeries are fever and surgical site

infections (SSIs). The use of prophylactic

antibiotics in hysterectomy and cesarean

section in Egyptian hospitals is not

standardized and is determined by the

consultant in charge of the case.

Inappropriate and prolonged use of

antibiotics is a serious problem. It increases

the morbidity and mortality of patients and

also increases health care costs due to

increased antibiotic resistance rates (2)

.

SSIs developed in 4% of inpatient

undergone gynecologic surgery and in 5% to

7% of patients’ undergone primary cesarean

section (1,3)

. According study In Egypt

about wound infection after Cesarean

Section and women weight; wound

infections were 11.4 % in normal Surgical

site infections (SSIs) continue to pose a

major problem for many surgery patients. Its

occurrence is associated with readmission,

repeated surgery or intervention, prolonged

hospitalization and significant clinical and

economic consequences. The risk is

particularly high in developing countries due

to mal-nutrition, illiteracy, improper surgical

technique, substandard sterilization of

operation theatres and inadequate or over

burdened health facilities (5,6,7)

. Data on SSI

rates is not available in Egypt; however,

other sources of data suggest that there is

poor compliance in aseptic techniques and

Increase the cost of the hospital stay 7 – 8

days for a SSI (7)

. In Egypt, every one

Egyptian pound spent for infection control

saves 60 Egyptian pound spent on

nosocomial infection (8)

.

Nursing care of the female surgical patient

requires an accurate understanding of the

pathophysiologic changes that occur

perioperatively. The nurse should maintain

proper environment and appropriate

interventions; the first nurse's goal during

the postoperative period is to provide

appropriate support that allows for the

maintenance of homeostasis and the

prevention of potential complications. The

second goal is to recognize unfavorable


Vol. 2 No. 2 May 2012 89

trends in the course of recovery and respond

expeditiously to prevent further compromise.

Much information can be obtained by close

monitoring of vital signs. Changes of these

measurements reflect the patient's ongoing

condition (9)

.

The management of the incision is based

on the normal biology of the healing

process, which is conceptually divided into

three phases. Initial phase (inflammation),

second phase (fibroblast proliferation) and,

third phase (maturation). The operative

dressing can be removed after 24-48 hours.

If wound drainage is noted upon inspection,

a sterile dressing must be replaced until the

drainage ceases and closure is attained. On

the other hand, allowing sutures to stay in

place for a long period increases scar

formation at the sites of skin penetration. In

healthy individuals with an abdominal

incision, sutures can be removed on the third

postoperative day. (9.10)

. Temperature

elevation higher than (38°C) in the surgical

patient should alert the nurse of potential

complications. Evaluation and subsequent

therapy are dependent on how soon after

surgery the fever develops. Postoperative

fever in the First 24-48 hours may refer to

wound infection. Signs may include crepitus,

pain, and edematous discoloration.

Treatment consists of aggressive

intraoperative debridement and drainage and

broad-spectrum antibiotics. The use of

drains, tubes, and suction devices at the

wound site is often necessary to promote

healing. It is important to know the type of

drain or tube in use so that patency and

placement can be accurately assessed. Once

a diagnosis of wound infection has been

confirmed and antibiotic sensitivities

identified, appropriate management

regimens should be considered, with a high

priority given to reducing the risk of cross

infection. It is important to treat the patient

as a whole and not the infection alone, so

management strategies must be based on

data driven from a holistic assessment of

individual needs (11, 12,13)

.

Many researchers supported the use of

honey in managing infected wounds and

stated its prophylactic use on the wounds of

patients susceptible to infections and

antibiotic-resistant bacteria. Egyptian honey

is effective as an antibacterial agent against


Vol. 2 No. 2 May 2012 90

different pathogenic bacteria. Most of

honey samples can completely inhibit the

growth of all bacteria. The use of honey as a

wound dressing material is an ancient

remedy that has been rediscovered. Honey is

produced from many different floral sources

and its antibacterial activity varies with

origin and processing. Honey selected for

clinical use should be evaluated on the basis

of antibacterial activity levels determined by

laboratory testing. Antibacterial properties of

honey include the release of low levels of

hydrogen peroxide and phytochemical

antibacterial components. So appropriate use

of topical honey dressing helps to reduce the

bacterial burden on the wound surface

(4,10,14).

Post operative obstetrical and gynecological

nursing professionals play a crucial role in

early detection of wound infections. Failure

to do this, can result in serious patients'

outcomes. Post operative nurses can expand

their current efforts through implementing

strategies to providing effective management

of infected surgical wound (11,12,13,15)

.

Practical guide on the use of honey in

managing infected surgical wounds, such as

amount of honey, concentration, type of

dressing, appropriate use and frequency

were considered and followed by the

researcher. So, this research was carried out

to early detection of SSIs and examines the

effects of honey dressing on optimal healing

of infected abdominal surgical wound of

obstetrical & Gynecological surgeries.

The aim the study was:-

To evaluate the effects of topical honey

dressing on infected wounds after obstetrical

and gynecological abdominal surgery as

compared to the routine hospital wound care.

Materials and Method

Subjects:

A total sample of 60 women was recruited

from the previously mentioned setting,

through the first three days after the surgery

according the following criteria:

Women are in the childbearing age (16-49

year). Post operative abdominal obstetrical

or gynecological patients. Appearance of

surgical site infection signs or symptoms

such as; redness, tenderness, infected

discharge, bad smell in the wound, fever

more than 38oC, faster pulse rate and faster

breathing. Signs and symptoms of infection

http://www.scialert.net/asci/result.php?searchin=Keywords&cat=&ascicat=ALL&Submit=Search&keyword=pathogenic+bacteria


Vol. 2 No. 2 May 2012 91

would are confirmed by wound culture.

Excluding patients who have any

medical disorder as; cardiac failure, chronic

respiratory problems, vascular disorders,

diabetes, renal and liver insufficiency and,

patients with hemoglobin ≤8 mg/ml. In

addition, patient receiving drug therapies

which may interfere with wound healing as

chronic steroid therapy, immunosuppressant

drugs, and anticoagulants were also

excluded.

Then the sample was divided into two

groups 30 women each. These subjects were

randomly divided into control group in odd

number and study group in even number.

The aim is to evaluate the effects of topical

honey dressing on surgical site infection

after obstetrical and gynecological

abdominal surgery compared to the routine

hospital wound care.

A- Control group:They were exposed to the

routine wound care of the hospital, which

include local antiseptics, daily dressing,

cultures from purulent discharge and

antibiotic policy.

B- Study group: They were exposed to

application honey dressing plus the

routine hospital wound care. The amount

of applied honey depended on the amount

of exudates. Tools of data collection

To achieve the aim of the study the

following tools were used.

I- Interview questionnaire was

developed by the researcher to collect

the required data about the study.

It was comprised of:

1- Sociodemographic data, which include:-

age, occupation, education, and family

history of medical diseases….etc

2- Patient medical history includes:- history

of the operation treatment and

complications….etc

II: An observation checklist to assess the

wound characteristics: site, size, color, odor,

amount, type of exudates and pain

assessment during hospitalization.

The findings of the current study are as

follows:-

There were significant differences in

progress of wound healing concerning skin

appearance surrounding wound. The

differences in progress started to be clear in

the 6th

day after application of honey


Vol. 2 No. 2 May 2012 92

dressing . The skin became normal in the 9th

day in the study group.

Table (1): Represents Follow-up signs of

wound assessment (Skin appearance

surrounding wound) among the studied

subjects (study and control groups).It was

observed that, there were statistical

significant differences in progress of wound

healing concerning skin appearance

surrounding wound. In the first three days

the skin was White or gray pallor in the two

groups, But in the 6th day the difference in

progress started to be clear as (76.7%) of the

study group become pink and 23% is bright

red or blanch to touch. Gradually at the 9th

day skin become normal in the study group.

Contingency concerning control group there

was (86.7%) Skin appearance surrounding

wound was Bright red or blanches to touch

and (13.3 %) their wound was White or gray

pallor or hypo pigmented. Regarding

inflammatory response at the 9th

day of

management, there was not any response in

each case in the study group (100%) But, in

the control group there was (63.3%) their

wound was red and (13.3%) was red with

hotness. But at 21st day (86.7%) of subjects

was relived from inflammatory response

except (13.3%) of subjects) were still

suffering.

Graph (4) shows illustration of the mean

rank for the inflammatory variable for

both groups and the results was as

following:

In the first three days, there is

difference between the two

groups as the control group takes

the mean rank value (16.38) and

study group takes the mean rank

value (44.62) which means that

the treatment on the control

group has a better effect in that

earlier period.

After six days there is difference

between the two groups as the

control group takes the mean

rank value (17.43) and study

group takes the mean rank value

(43.57) which means that the

treatment on the control group

has a better effect.

After nine days there is

difference between the two

groups as the control group takes


Vol. 2 No. 2 May 2012 93

the mean rank value (40) and

study group takes the mean rank

value (21) which means that the

treatment on the study group has

a better effect at the end of the

nine days.

Exudates disappeared in all subjects

(100%) in the study group at the 9th

day after application of honey

dressing, whereas the amount of

exudates was large in (36.3%) of

subjects and small in (36.3%) of

subjects in the control group till the

9th

day.

Concerning control group at 21st day

(13.3%) were purulent and (83.3%)

were changed to serous.

After the 6th

day, all wounds were

closed with a remarkably observed

improvement in the study group.

At the 9th

day, the pain during wound

dressing disappeared in the study

group comparing to two third (63.3%)

of subjects were complaining from a

severe pain and (36.7%) of subjects

were complaining from a mild pain in

the control group.

Graph (6) represents distribution of

the study groups according to their

wound size after 3 weeks of honey

application. It was found that the

mean of wound length was

15.83±2.45 in the study group and

16.37±2.95 in the control group.

Regarding width of wound after three

week of the application of honey,

there were significant different. As it

was 3-5 mm in the study group and 5-

8 mm in the control group with mean

4.10±0.76, and 6.63±0.96

respectively.

After 3 weeks of honey application.

Regarding width of wound , it ranged

from 3-5 mm in the study group and

from 5-8 mm in the control group

with mean 4.10±0.76, and 6.63±0.96

respectively


Vol. 2 No. 2 May 2012 88

Table (1): Follow-up signs of surgical site assessment among the studied subjects (study and

control groups).

Follow-up signs

of surgical site

assessment

( Skin appearance

surrounding

wound)

Study group

(n=30)

Control group

(n=30)

3rd

days 6th

day 9th

day 3rd

days 6th

day 9th

day

N % n % N % N % N % n %

-Color:

-Pink or normal 0 0 23 76.7 30 100 0 0 0 0 0 0

-Bright red or

blanches to touch

0 0 7 23.3 0 0 0 0 11 37 26 86.7

-White or gray

pallor or hypo

pigmented

30 100 0 0 0 0 30 100 19 63 4 13.3

-Black or

hyperpigmentate

d

0 0 0 0 0 0 0 0 0 0 0 0

X 42.889* 60*

-Inflammatory

response:

None 0 0 0 0 30 100 0 0 0 0 11 36.7

Redness 23 76.7 28 93.3 0 0 29 96.7 28 93.3 15 63.3

Redness &

Hotness

7 23.3 2 6.7 0 0 1 3.3 2 6.7 4 13.3

X 56.5* 56* 27.805*


Vol. 2 No. 2 May 2012 89

Graph (4) illustration of the mean rank for the inflammatory variable for both

groups

Graph (2): Mean width of wound of the studied groups after 3 weeks of honey application

0

1

2

3

4

5

6

7

Experimental group(n=30)

Controll group (n=30)

4.1

6.63

Wound width (mm)

Woundwidth(mm)


Vol. 2 No. 2 May 2012 90

Discussion

Socio-demographic data include age,

education, occupation, smoking, income,

and residency. As determined in the

study criteria all women were in

childbearing period but the current study

revealed that the mean and the standard

deviation of the age were 30.87 and 8.41

years respectively for the study group

and were 35.17 and 9.92 years

respectively for the control group. Most

of study group and control group were

illiterate. As known from our previous

experience, most of the university

patients are poor and with low level of

education. This was clear in the present

study as the majority of subjects were

housewives, live in rural area and their

income was less than enough. (El-

Zanaty & Ann, 2008) (8)

.

In the present study, obesity was the most

determent grade representing about two

fifth in the study group and nearly three fifth

in the control group, with considerable

percentages of over-weight in both groups.

This finding is in accordance with

(Nahmias, 2007) (125)

, who stated that, in

2005, both the mean and the median of BMI

increased to about 28. Obesity and

overweight have been increasing in Egypt

over the last decade and are still now at

levels that are even higher than those seen in

the West. Obese women are more at risk of

postpartum complications such as infections,

hemorrhage and embolisms. Taken all

together, maternal mortality and morbidity is

significantly elevated for obese women.

In the present study concerning the

obstetrical history, about half of the two

groups were gravid 3-4, Para 3-4. In

addition to 3-4 as the number of living

children represents the highest

percentage in both groups. The majority

of subjects were not exposed to abortion.

These results approximately match with

the study carried out by Nahmias (2007)

(125). who had extracted the data from the

demographic and health Surveys

conducted in Egypt in 1992, 1995, 2000

and 2005. These are large surveys carried

out periodically and intended to be

uniform to facilitate cross-national

comparisons.

Regarding the types of undergoing

surgery, It was observed that, the

majority of both groups had under gone

cesarean section except about one third

had under gone hysterectomy and only

(3.3%) had under gone oopheroectomy in


Vol. 2 No. 2 May 2012 91

the control group. Also in the present

study, it was observed that the majority

of women delivered vaginally in the last

delivery followed by current cesarean

section. This result is supported by

(Khawaja et al, 2009) (107)

. who reported

that, cesarean rates for hospital-based

deliveries were much higher than the

overall rates, and the rate also increased

slightly from a low level of 15.3 percent

in the 1992 survey to 18.5 percent in the

1995 survey to 20.9 percent in the 2000

survey, representing a 72 percent

increase during the study period.

Although the cesarean section rate was

slightly higher in private hospitals, the

rate also increased consistently in public

hospitals. The present study also revealed

that, only low pfannenestiel incision was

done in all the subjects.

Concerning recognition of surgical site

infections Collier et al (2004) (111)

,

reported that, There are a number of

indicators of surgical site infections;

include redness, tenderness, infected

discharge, a bad smell in the wound, and

fever. The patient may have a faster

pulse rate and faster breathing, in

addition to unexpected pain and/or

tenderness either at the time of dressing

change or reported by the patient even

when the wound dressing is in place.

After careful assessment, it is apparent

that the wound is infected, it is important

to confirm this and identify the causative

organism(s) and possible sensitivities to

antibiotics.

In the present study, the first indicator of

surgical site infections was the increase

of body temperature to 38 oC or more for

24 hours for all cases. Then positive

wound culture for all cases. The third

indicator was the local signs, it was

detected that more than half of wounds in

the study group were erythematized

compared to entire control group.

Although pain was present in all cases of

the two groups, it was different in

severity and quality. While pain was

moderate in the entire study group, it was

mild in about one quarter and moderate

in about three quarters of the subject of

the control group. Pain was intermittent

all over the time. All studied groups were

felt stabbing pain compared to the

control group, half of them were felt

stabbing pain and the other half were felt

aching pain.


Vol. 2 No. 2 May 2012 92

In addition, the researcher confirmed

diagnosis of surgical site infections

among the studied subjects (study and

control groups) by wound culture.

Regarding wound culture, it was found

that, the causativeorganisms, Gram –ve

organisms represent two fifth in the study

group and more than three fifth in the

control group while Gram +ve organisms

represent the majority in the study group

and more than a half in the control group.

On the other hand, Staff org. represents

more than three fifth and about one

quarter, Pseudomonas represents one

fifth and nearly two fifth and Proteus

represent represents about half and one

fifth in the study and control group

respectively.

Regarding sensitivity to antibiotic, in the

study group, about one quarter of the

subject was sensitive to Amoxicillin and

one quarter was sensitive to cefotax

compared to one tenth of subjects in the

control group. In addition to more than

two fifth of subjects in the study group

were sensitive to another type of

antibiotics as ciprofloxacin &

levofloxacin compared to four fifth of

subjects in the control group. This

finding is in accordance with Al-Waili’s

and Saloom’s (1999) (3)

who reported

that, Period for antibiotics use was 6.88

+/- 1.7 days in the study group and 15.45

+/- 4.37 in the control group (p <0.05).

They also stated that complete wound

healing was evident after 10.73 +/- 2.5

days in the study group and after 22.04

+/- 7.33 in the control group.

Concerning results of wounds culture, 7

days after honey application, the majority

of study group were negative and less

than two fifth were positive. on the other

hand all the control group (100%) were

positive. This finding is in accordance to

Al-Waili’s and Saloom’s (1999) (3)

who

reported that, eradication of bacterial

infections was obtained after 6 +/- 1.9

days (mean +/- SD) in the study group

using topical honey, and after 14.8 +/-

4.2 days in the control group who didn’t

not use topical honey.

This finding is ascribed to that; honey

provides a moist healing environment and

prevents bacterial growth even when wounds

are heavily infected. Honey is a very

effective mean of quickly rendering heavily

infected wounds sterile, without the side-

effects of antibiotics, and it is effective

against antibiotic-resistant strains of bacteria.


Vol. 2 No. 2 May 2012 93

Its antibacterial properties and its viscosity

also provide a barrier to cross-infection of

wounds. (Molan, 2001) (84)

.

Moreover, concerning wound size in the

present study, the wound lengths didn’t

exceed 20 cm in both groups with mean

15.83±2.45 in the study group and

16.37±2.95 in control group. Regarding

width of wound after three week of the

application of honey, it ranged from 3-5

mm in the study group and from 5-8 mm

in the control group with mean

4.10±0.76, and 6.63±0.96 respectively.

This finding is in accordance to Al-

Waili’s and Saloom’s (1999) (3)

who

reported that, Size of postoperative scar

was 3.62 +/- 1.4 mm in the study group

which used topical honey and was 8.62

+/- 3.8 mm in the control group who did

not use topical honey.

In the current study the researcher used a

follow up record to assess prognosis of

infected surgical site. the researcher

categories the time variable to three, six

and nine days, the main objective is to do

a comparison between study group(

women exposed to honey dressing +

routine hospital wound care hospital

wound care) and control group (women

exposed to routine hospital wound care

hospital wound care only) and the results

was as following:

Concerning skin appearance surround

wound. In the first three days the skin

was White or gray pallor in the two

groups, But in the 6th day the difference

in progress started to be clear as more

than three quarter of the study group

become pink and one quarter is bright

red or blanch to touch. Gradually at the

9th

day skin become normal in the study

group. Contingency concerning control

group the majority of Skin appearance

surrounding their wound was Bright red

or blanches to touch and less than one

fifth their wound was White or gray

pallor or hypo pigmented. In addition;

regarding inflammatory response at the

9th

day of management, the inflammatory

response disappeared in the entire study

group. But, most of the control group

their wound was red and less than one

fifth was red with hotness.

Regarding exudates amount there were

significance difference between study

group and control group, the in the

exudates disappeared from the majority

of the study group at the 6th of

management. On the other hand, the


Vol. 2 No. 2 May 2012 94

exudates amounts were moderate in all

the control group. In the 9th,

the exudates

disappeared completely from the study

but still large in the most of the control

group. At the 21st of wounds

managements the amounts of exudates in

the majority of the control group were

very scant except more than one tenth

were large until the 21st of wound

managements.

When exploring the type of exudates

especially at the 9th day of management

the exudates were absent completely in

the study group. During exploring the

control group it was observed that one

third of them were foul purulent ,about

one fifth were purulent, about one fifth

were serous, one fifth were was

Serosanguieous and one tenth was

bloody. In the day 21st still more than

thirteen percentages were purulent and

the majorities were changed to serous.

This may be due to Honey provides a

supply of glucose for leucocytes, which

is essential for the respiratory burst that

produces hydrogen peroxide, which is

the dominant component of the

antibacterial activity of macrophages.

Furthermore the use of honey provides

substrates for glycolysis, which is the

major mechanism for energy production

in the macrophages, and thus allows

them to function in damaged tissues and

exudates where the oxygen supply is

often poor. In addition, the acidity of

honey (typically below pH 4) may also

assist in the antibacterial action of

macrophages, as an acid pH inside the

vacuole is involved in killing ingested

bacteria. Whether it is through this

action, or through preventing the toxic

unionized form of ammonia from

existing that is involved, topical

acidification of wounds promotes

healing. The high glucose levels that the

honey provides would be used by the

infecting bacteria in preference to amino

acids from the serum and dead cells, and

thus would give rise to lactic acid instead

of ammonia and the amines and sulphur

compounds that are the cause of

malodour in wounds. (Leveen et al,

1973) (126)

.

Regarding the wound status, it was

observed that, there were improvements

in the study group throughout six days of

honey application. On the other hand, the

deterioration started to appear in the


Vol. 2 No. 2 May 2012 95

control group, but at the 9th

day, more

than two thirds of control group showed

a slight improvement. Also at the 21st

day, the majority of subjects in the

control group showed a significant

improvement, and less than one fifth of

them their wounds were deteriorated.

This finding is in accordance to Al-

Waili’s , Saloom (2005) (3)

. who reported

that, after using honey, (84.4%) of

patients showed complete wound healing

without wound disruption or a need for

re-suturing and only (4) patients showed

mild dehiscence. In their control group,

(50%) of patients showed complete

wound healing and (50%) of patients

showed wound dehiscence, half of them

needed re-suturing under general

anesthesia (Molan, 2005) (84)

.also

reported that honey used as a wound

dressing has been promoted the

formation of a clean healthy granulation

tissue, promoted epithelialisation of the

wound, Improvement of nutrition of

wounds has been observed, increased

blood flow has been noted in wounds,

and free flow of lymph. Another effect of

honey on wounds has been noted is, it

reduces inflammation and hastens

subsidence of passive hyperemia. It also

reduces edema and exudation, and

absorbing fluid from the wound. This may

be due to that, honey is be expected to have a

direct nutrient effect on regenerating tissue

because it contains a wide range of amino

acids, vitamins and trace elements, in

addition to large quantities of readily

assimilable sugars. The vitamin C content of

honey, which is typically more than three

times higher than that in serum, and may be

many times higher, it could be a particular

importance because of the essential role of

this vitamin in collagen synthesis. In

addition, the high osmolarity of honey causes

an outflow of lymph which serves to provide

nutrition for regenerating tissue which

otherwise can only grow around points of

angiogenesis (seen as granulation). Healing

is delayed if the circulation to an area is

poor, or if a patient is poorly nourished. Also

it has been suggested that, the decreased

turgor resulting from the application of

honey may increase oxygenation of tissues.

In addition, honey gives a fast rate of tissue

regeneration and suppression of

inflammation, oedema, exudation and

malodour in wounds. The antibacterial

properties clearing infection could alone

account for these effects by preventing the

production of the products of bacterial

metabolism which are responsible for the


Vol. 2 No. 2 May 2012 96

contrary conditions. Furthermore, honey has

a direct trophic and anti-inflammatory effect

on wound tissues (Efem, 1988) (127)

.

Regarding pain during wound dressing in

the beginning there were no difference,

but at the 9th

day the pain disappeared in

the study group but in the control group,

there were two third of subjects

complaining from severe pain except

around two fifth of subjects whose pain

was slight. At the 21st day, concerning

the control group, thirteen percent of

subjects were having a severe pain and

the rest were having a slight pain. This

result is in accordance with Molan’s

(2005) (84)

who reported that, honey is

soothing when applied to wounds and

that honey causes no pain on dressing or

causes only momentary stinging. They

also added that honey is non-irritating,

causes no allergic reaction, and has no

harmful effects on tissues. In addition, it

has been noted that, honey dressings are

easy to apply and to remove because

there is no adhesion to cause damage to

the granulating surface of wounds.

Honey also causes no bleeding when

removing dressings. Any residual honey

is easily removed by simple bathing.

Concerning duration of wound management,

the study group did not exceed 11 days in

wound management but the control group

exceeded 21 days. All women in the two

groups were taken antibiotics and analgesics

according hospital routine. This result

matches with Efems’ et al (1988) (127)

who

reported that, the wounds become sterile in 3

- 6 days, or 7 - 10 days after clinical studies

on the usage of honey as a dressing for

infected wounds and with Molan’s who

reported that, the mean hospital stay was

9.36 +/- 1.8 days in group A (treated by

honey dressing) and 19. 91 +/- 7.35 days in

group B (treated according hospital routine).

There is also an economical advantage of

using honey as a wound dressing. This is

seen in the direct cost savings when

compared with conventional treatments

and in the savings in ongoing costs when

consideration is given to the more rapid

healing rates that are achieved. Other

observations on cost savings have been

use of antibiotics ceased, length of

hospitalization reduced by at least half.

To conclude that, various studies on the

usage of honey as a dressing for infected

wounds have reported that, the wound

become sterile in 3-10 days. Honey used as

wound dressing has been reported to

promote the formulation of clean healthy


Vol. 2 No. 2 May 2012 97

granulation tissue. It has also been reported

to promote epithelialisation of the wound

and rapid growth of new tissue is

remarkable. Inflammation, swelling and pain

are quickly reduced, odor is reduced,

sloughing of necrotic tissue is induced, and

healing occurs rapidly with minimal

scarring. Improvement of wounds nutrition

has been noted in addition to free flow of

lymph. Finally, topical honey dressing as

alternative method of managing abdominal

surgical site infections provides a specific

desirable affects (Ahmed, 2003) (89)

.

Conclusion

Based on the findings of the present

study, the researcher can conclude that

topical application of sterile honey could

eradicate organisms within a short period of

time, reduce the period of antibiotic use,

accelerate the healing process in a unique

and an economic way, result in minimal

scar formation, prevent wound dehiscence

and the need for re-suturing

Recommendation:

-Mass media should be utilized for the

dissemination of simple, correct and

relevant information about honey

dressing for infected wound.

-The use of standardized scale for

measuring surgical wound healing must

be an integral part of surgical wound

managements

-Herbal management of surgical site

infections should be included in the

curricula of basic nursing education and

continuing education in variable nursing

educational settings.

-Appropriate and accessible public services

which include information, education

and counseling about herbal management

of surgical site infections must be

included in the health care delivery

system.

Recommendations (Suggestion) for further

studies:-

Studies to find out factors that affect the

dissemination and implementation of up

to date information about complementary

therapy for surgical site infections.

- Replication of the present study at

different settings and among different

samples of selected high risk women for

surgical site infections.

- Studies about the effect and techniques

of complementary therapy on surgical

site infections.

- The study need to be conducted on a

larger sample and be extended for a

longer period of time to allow


Vol. 2 No. 2 May 2012 98

generalization of the results. 6- The study

can be conducted on any age of women,

any post operative abdominal obstetrical

or gynecological patients, women with

medical disorder as cardiac failure,

chronic respiratory problems, vascular

disorders, diabetes, renal and liver

insufficiency, patients with hemoglobin

≤8 mg/ml, and patient receiving drug

therapies which interfere with wound

healing as chronic steroid therapy,

imunosuppressant drugs, and

anticoagulants.

References

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Betrán A. P., Merialdi M. & Althabe F.

World Health Report Background Paper:

The Global Numbers and Costs of

Additionally Needed and Unnecessary

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Coverage, (2010). Available at

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2- Shetty Jyothi, Vyas Neetha M, Kumar

Pratap, Kamath Asha. Antibiotic

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negative bacteria following caesarean

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09/9789241597906_eng.pdf. Accessed

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6- Jyothi S., Neetha V., Pratap K., Asha K.

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7- Ministry of Health and Population Egypt

(MOHP). Standards of practice for

integrated maternal and child health and

reproductive health services, First

edition, Infection Control Department,

2005;MOHP Egypt. Available at

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2.pdf. Last accessed on 25th January

2012.

8- El-Zanaty, F. & Ann, W. Egypt

Demographic and Health Survey. Kasr

Al-Aini Journal Of Obstetrics &

Gynecology, 2008; Egypt Ministry of

Health. Available at

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R220/FR220.pdf. Last accessed on 26th

January 2012.

9- Spry, C. Essentials of perioperative

nursing. Jones & Bartlett Learning, 2009,

pp214

10- MOLAN, P .Mode of action, In White,

R; Molan, P; Copper, R (eds) Honey: A

modern wound management product,

Wounds UK; Aberdeen, 2005; pp 1-23.

11- Banister, E., Schreiber, R. The tyranny

of consensus: Implications for nursing

education. International Journal of

Nursing Education Scholarship, 2004;

1(1). Retrieved from

http://www.bepress.com/ijnesnaty. Last

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12- Pillitteri, A. Maternal & child health

nursing care of the childbearing and

childrearing family, 4th

ed., USA,

Lippincott Williams& Wilkins, 2003; Pp

540-49,552-57,596-98,604-6.

13- Nettina, S. Lippincott manual of

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17- Khawaja, M., Choueiry, N., Jurdi R.

Hospital- based caesarean section in the

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Published: Jan 2004.

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/january/Collier/Management-of-Wound-

infections.html Last Modified: Monday,

18-Oct-2004 14:11:49 BST

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Blackwell, L., Snyder, J. A randomized

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chlorhexidine as antiseptics for vaginal

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et al. Chemical acidification of wounds:

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unfavorable action of alkalinity and

ammonia. Ann Surg., 1973;178(6): pp

745–753

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the wound healing properties of honey

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75: 679-681. 22- Centers for Disease

Control and Prevention (CDC). (2012).

Frequently Asked Questions about

Surgical Site Infections. Available at

http://www. cdc.gov/HAI/ssi/

faq_ssi.htm l#a1. Last accessed on 25th

January 2012.

Effect of Nursing Intervention on the Supportive Role Played by Peers on Glycemic

Control Among Diabetic School Students in Tanta City.

http://www.worldwidewounds.com/2004/january/Collier/Management-of-

http://www.worldwidewounds.com/2004/january/Collier/Management-of-

http://www/


Vol. 2 No. 2 May 2012 101

Bassima Ezat Gowayed

Community Health Nursing –Tanta University

Ikbal Fathala Elshafay


Latifa Mahmod Foda


Lulah Abd Elwahab Abd Elaty Hassan

Abstract:

Diabetes mellitus is one of the most common metabolic and chronic diseases of school age

children. The main aim of diabetes management for diabetic teenage is to achieve optimal

glycymic control. Peer support may help achievement of this aim. Aim: is to investigate the

effect of nursing intervention on the supportive role played by peers on glycymic control among

diabetic school students in Tanta city. Research design: Quasi-experimental research design.

Material and method: The study was conducted at the outpatient medical clinics of all school

health units (I, II, and III) affiliated to the students’ health insurance serving Tanta city as well

as governmental schools. A convenient sample of diabetic school children were selected from

the previous settings representing fifty percent of the total subjects. The study sample was

divided into two equal groups (control& study). The control group received an individual

program for glycemic control. The study group received the same glycemic control program in

addition to peer support sessions. An interview questionnaire and anthropometric measurements

sheets were used to collect data and for evaluation. They were used three times during the study

period; before the program, immediate, and three months post program. Results: the result of

this study showed that before implementation of the program the study and control groups

showed poor glycemic control, low scores of knowledge, self care practices and perceived peer

support. After implementation of the program, the two groups showed significant glycemic

control and improvement in their knowledge and self care practices. This improvement was

highly significant among the study group who received peer support than the control one.

Conclusion and recommendation: peer support approach is a predictor of glycemic control

among school age children. Therefore, the school health nurse could do her best effort to make


Vol. 2 No. 2 May 2012 102

peer support available to every diabetic student, in particular, those with poor glycemic control

or newly diagnosed.

Introduction

Diabetes mellitus is one of the most

common metabolic and chronic diseases of

school age children (1)

. There are two main

types of diabetes mellitus. Type 1 diabetes

also called insulin dependent diabetes or

juvenile diabetes. The average age of its

onset is 10 to 14 years. It is autoimmune

disorder in which the body destroys the

insulin- producing islet cells in the

pancreases of those who are genetically

vulnerable. Environmental and genetic

factors are strongly implicated. This is the

most prevalent type among children (2, 3)

.

The International Diabetes Federation

(IDF) reported that, every day more than

200 children are diagnosed with type 1

diabetes. It is increasing at a rate of 3%

each year among children and rising even

faster in pre-school children at a rate of 5%

per year. Currently, over 500,000 children

under the age of 15 live with

diabetes(4)

.Approximately 5% of children

have a first or second degree relative with

DM type 1. In the United States, surveys

indicated the prevalence of type1 DM to be

14.9 per 100000 in 2004. The frequency

increases with age (2).

The International Diabetes Federation

(IDF) mentioned that, Egypt is in the

world's top 10 in terms of highest number

of people with diabetes in 2003 (3.9

million) and highest projected number of

people with diabetes in 2025 (7.8 million).

Also, the prevalence rate of diabetes is as

high as 20% in the United Arab Emirates,

16% in Qatar and 15% in Bahren(5). In

Egypt (2005) the prevalence of diabetes

among children aged 10 to 18 was 0.7 per

cent. The frequency was higher among

females than males and equal in urban and

rural areas. Children with fasting blood

glucose levels between 100mg and 125mg

were considered pre-diabetic; they

represented 16.4 per cent of the total

sample (6)

.

Type 1 diabetes is a challenging disease,

with a daily regimen that include multiple

insulin injections, monitoring of blood

glucose level, and a special diet and

exercise regimen. Treatment management

is very difficult, especially for school age


Vol. 2 No. 2 May 2012 103

children who are experiencing a series of

social, psychological, emotional and

physiological changes(7,8)

. Diabetes

management is complicated because it

must occur across different settings such as

at home and in school. Consequently,

diabetes management should be facilitated

by the support of both family members and

peers(9)

.Peer support among patients with

the same chronic health problem may be a

particularly potent intervention, combining

the benefits of both receiving and

providing social support. “Peer support” is

defined as “support from a person who has

experiential knowledge of a specific

behavior or stressor and similar

characteristics as the target population”.

Peer support helps reduce problematic

health behaviors, depression, and

contribute to improve diabetes

management, including improving

behaviors related to medication adherence,

diet, exercise, and blood glucose

monitoring. The success of peer support

appears to be due to the nonhierarchical,

reciprocal relationship that is created

through the sharing of similar life experi-

ences(10)

.The child's concept of self is

shaped by relationship with others. Peers

play an important role in the approval and

critiquing of skills of school-age children.

Continuous peer relationship provide the

most important social interaction for

school age children. Valuable information

are learned from interaction with children

of their own age(11)

.

Working with groups is an important

community nursing skill. Groups are an

effective and powerful way to initiate and

implement changes for individuals,

families, organization, and community.

Moreover, groups can be used to

disseminate health information in a cost-

effective way to a number of clients who

meet together: for instance, individuals

with diabetes can brought together to

consider diet management, physical care

and to share in problem- solving

remedies(12)

. The nurse's role with this

support group is to facilitate group

interaction and to serve as a role model of

acceptance (13)

.

Aim of the study The aim of this study is

to:- Identify the effect of nursing

intervention on the supportive role played

by peers on glycym control among diabetic

school students in Tanta city.

Subjects and methods :


Vol. 2 No. 2 May 2012 104

Study design:-This study was a quazi

experimental study.

Subjects:- A convenient sample of diabetic

school children was selected from health

units affiliated to the students' health

insurance serving Tanta city. The study

was conducted at the out patient medical

clinic of the all school health units (I, II,

and III) in Tanta city, representing half of

the diabetic students in the school health

units.

Study population and sampling: The field

work of this study was done in nine months

starting from March to November 2010.

Each student of the studied sample was

informed about the program objectives, as

well as the time schedule in order to obtain

their active participation and cooperation

during implementation of the intervention.

Then the pretest was fulfilled from each

student. The program sessions were 11

sessions for group I with two additional

sessions for group II. The duration of each

session was 30-60 minutes.

Inclusive criteria: Age from 10- 18

years, had no other chronic disease. The

child was enrolled in governmental school

in Tanta city.

The total study sample was 40 diabetic

school children. The study sample was

divided into two equal groups (20 students

each). Group I (control group):- Each

student in this group will receive an

individual program for glycemic control.

Group II (study group):- This group was

divided into 4 subgroups (5 students in

each). Each group received the glycemic

control program in addition to additional

two sessions for social group support for

each other.

Ethical consideration: 1- Official

permission to conduct the study will be

obtained from the responsible authorities

(Ministry of Education and Health

Insurance).\Consent of the diabetic

children and their parents were obtained.

The researcher meet with the diabetic

children at their schools according to the

convenient time. All participants was

informed about the purpose, benefits, and

procedure of the study.

A pilot study was carried out on four

diabetic students(10% of the study sample)

Tools of the study:-

Tool I:- An Interview Questionnaire

Schedule: It included four parts:-


Vol. 2 No. 2 May 2012 105

Part 1: Sociodemographic characteristics

of the diabetic children: This included

three items as follows:- (a)- Personal data

about the diabetic students, (b)- Students'

parents data, and (c)- Past medical history

of students and their family.

Part 2: Diabetic Educational Assessment

Tool (DEAT):- This tool was developed

by the researcher to assess diabetic

children's knowledge and practice about

diabetes. It will cover the following areas;

definition of diabetes mellitus and its

manifestations, complications,

management such as diet, exercise,

medications, medical follow up and health

promotion, how to prevent injuries and

activities of daily living.

3Part 3: Diabetic Support Assessment

(DSA):-

This tool was adapted from "Medical

Outcomes Study Social Support Survey

Instrument", for the Advancing Diabetes

Self Management Project at the clinic of

Raza( 14)

. It assess the availability for

social support for diabetic patients. It was

modified by the researcher to suit school

children. It was used to assess children's

needs for support in dealing with diabetes.

Part 4: Self- Care Inventory (SCI):

The self care inventory, is a 13 items

self report measure. It was developed by

La Greca (1988) (15)

to assess patient

perceptions of the degree to which they

adhere to treatment recommendations for

their diabetes self care. The instrument was

subsequently revised and now consists of

14 items. The SCI is a likert type scale

ranged from 1-5. It includes items that

focus on blood glucose testing, insulin and

food regulation, exercise and emergency

precautions. The researcher translated this

scale into Arabic language to introduce it

to the study subjects.

Tool II: Measurement sheet:- This

consisted of two parts:-

Part 1: Anthropometric measurements : It

included height, and weight and then

calculation of body mass index. These

measures were done at the beginning of

the study. Then, weight was measured

every month for three months after the

application of the intervention. The body

mass index (BMI) was calculated as

follows:

Part 2: Fasting blood glucose test:- The

fasting blood glucose level of each

participant student was tested by using

him/ her own one touch apparatus.


Vol. 2 No. 2 May 2012 106

Developing the nursing intervention

program

1- Preparatory phase:-

–Rational: Studies carried out on Egyptian

diabetic adolescents at Alexandria city

revealed that, although they had a good

knowledge about DM they showed partial

adherence to diabetes self care (16,17)

. About

74.8% of diabetic students had

uncontrolled diabetes and 7.4% of them

developed complications (17)

.

-Analysis of the resources:

Human resources:- The program was

totally carried out by the researcher.

Non human resources (audiovisual

material).It included booklet, power point

sides, doll, and real material (e.g. one

touch blood glucose check apparatus and

its strips, syringe, cotton, and alcohol) to

demonstrate procedures related to DM

management like insulin injection and

blood glucose test. The booklet and power

point were prepared by the researcher

based on literature review. The booklets

were distributed to the studied sample at

the end of sessions and the power point

was presented according to students' level

during each session as needed.

2- Planning phase:-

1- General objectives:

The general goal of the nursing

intervention is to enable the diabetic

students to control their diabetes.

2- Specific objectives:-

The program sessions was 11

sessions as follows for group I with two

additional sessions for group II. Specific

objectives of the intervention and its

sessions was as follows:- Session 1:The

aim of this session was to orient the

students about the importance of the

program, its sessions and expectation of

each session. Session 2:- The aim of this

session was to increase students'

knowledge about the disease related to its

causes and manifestations. Session 3:This

session aimed to allow students to identify

steps of how to calculate the diabetic diet

and how to improve it. Session 4The goal

of this session was to increase students'

awareness about how to mange diabetes

through exercise. Session 5:- The purpose

of this session was to inform the

participants about diabetic medication, its

type and its administration. Session 6:- The

objective of this session was to enable

students manage insulin administration and

site rotation. Session 7:- The aim of this


Vol. 2 No. 2 May 2012 107

session was to enable students practice

blood glucose testing & interpret its normal

and abnormal values. Session 8:- The goal

of this session was to increase the students'

awareness about signs and symptoms of

hypoglycemia and hyperglycemia and

proper dealing with them. Session 9:- The

aim of this session was to discuss with the

group the probable complications that may

arise from uncontrolled diabetes (short

term& long term). Session 10:- The

purpose of this session was to help the

participants to identify the behaviors and

activities that promote their health and

prevent injuries. Session 11:-The objective

of this session was to encourage the

diabetic students to deal constructively

with decisions related to their disease and

glycemic control.

The sessions for group II was as sessions

for group I, in addition to the following

two sessions. These two sessions will be

given to the students after the orientation

session.

Session 1:- The aim of this session is to

help the individual student and all group

members to establish relationship with

each other and with the researcher. Session

2:-:The purpose of it is to enable the

participants to develop social support skills

that help them to manage their diabetes

properly.

Implementation of the program:-

The implementation of the program was as

follows:-

Group I (control group):- Implementation

of the program was based on providing

individual instructions to each student and

discussing problems encountered during

management of the disease. Group II

(study group):- Instructions was provided

in a form of group discussions. Each

student in the group will be encouraged to

express oneself, share problems, concerns

and way of management. The researcher

will act as a facilitator for the group

interaction by providing support,

clarification, interpretation and positive re-

enforcement. discussion, simulation and

demonstration will be used as a teaching

strategy. Hand outs, booklets and power

point presentation will be used as a

teaching aid

Result

Table 1 showed the distribution of the

studied sample regarding to their

sociodemographic characteristics. The

table revealed that the mean age of the


Vol. 2 No. 2 May 2012 108

study group was 15.75±1.74 years while

the mean age of control group was 14.40

±2.91 years. The table also illustrated that

50% and 55% of the study group and

control group respectively were females.

As regard to the educational level, 70% of

the study group and 50% of control group

were students at secondary schools

compared to 30% of both groups were

from preparatory schools.

Concerning birth order, the table showed

that those who were the first or the second

child in the family constituted the highest

percentage of the study and control group

70% and 60% respectively. This is

followed by 20% and 30 % respectively of

both groups who were the third on birth

order. Half of the students of the study

group had five or more siblings compared

with the majority of the control group. The

highest percentage of students (85%) of

both groups was from urban areas.

As regard fathers' education, 35% of

the study group and 25% of the control

group their fathers were university

graduates, and 30% of the students from

both groups their fathers had secondary

education. In relation to mothers’

education, the same table revealed that

(40%) of the study group their mothers

were university graduates, compared with

25% of the control group. More than half

(55%) of the control group their mothers

had secondary education, compared with

35% of the study group. About two thirds

(65%) of both groups their mothers were

housewives. In addition, the table revealed

that only one quarter (25%) of the study

group and one fifth of the control group

had consanguinity between their mothers

and fathers.

Table (2) showed the distribution of

the studied sample regarding personal and

family history of disease. It was observed

that, three quarters (75%) of both groups

had a family history of diabetes mellitus.

Concerning the duration of diabetes

mellitus among students, the mean duration

of disease among the study group was

4.20±3.05 years compared with 4.07± 2.36

years for the control group. Three quarters

(75%) of both groups admitted previously

to hospital because of diabetes mellitus.

However, one quarter (25%) of the study

group reported complications of diabetes.

Table (3) showed the mean score &

standard deviation of knowledge of the

studied sample about diabetes mellitus. It


Vol. 2 No. 2 May 2012 109

was observed that there was a significant

improvement in the mean score of

knowledge of the study group and control

groups about diabetes mellitus (definition,

predisposing factors, manifestation,

accurate blood glucose level,

complications, hypoglycemia, and

hyperglycemia) (P˂ 0.05).The highest total

mean score of knowledge of the study and

control groups was noticed immediately

post program (42.95±6.19 and 41.45±5.86

respectively). There was a significant

difference between the two groups at three

months post program as regard the

definition, accurate blood glucose level,

and complications of diabetes, as well as

the total mean score (X2

= 2.787,

Table (4) showed the mean score and

standard deviation of knowledge of the

studied sample about management of

diabetes mellitus. There was a significant

improvement of the mean score of

knowledge of the study and control groups

for all the studied items (P˂ 0.05). There

was a significant difference between the

two groups at three months post

intervention as regard treatment of diabetes

(t=2.127), types of insulin (t=3.793),

importance of adherence to diabetic diet

(t=2.494), and the importance of exercise

(t=2.494).The study group had a higher

means score of knowledge than the control

group about diabetes management

immediately post program (25.95±2.56 and

24.55±4.65 respectively) and three months

post program (26.59±1.87 and 23.90±4.40

respectively). There was a significant

difference between the two groups through

the study (pre, immediate, and three

months post program) (P˂0.05).

Table (5) showed the total mean

score of knowledge of the studied sample

about diabetes mellitus. The table revealed

that, there was a significant improvement

in the total mean score of knowledge for

both groups through the study period.

However, the study group gained higher

mean score than the control group

immediately post program (68.9±8.75 and

65.89±10.51respectively) and three

months post program (69.14±6.43 and

62.3±12.51 respectively). There was a


groups through the study periods (pre,

immediate, and three months post program

(P˂ 0.05).

Table (6) showed the mean score & standard

deviation of the studied sample regarding self

care inventory through the study. There was a


Vol. 2 No. 2 May 2012 110

significant improvement in the mean score of

self care items among the study and control

group in relation to blood glucose

testing(P=0.009 and P=0.010 respectively),

recording(P=0.008 and P=0.007 respectively),

changing insulin dose according to blood

glucose level (P=0.001 and P=0.006

respectively) adherence to diabetic diet

(P=0.044 and P=0.012 respectively), carrying

sweaty foods to manage hypoglycemia

(P=0.001 and P=0.017respectively), and

practicing exercise regularly (P=0.044 and

P=0.037 respectively). Moreover, the table

illustrated that, there was a significant

improvement in the mean score of the study

group regarding eating snakes

regularly(P=0.001), while the improvement of

the control group was not significant(P=0.273).

On the other hand, there was a non significant

improvement in the mean score of self care

items among the study and control group in

relation to talking accurate insulin dose

(P=0.102 and P=0.130 respectively), talking

accurate insulin dose on the right time, eating

meal at times(P=0.317 and P=0.052

respectively), medical follow up (P=0.170 and

P=0.186 respectively), and practicing exercise

strenuously(P=0.058 and P=0.141

respectively). It was also observed that there

was no significant improvement in the mean

score of ketones testing among the study and

control group (P=0.946 and P=0.530

respectively).

Moreover, there was a significant

difference between the two groups regarding

all self care inventory items three months post

program except for ketones testing (P= 0.206).

Table (7) showed the correlation between

knowledge, Self- Care Inventory, diabetic peer

support, performed steps in measuring blood

glucose level and injecting insulin by pen

among the studied sample (study and control

groups) immediately post-test. The table

illustrated that, there was positive correlation

between the knowledge of the study group and

Self- Care Inventory (P=0.019), measuring

blood glucose level(P=0.044), injecting insulin

by pen(P=0.012) and fasting blood glucose

level(P=0.04 Table (8) showed correlation

between knowledge, Self- Care Inventory,

diabetic peer support performed steps in

measuring blood glucose level and injecting

insulin by pen among the studied sample

(study and control groups) 3 months post-test.

The table revealed that, there was a significant

positive correlation between the knowledge of

the study group and Self- Care Inventory

(P=0.001), diabetic peer support (P=0.026),

measuring blood glucose level(P=0.038),

injecting insulin by pen(P=0.023) and fasting

blood glucose level(P=0.005). There was also a

positive correlation between the same group's

Self- Care Inventory and diabetic peer support


Vol. 2 No. 2 May 2012 111

(P=0.041)& measuring blood glucose

level(P=0.019). Moreover, a positive

correlation was found between injecting insulin

by pen and diabetic peer support (P=0.047)&

measuring blood glucoselevel(P=0.001)

Table 1: Distribution of the studied sample regarding to their sociodemographic

characteristics

Socio-demographic characteristics

The studied diabetic school children

(n=40)

The study

group

(n=20)

The control group

(n=20)

X2 P

n % N %

Age:

10- 0 0 7 35.0 10.048 0.007*

13- 9 45.0 3 15.0

16-19 11 55.0 10 50.0

Range 13-18 10-18

Mean±SD 15.75±1.74 14.40±2.91

t-test 1.780

P 0.083

Sex:

Males 10 50.0 9 45.0 0.100 0.752

Females 10 50.0 11 55.0

Education level:

Primary school 0 0 4 20.0 4.667 0.097

Preparatory 6 30.0 6 30.0

Secondary 14 70.0 10 50.0

Birth order:

1 5 25 2 10 5.738 0.333

2 9 45 10 50

3 4 20 6 30

4 and more 2 10 2 10

No. of siblings:

3 3 15 0 0 8.725 0.121

4 7 35 2 10

5 and more 10 50 18 90

Place of residence:

Urban 17 85.0 17 85.0 0.00 1.00

Rural 3 15.0 3 15.0

Fathers' educational level:

-Illiterate Or read & writs 3 15.0 3 15.0 0.833 0.934

-Basic education 4 20.0 6 30.0

-Secondary 6 30.0 6 30.0


Vol. 2 No. 2 May 2012 112

-Univesity educ. 7 35.0 5 25.0

fathers' occupation:

-Working: 18 90.0 20 100 2.105 0.147

skilled workers 8 44.4 11 55.0

Employee 3 16.7 4 20.0

Professional 7 38.9 5 25.0

-Not working 2 10.0 0 0

Mothers' educational level:

-Illiterate Or read & writs 3 15.0 3 15.0 2.581 0.630

-Basic education 2 10.0 1 5.0

-Secondary 7 35.0 11 55.0

- Univesity educ. 8 40.0 5 25.0

Mothers' occupation:

-Working: 7 35.0 7 35.0 0.00 1.00

skilled workers 0 0 0 0

Employee 3 42.9 3 42.9

Professional 4 57.1 4 57.1

-House wife 13 65.0 13 65.0

Presence of consanguinity between

parents:

Yes 5 25.0 4 20.0 0.143 0.705

No 15 75.0 16 80.0

Table (2): Distribution of the studied sample regarding personal and family history of disease.


Vol. 2 No. 2 May 2012 113

History of disease


(n=40)

The study group

(n=20)

The control group

(n=20)

X2

P

N % n %

Family history of DM:

Yes 15 75.0 15 75.0 1.00

No 5 25.0 5 25.0 0.00

Duration of DM (years):

-<3 8 40.0 5 25.0 3.69

3- 4 20.0 9 45.0 0.297

6 and more 8 40.0 6 30.0

Mean±SD 4.20±3.05 4.07±2.36

t-test 0.145

P 0.885

Previous admission to hospital due

to DM:

Yes 15 75.0 15 75.0 1.00

No 5 25.0 5 25.0 0.00

Presence of DM complications:

Yes 5 25.0 14 70.0 0.004*

No 15 75.0 6 30.0 8.120

*Significant (P<0.05)


Vol. 2 No. 2 May 2012 114

Table (3): Means & standard deviation of knowledge of the studied sample about diabetes mellitus

Knowledge

items about

diabetes

mellitus

The study group

(n=20)

The control group

(n=20) Study versus control group

Pretest

Immediate

post test

3 months

post test

F-test

P

Pretest

Immediate

post test

3 months

post test

F-test

P t-test

Mean±

SD

Mean±

SD

Mean±

SD

Mean±

SD

Mean±

SD

Mean±

SD

Pretest

Immediate

post test

3

months

post test

Definition of

DM 2.90±1.29 5.75±0.44 5.75±0.44

78.538

0.0001* 2.00±1.62 5.55±0.76 4.70±1.62

35.239

0.0001*

1.940

0.060

1.017

0.316

2.787

0.008*

Predisposing

factors of DM: 1.00±0.65 2.85±0.59 2.65±0.49

61.526

0.0001* 0.95±0.89 2.70±0.47 2.50±0.51

43.311

0.0001*

0.203

0.840

0.892

0.378

0.946

0.350

Manifestations

of DM: 4.25±1.71 6.55±0.60 6.75±0.44

33.111

0.0001* 4.35±1.81 6.65±0.67 6.25±1.07

18.540

0.0001*

0.179

0.859

0.492

0.623

1.930

0.061

Accurate blood

glucose level: 0.20±0.41 2.00±0.00 1±0.00

155.17

0.0001*

0.20±0.41 0.95±0.22 0.65±0.49

18.672

0.0001*

0.00

1.00

21.00

0.0001*

3.199

0.003*

Complications of

DM

2.85±1.72 6.40±0.88 6.65±0.59

66.110

0.0001* 2.30±1.78 6.15±0.93 5.65±0.99

52.424

0.0001*

0.992

0.327

0.870

0.390

3.891

0.0001*

Hypoglycemia

manifestations

3.65±1.98 6.95±0.94

7.55±0.76

49.072

0.0001* 4.00±2.47 7.35±0.99 7.15±1.27

24.380

0.0001*

0.494

0.624

1.309

0.198

1.210

0.234

Causes of

hypoglycemia

2.05±0.94

2.85±0.49

2.85±0.49

9.336

0.0001* 1.40±0.99 2.90±0.31 2.80±0.41

33.689

0.0001*

2.119

0.041*

0.387

0.701

0.350

0.728

Hyperglycemia

manifestations 2.85±1.63 6.35±1.09 6.70±.86

59.187

0.0001* 2.15±1.84 6.35±1.14 6.10±1.25

53.221

0.0001*

1.272

0.211

0.000

1.000

1.763

0.086

Causes of

hyperglycemia 1.65±0.74 3.25±1.16 2.65±0.49

18.233

0.0001* 1.30±0.73 2.85±0.37 2.60±0.50

44.983

0.0001*

1.498

0.142

1.466

0.151

0.319

0.752

Total 21.40±11.07 42.95±6.19 42.55±4.56 134.80

0.0001* 18.65±12.54 41.45±5.86 38.40±8.11

50.344

0.0001*

1.199

0.238

0.142

0.888

2.952

0.005*



Vol. 2 No. 2 May 2012 115

Table (4) Mean score and standard deviation of knowledge of the studied sample about management of diabetes mellitus.

Knowledge items

about management of

diabetes mellitus

The study group

(n=20)

The control group


Pretest

Immediate

post test

3 months

post test

F-test

P

Pretest

Immediate

post test

3 months

post test

F-test

P t-test

Mean±

SD

Mean±

SD

Mean±

SD

Mean±

SD

Mean±

SD

Mean±

SD

Pretest

Immediate

post test

3 months

post test

Insulin management:

Treatment of DM 3.90±0.45 4.00±0.00 4.00±0.00 1.000

0.374 2.35±1.22 3.85±0.67 3.50±1.05

12.083

0.0001*

5.312

0.0001*

1.000

0.324

2.127

0.040*

Types of insulin 0.80±0.41 1.65±0.49 1.90±0.31 39.691

0.0001* 0.75±0.44 1.65±0.49 1.40±0.50

18.782

0.0001*

0.370

0.714

0.000

1.000

3.794

0.001*

Different, sites of insulin

injection 2.80±0.61 3.95±0.22 3.95±0.49

31.941

0.0001* 2.40±0.68 3.20±1.44 3.35±0.49

5.658

0.006*

1.949

0.059

2.307

0.027*

1.939

0.060

Diet management:

Importance of adherence

to diabetic diet 1.40±0.60 1.95±0.22 1.95±0.22

13.213

0.0001* 1.15±0.49

1.80±0.41 1.65±0.49

10.736

0.0001*

1.447

0.156

1.435

0.159

2.494

0.017*

No of meals /day for

diabetic child 0.45±0.51 1.85±0.37

1.80±0.41

25.783

0.0001* 1.00±0.65 1.80±0.41 1.80±0.41

16.889

0.0001*

6.892

0.0001*

0.406

0.687

0.000

1.000

Types of food that

increase blood glucose

level

3.15±1.09 4.95±0.22 5.00±0.00 53.887

0.0001* 3.25±1.07 4.95±0.22 4.95±0.22

46.436

0.0001*

0.293

0.771

0.000

1.000

1.000

0.324

Exercise management:

Importance of exercise

for diabetics 2.00±1.26 3.80±0.52 3.95±0.22

37.133

0.0001* 0.95±0.76 3.65±0.49 3.65±0.49

138.16

0.0001*

3.199

0.003*

0.936

0.355

2.494

0.017*

Foot mamagement:

Importance of foot car

for diabetics

1.95±1.14 3.80±0.52 3.95±0.22 45.484

0.0001* 1.20±0.106 3.80±0.52 3.60±0.75

64.151

0.0001*

2.152

0.038*

0.000

1.000

1.990

0.054

Total knowledge 16.45±6.07 25.95±2.56 26.59±1.87 111.73

0.0001* 13.05±5.41 24.55±4.65 23.90±4.40

116.64

0.0001*

3.798

0.001*

2.177

0.036*

3.168

0.003*



Vol. 2 No. 2 May 2012 116

Table (5): Total mean score of knowledge of the studied sample about diabetes mellitus.

Total

Knowledge

scores


(n=40)

The study group

(n=20)

The control group

(n=20)

Pretest

Immediate

post test

3

months

post test

F-test

P

Pretest

Immediate

post test

3

months

post test

F-test

P

Range 22-61 57-76 66-74 20-61 51-76 42-74

Mean±SD 37.85±17.14 68.9±8.75 69.14±6.43 157.933 31.7±17.95 65.89±10.51 62.3±12.51 92.860

Median 40.00 71.50 71.00 0.0001* 33.50 68.00 66.00 0.0001*

Study vs

Control:

T-test

P

2.153

0.038*

2.240

0.031*

3.261

0.002*



Vol. 2 No. 2 May 2012 117

Table (6): Mean score & standard deviation of the studied sample regarding self care inventory through the study.

self care inventory

items

The study group

(n=20)

The control group


Pretest

Immediate

post test

3 months

post test

F-test

P

Pretest

Immediate

post test

3 months

post test

F-test

P

t-test

P

Mean±

SD

Mean±

SD

Mean±

SD

Mean±

SD

Mean±

SD

Mean±

SD

Pretest

Immediate

post test

3

months

post test

1- Blood glucose

testing

2.6±1.37 3.65±1.04 3.95±0.89 5.146 2.50±0.76 3.30±0.86 3.00±0.79 5.005 1.710 1.157 3.567

0.009* 0.010* 0.095 0.254 0.001*

2- Rrecording blood

glucose level

2.30±1.75 3.90±1.21 3.9±1.02 5.841 1.40±0.94 2.35±0.87 2.05±1.00 5.345 2.026 1.648 2.662

0.008* 0.007* 0.050 0.108 0.011*

3-Ketones testing 1.45±0.94 1.55±1.23 1.55±1.10 0.055 1.50±1.10 1.50±1.15 1.20±0.52 0.643 0.154 0.133 1.286

0.946 0.530 0.878 0.895 0.206

4- Talking accurate

insulin dose

3.5±1.12 4.50±0.51 4.55±0.51 1.789 3.60±1.14 4.15±0.74 4.05±0.76 2.113 1.398 1.730 2.444

0.102 0.130 0.170 0.092 0.019*

5- Talking accurate

insulin dose right

time

4.20±0.89 4.50±0.61 4.50±0.61 1.171

0.317 3.45±1.05 4.10±0.72 3.90±0.72

3.116

0.052

2.432

0.020*

1.902

0.065

2.854

0.007*

6- Change insulin

dose according

blood glucose level

2.90±1.42 4.20±0.01 4.30±0.70 7.465

0.0001* 2.40±1.27 3.95±1.07 3.25±1.05

6.102

0.006*

3.051

0.004*

3.133

0.003*

4.715

0.0001*

7- Adherence to

diabetic diet

3.15±1.35 3.65±0.99 4.00±0.72 3.297 2.60±1.43 3.65±1.23 3.40±1.26 5.002 1.252 1.697 3.997

0.044* 0.012* 0.218 0.098 0.0001*


Vol. 2 No. 2 May 2012 118

Table 6 continue

8- Eat meal at

times

2.95±1.32 3.30±0.86 3.60±0.75 2.082 2.50±1.23 3.25±1.21 2.65±1.18 2.155 1.115 0.150 3.030

0.134 0.125 0.272 0.881 0.004*

9- Eat snakes

regularly

2.65±1.39 3.50±1.00 3.90±0.64 7.33 2.95±0.89 3.50±1.19 3.20±1.10 1.327 0.815 0.000 2.451

0.001* 0.273 0.420 1.000 0.019*

10-Carry sweaty

foods to manage

hypoglycemia

2.70±1.87 3.85±1.14 4.60±0.60 10.703 2.55±1.73 3.70±1.22 3.60±1.05 4.367 0.263 0.403 3.711

0.0001* 0.017* 0.794 0.689 0.001*

11-Medical

follow up

2.80±1.54 3.35±1.35 3.60±1.14 1.826 2.25±1.16 2.85±0.93 2.55±0.94 1.732 1.273 1.363 3.168

0.170 0.186 0.211 0.181 0.003*

12-Carry

identification

card

1.70±1.45 2.20±1.32 2.35±1.22 1.295 1.05±0.22 1.45±0.60 1.20±0.41 4.194 1.975 2.307 3.978

0.282 0.020* 0.056 0.027* 0.0001*

13-Practice

exercise

regularly

2.85±1.69 3.30±1.30 3.95±1.00 3.298 1.55±0.76 2.20±1.00 2.15±0.81 3.493 3.131 2.991 6.252

0.044* 0.037* 0.003* 0.005* 0.0001*

14- Practice

exercise

strenuously

2.75±1.68 3.30±1.26 3.80±1.06 2.990

0.058 1.55±0.89 2.15±1.04 1.95±0.94

2.029

0.141

2.822

0.008*

3.147

0.003*

5.839

0.0001*


Vol. 2 No. 2 May 2012 119

Figure (1) showed means of the studied sample regarding to the total score of Self Care

Inventory throughout the study period. The there was a significant improvements in the mean score of

self care inventory of both groups (study & control) from preprogram, immediate program, and three

months post program with a significant between the two groups throughout the study.

Figure (1): means of the studied sample regarding to the total score of Self Care Inventory

throughout the study period.

Figure (2) showed the total mean score and standard deviation of students regarding to

Diabetic Support Assessment (DSA) throughout the study period. There was a significant

improvement in the mean total score of diabetic support of the study group through the

study period, as the total mean score increased from 36.15±21.46 preprogram, to

49.00±18.97 immediate post program, and 54.65±18.09 three months post program (P˂

0.05). Meanwhile, a slight change was observed among the control group. There was a

significant difference between the study and control group in relation to the total mean score

of diabetic support at immediate post program and three months post program (t= 4.391 &

t= 6.759) respectively.

37.6

48.75

52.55

31.85

42.1

38.15

0

10

20

30

40

50

60

Mean

Self

care in

ven

to

ry s

co

re

Pre-test Immediate

post-test

3 months

post-test

Pre-test Immediate

post-test

3 months

post-test

The study group (n=20) The control group (n=20)


Vol. 2 No. 2 May 2012 120

Figure (2): Diabetic Support Assessment (DSA) scores of the studied diabetic school children

(study and control groups) .

Figure 3 shows mean fasting blood sugar (FBS) of the studied diabetic school children

(study and control groups). The table showed that, there was a significant improvement of glycemic

control among the study and control groups throughout the study period. The mean fasting blood sugar

of the study group was 263, 193 and 125ml/dl respectively at preprogram, immediate, and 3 months

post program. While the mean fasting blood sugar of the control group was 351.90, 285.85 and 206.25

ml/dl respectively at preprogram, immediate, and 3 months post program. A significant difference was

found between the two groups in relation to their fasting blood sugar from preprogram, immediate, to

3 months post program.

Figure (3): Mean fasting blood sugar (FBS) of the studied diabetic school children (study and

control groups).

36.15

49

54.65

33.4932.35 33.55

0

10

20

30

40

50

60

Mean

DS

A

Pre-test Immediate

post-test

3 months

post-test

Pre-test Immediate

post-test

3 months

post-test


S

263.9

193.6

125

351.9

285.8

206.2

0

30

60

90

120

150

180

210

240

270

300

330

360

Mean

fasti

ng

blo

od

su

gar

(mg

/dL

)

Pre-test Immediate

post-test

3 months

post-test

Pre-test Immediate

post-test

3 months

post-test



Vol. 2 No. 2 May 2012 121

Table (7): Correlation between knowledge, Self- Care Inventory, diabetic peer support performed steps in assuring blood glucose level and

injecting insulin by pen among the studied sample (study and control groups) immediately post-test.

Variables The

study

group

(n=20)

The

control

group

(n=20)

Knowledge

Self- Care

Inventory

(SCI)

Diabetic

Support

Assessment

(DSA)

Measuring

blood glucose

level

Injecting

insulin

by pen

(n=18)

Knowledge

Self-

Care

Inventory

(SCI)

Diabetic

peer

support

Measuring

blood

glucose

level

Injecting

insulin

by pen

(n=18)

R

P

r

P

r

P

r

P

r

P

r

P

R

P

r

P

r

P

r

P

Self-

Care

Inventor

y (SCI)

0.518

0.019*

- - - 0.490

0.049*

- - -

Diabetic peer

support

0.040

0.869

0.410

0.072

- - 0.365

0.113

0.126

0.597

- -

Measuring blood

glucose level

0.454

0.044*

0.165

0.486

0.430

0.059

- 0.005

0.984

0.080

0.736

0.315

0.176

-

Injecting insulin

by pen

0.501

0.012*

0.246

0.325

0.153

0.545

0.346

0.159

0.486

0.041*

0.499

0.025*

0.404

0.096

0.344

0.162


Vol. 2 No. 2 May 2012 122

(n=18)

Fasting Blood

Glucose

0.454

0.044*

0.165

0.486

0.430

0.059

0.325

0.163

0.346

0.159

0.113

0.635

0.066

0.783

0.097

0.683

0.682

0.001*

0.383

0.117


r=Correlation coefficient

Table (8): Correlation between knowledge, Self- Care Inventory, performed steps in injecting insulin by pen and by syringe among the studied

diabetic children (study and control groups) 3 months post-test.

Variables The study

group

(n=20)

The control

group

(n=20)

Knowledge

Self- Care

Inventory

(SCI)

Diabetic

Support

Assessment

(DSA)

Measuring

blood

glucose level

Injecting

insulin by

pen

(n=18)

Knowledge

Self- Care

Inventory

(SCI)

Diabetic

peer

support

Measuring

blood

glucose level

Injecting

insulin by

pen

(n=18)

r

P

r

P

r

P

r

P

r

P

r

P

r

P

r

P

r

P

r

P

Self- Care

Inventory

(SCI)

0.673

0.001*

- - - 0.454

0.044*

- - -


Vol. 2 No. 2 May 2012 123

Diabetic peer

support

0.497

0.026*

0.486

0.041*

- - 0.414

0.070

0.347

0.134

- -

Measuring

blood

glucose level

0.467

0.038*

0.518

0.019*

0.311

0.181

- 0.216

0.362

0.047

0.844

0.149

0.530

-

Injecting

insulin by

pen

(n=18)

0.532

0.023*

0.433

0.073

0.475

0.047*

0.890

0.0001*

0.524

0.018*

0.271

0.277

0.038

0.880

0.297

0.231

Fasting

Blood

Glucose

0.598

0.005*

0.139

0.558

0.282

0.228

0.392

0.088

0.569

0.014*

0.210

0.375

0.490

0.028*

0.043

0.858

0.552

0.012*

0.737

0.0001*

*Significant (P<0.05) r=Correlation coefficient


Vol. 2 No. 2 May 2012 124

Discussion

Type 1 diabetes mellitus (T1DM) is a

lifelong metabolic disorder for which no cure is

known. The management of T1DM is a complex

regimen of multiple daily insulin injections,

frequent monitoring of blood glucose level and

life style adjustment such as meal planning and

exercise. TIDM presents a unique challenge to

health care provider, diabetic school children

and their families (18,19)

.

The main aim of diabetes management of

diabetic teenage is to achieve optimal glycymic

control as it prevents long term complications.

Glycymic control usually deteriorates during

adolescence (20)

.

Peer support helps reduce problematic

health behaviors, depression, and contribute to

improve diabetes management, including

improving behaviors related to medication

adherence, diet, exercise, and blood glucose

monitoring. The success of peer support appears

to be due to the nonhierarchical, reciprocal

relationship that is created through the sharing

of similar life experiences(21)

.

At the begaining of this study, the pretest

was applied to students of both the study and

control groups to analyze their

sociodemographic data, knowledge, self care

practices, glycemic control, and availability of

peer support of the diabetic school children in

order to develop specifically targeted

comprehensive guidelines on diabetes self-

management according to their needs,

knowledge and practices deficit.

In this context, the result of this study

showed that before implementation of the

program the study and control groups showed

poor glycemic control, low scores of

knowledge, self care practices and perceived

peer support. After implementation of the

program, the two groups showed significant

glycemic control and improvement in their

knowledge score and self care practices. This

improvement was highly significant among the

study group who received peer support than the

control one.

Maintaining glycemic levels is an

extremely difficult task for most school- age

children and their families(22)

. Preprogram, the

two groups showed poor glycemic control as

they had high means of fasting blood glucose

levels. Immediately and three months after

applying the program, a significant progressive

reduction in the means of the fasting blood

glucose levels was found among the two groups.

However, the reduction was more obvious

among the study group than the control one.


Vol. 2 No. 2 May 2012 125

This could be due to that students included in

the peer support group were more motivated

and supported each other to adhere to diabetic

diet, regular exercise in the form of walking,

regular monitoring of blood glucose level and

adjust insulin injection dose according to the

results. Such support was mainly through

telephone call or meeting during school day

break to discuss daily events related to diabetes.

This result is in agreement with the result of

Deakin et. al., (2005), who reported that group

based training significantly improved fasting

blood glucose level of diabetic people at both

short- and long- term follow up(23)

.

As regard students’ knowledge about

diabetes, the present study showed that, results

of pretest showed that only a few percent of

both the study and control groups reported

correct and complete knowledge about diabetes

as well as its management. This result may be

attributed to unavailability of an organized-

structured health education program about

diabetes to those diabetic students. The present

result is in agreement with El Rafay

SS(2004)(24)

,who reported that the diabetic

children had improper knowledge of diabetes

including its meaning, types and causes.

The importance of knowledge in health

education must not be ignored as improvement

in knowledge is the first step toward health

behavior modification. After applying the

program, the two groups in this study showed a

significant improvement in their mean score of

total knowledge about diabetes, its management

and all its aspects immediately and 3 months

post program. This improvement was relatively

higher among the group who received peer

support than the control group. This reflects the

importance of continuous education of diabetics

in conjunction with peer support to refresh their

knowledge as some details may be forgotten, so

peers can review them together. In accordance

with the present study Coleman et. al., (2011)

(25) reported that peer education had a significant

increase in diabetic students' knowledge related

to diabetes. The result also is in agreement with

the finding of Hassan S(2007) (16)

, El zubier

(2001) (26)

, and Norris et. al., (2001) (27)

who

found significant improvement in knowledge of

diabetic children after health education program.

El Rafay (2004) (24)

, mentioned that diabetic

adolescent reported appropriate understanding

about the difference between the traditional and

the unfamiliar symptoms of hypoglycemia after

health education.

Concerning Self Care Inventory (SCI),

the pretest in this study revealed that the two

groups had low frequency of practicing most of


Vol. 2 No. 2 May 2012 126

its items e.g. blood glucose testing, recording,

ketones testing, changing insulin dose according

to result of blood glucose test, eating meals at

times, having snacks regularly, carry sweaty

foods to manage hypoglycemia, medical follow

up, carrying identification card, and practicing

of exercise. This finding may be due to many

facts as lack of their knowledge about DM and

its management, negligence, as well as their

desire for not to be different from their

colleagues or friends. After applying the

program, there was a significant improvement in

all items of SCI for both groups immediately

post program except for testing of ketones,

taking accurate insulin dose, taking it at right

time, and eating meals at times. This

improvement was higher and significant among

the study group than the control one through the

study period especially three months post

intervention. Moreover, the overall score of SCI

was higher among the study than the control

with significant difference between the two

groups either, immediate, and post test. These

results may be attributed to the core element of

peer support which depends on sharing and

exchanging of experiences related to diabetes

among the study group. Peer support may

improve self-management among millions of

people with diabetes around the world(28)

.

The realization of the importance and

effectiveness of peer support among adolescents

has encouraged its implementation in various

health problems as engaging peer support to

help adolescent and child to deal with public

health problems such as smoking(29)

. A assessed

the influence of peer relationships on adjustment

to cystic fibrosis during adolescence by

D’Auiria et. al., (2000) (30)

, showed that, peer

support help adolescents to incorporating cystic

fibrosis into their developing ideas of who they

are and who they will become, gave them a

greater perspectives of illness, its consequences,

coping and the importance of believing in a

positive future.

Therapy of T1DM involves greater and

earlier use of intensive insulin regimens in order

to achieve better control of blood glucose

level(31)

. The result of the present study revealed

that, study group showed high compliance with

insulin dose and adjusting it according to results

of blood glucose test more than the control one.

This result may be attributed to their influence

by familial experiences as three quartres of the

studied sample had family history of diabetes

mellitus in particular among first degree relati

relatives (father mother, sister and brother).

Moreover, every student in the peer support

group competed to be more compliant than his


Vol. 2 No. 2 May 2012 127

peers. In agreement with the current result, La

Greca (2004), reported that most people with

diabetes report compliance with insulin

management very often(15)

. This result is

contradicted with Abdel Gaffar (2003)(17)

who

found that only thirty percent of the diabetic

students had good self care practice scores in the

area of insulin injection therapy.

The American Diabetes Association

(ADA) (2005) (32)

recommended that patients

with DM perform self monitoring blood glucose

at least 3 times/day especially before meals. In

the present study before implementation of the

program a varied percentage of the study and

control groups used to test blood glucose level

before meals, two hours after meal, or at any

time. Immediately after applying the program,

the majority of the two groups tested their blood

glucose level before meals and two hours after

meals. At three months post program, all the

study group reported that they test their blood

glucose at such times while the control group

showed slight decrease than this percentage.

Their scores regarding recording of the result of

blood glucose test increased through the study

period especially among the study group. These

results may be explained by the role played by

peers as they reminded each other about

adherence to testing blood glucose at time

through a mobile telephone call at morning and

at night before sleeping. Moreover, the health

insurance provided each diabetic student with an

apparatus for blood glucose testing that makes

blood glucose testing available for the student at

any time.

Although insulin therapy is the

cornerstone of treatment for type 1 DM, a

dietary plan is important in maintaining near-

normoglycemia without wide swings in blood

glucose levels. Long term adherence to the

dietary plan is probably the most difficult aspect

of the diabetic regimen (33)

. The results of the

present study denoted that preprogram more

than half of the two groups showed improper

practices regarding diabetic diet (adhered to

wrong diet regimen, take no action if they want

to eat sweaty foods, had few meals /day, ate

inappropriate snacks, and did not weight body

regularly).

Poor dietary regimen adherence could be

also attributed to both inadequate patients'

knowledge of dietary management, and that

food habits are the most difficult habit to

change(34)

. Immediately post program, the

majority of the study group and more than half

of the control group showed improvement in

their practice regarding diabetic diet. This

improvement was maintained among the study


Vol. 2 No. 2 May 2012 128

group at three months post program more than

the control group. This result as mentioned by

the study group is related to the presence of a

peer who helped them to select appropriate food

and encourage them to eat proper snacks e.g.,

one peer supporter had previous health

education sessions about diabetes and its

suitable diet at Abo El-Resh hospital and the

students usually search net wipe site for

diabeteic diet and intern they benefit their peers.

Such peers were not available to the control

group. In agreement with the present results El

Saleet (2000), assessed the effect of improving

knowlegde and practice among diabetic children

and their mothers in Tanta city and reported

improved adherence to diet control among

diabetic children(35)

. On the other hand results of

Hassan (2007) (16)

, are contradicted with this

result as it revealed that there was a significant

reduction in the mean score of adolescents’

adherence to diabetic diet after implementation

of the intervention.

Regular physical activity is associated

with immediate and long-term health

benefits(36)

. According to American Diabetic

Association (ADA) guidelines, all patients with

diabetes should be given the opportunity to

benefit from the effect of exercise(37)

. At the

pretest more than half of the study group and

only more than one tenth of the control

practiced physical exercise. This finding is in

agreement with many researches that assessed

self- care and physical practices of diabetics

which denoted poor physical exercise practices

among diabetic children(17,32,38)

. Immediately

and 3 months after implementation of the

program, there was a significant improvement in

the practice of physical exercise of the two

groups, but it was more significant among study

group than the control one. This finding may be

related to the influence of peers as peers

encouraged each other to practice exercise.

Friends' support in this study consisted primarily

of companionship behaviors, such as sharing

various activities (e.g. they go to biking or

walking together).

Although circulatory problems of the feet

are less common in children, proper foot

hygiene habits need to be established(39)

. The

current study denoted that a varied percentage

ranged from 50% to 80% of both groups had

improper practices. Immediately and 3 months

after implementation of the program, the

majority of both groups showed improvement in

all items of foot care practices, but with no

significant differences between the two groups.

This result may be attributed to improvement of

their knowledge related to foot care. The


Vol. 2 No. 2 May 2012 129

students reported that they adhered to foot care

practices fearing of foot complications

especially diabetic foot and amputation.

Findings of El Sallet (2000)(35)

, are in agreement

with this results.

Adolescents and children tend to have

difficulty adherence to diabetic regimens(40)

.

Negative social attributions have a role in

adherence difficulties, so intensive psychosocial

support may be indicated (41)

. Peer support falls

within the social model, which is defined as the

process through which social relationships

might promote health and well-being(42)

. The

results of the present study denoted that,

preprogram, the majority of the two groups

reported that their parents were the resource

persons for diabetes social support. Immediately

and 3 months post program, the majority of the

study group reported that peers and parents were

the resource persons for diabetic social support,

while the majority of the control group reported

parents only. Furthermore, it was also observed

that, immediately and 3 months post program,

students exposed to peer support, reported peers

with high score than parents as a resource for

support. Finding of a study done by Greco P et.

al., (2001)(43)

, about peer group intervention for

adolescents with type 1 diabetes and their best

friends is in agreement with the result of the

present study and added that parents reported

that including peers in treatment has been

associated with decreased parent- child diabetes

conflict.

Concerning peer support, the present

study revealed that, pre-intervention the study

and control groups had nearly the same mean

scores on the diabetes peer support assessment

scale regarding all the studied items.

Immediately and 3 months post program, the

study group showed a significant continuous

increase in their total mean score of diabetes

peer support and for all the items. On the other

hand, the control group showed no

improvement. This result is in agreement with

Pendley et. al., (2002), who studied peer and

family support in children and adolescents with

type 1 diabetes and mentioned that adolescents

reported significantly more peer support for

various management tasks in every category of

peer support(44)

. These results may be justified

that, as adolescent experience more intimacy

and disclose information, as it is typical in

normative development, and they may also

share more disease-related information and, in

turn, perceive their peers as offering more

support for their diabetes(45)

.

The present study showed a positive

correlation between the knowledge of the study


Vol. 2 No. 2 May 2012 130

group and Self- Care Inventory, peer support,

measuring blood glucose level, injecting insulin

by pen and fasting blood glucose level at 3

months post program Self- Care Inventory was

also correlated with peer support and injecting

insulin. This correlation may be related to the

success of peer supporters in persuading the

diabetic student to correct their diabetic

knowledge and enhance their adherence to self

care practices. In relation to the control group, a

significant positive correlation was found

between the group's knowledge and Self- Care

Inventory, and injecting insulin by pen

immediately and 3 months post program. This

correlation is similar to that of Norris et. al.,

(2001)(46)

,who reported that self management

training was associated with improvement of

knowledge, frequency or accuracy of blood

glucose self monitoring, self-reported dietary

habits and glycemic control.

Three months post program there was

also a positive correlation between Self- Care

Inventory of study group and diabetic peer

support & measuring blood glucose level.

Moreover, a positive correlation was found

between injecting insulin by pen and diabetic

peer support & measuring blood glucose level.

In addition, there was a positive correlation

between fasting blood glucose level and diabetic

knowledge & injecting insulin by pen. This

correlation is clarifying that every student in the

study group gained benefit from the practical

experience of each other which intern improve

their self care practices and glycemic control.

Continuous effort should be made to help

diabetic school students achieving gylcemic

control and adhering to the management of the

disease. This can be achieved through

organization and implementation of diabetic

peer support group within the school. Proper

glycemic control will help students enhancing

their academic performance and relations with

the outside environment.

Recommendations

1- School health nurses should be informed

about the importance of peer support for

diabetic students and encouraged to do their best

effort to make peer support available to every

diabetic student in particular those of poor

glycemic control or newly diagnosed.

2-The school health nurse should conduct

periodic and continuous training programs for

the diabetic students to enhancing their diabetes

self care and glycemic control.

3- School health insurance needs to specify a

certain day and name it “day of diabetic

student”. This day give the chance for meeting


Vol. 2 No. 2 May 2012 131

of all diabetic students and doing recreational

and physical activities that enhance their social

support to each other.

4- School health insurance should provide every

diabetic student with a booklet with simple

instructions and diagrams about diabetes and its

management.

5- Mass media programs about type 1 diabetes

and peer support need to be prepared and

introduced by diabetic teenagers.

References

1- Ball JW and Blindler RC. Child Health

Nursing: Partnering with Children &

Families. New Jersey: Pearson Prentice

Hall Co., 2006; 1263-1275.

2- Price DL and Gwin JF. Pediatric

Nursing: An Introductory Text. 10thed.

Tokyo: Saunders Co., 2008; 291-302.

3- Towle MA and Adams ED. Maternal-

Child Nursing Care. New Jersy:

Pearson Prentice Hall Co., 2008; 753-

764.

4- International Diabetes Federation.

International Diabetes Federation calls

for global action to keep all children

with diabetes alive.2001.

5- International Diabetes Federation.

Diabetes. Diabetes is a chronic and

life- threatening condition. 2006.

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Vol. 2 No. 2 May 2012 136

Application of Designed Orientation Program for Nurse Interns Based on Learning

Needs Assessment

Heba K. Obied, Assistant lecturer in Nursing Administration Dep, Faculty of Nursing, Tanta University

Fouada M.Shabaan, Prof. of Nursing Administration, Faculty of Nursing, Tanta University

Helmy H. Shalaby, Prof. of Plastic Surgery, Faculty of Medicine, Tanta University

Samar H. Gadiry, Lecturer of Nursing Administration, Faculty of Nursing, Tanta University

Abstract

Orientation programs based on LNA encourage nurse interns to feel safe and enable them to demonstrate

competency in the basic clinical and management skills needed for providing high quality and safe patient care.

Using LNA ensure NIs commitment to these program. This study aimed to design, implement, and evaluate an

orientation program about clinical and management skills needed for nurse interns based on the findings of

learning needs assessment tool. Material and method the study was conducted at Tanta University Faculty of

Nursing and Tanta University Emergency and Main Hospitals ICUs and obstetric and dialysis departments.

(384) nursing students passed the 4th

academic year attended the orientation program. (198) spent their

internship year at Tanta University Hospitals were included in the researcher’s observation 3 month post

program. The data collection was achieved by using LNA scale, knowledge test, NIs’ orientation program and

follow up observation sheet. RESULTS: Pre program around half (51%) of NIs assessed themselves as cannot

carryout different clinical and management skills. Majority (87%) of NIs got low knowledge level for both

skills. Post orientation program statistical significant improvement at (P≤0.05) was found in NIs’ knowledge and

practical levels for both clinical and management skills. Conclusion designing orientation programs before

starting the internship year based on nurse interns LNA is important to ensure efficient interns performance.

Recommendation conduct orientation programs based on nurse interns’ LNA and knowledge test before

starting internship year and at the beginning of each new rotation, provide nurse interns with pass booklet

include standard procedures required to be carried out in each rotation, provide them also with designed

evaluation manual based on the pass booklet and implementing nursing mentor-ship and preceptor-ship

programs during internship year.


Vol. 2 No. 2 May 2012 137

Introduction

The internship year is considered a time of

transition from undergraduate nursing students to

beginning level registered nurses. During this year

nurse interns should acquire the values, attitudes,

and goals fundamental to the nursing

profession(1,2)

. At the beginning of the internship

year many nurse interns feel uncomfortable and

inadequacy as their skill levels do not match their

expectations of the role and responsibilities of a

practicing as a registered nurse(3)

. During

internship year nurse interns are expected to work

in intensive care units (ICUs) under supervision of

experienced knowledgeable supervisors (4)

.

Today’s health care arena become complex and

suffer from severe nursing shortage and limited

budgets for continuing education programs; that

affect organization’s ability to provide

comprehensive orientation programs for new

graduates or for nurse interns(5-6)

.

In addition hospital administrators’ expect nurse

interns to be competent to function and take

responsibilities in nursing service at the time of

graduation with adequate clinical and patient

management skills to cover shortage and decrease

the workload on experienced staff. Consequently

nurse interns are imposed to the work field

responsibilities early(7-8)

. Therefore, nursing

faculties have to provide interns with a supportive

clinical environment in terms of skills, knowledge,

practice, reflection and cultural socialization to

help them to feel competent and supported (9)

.

Effective internship year should starts with

orientation program to enhance the nurse interns’

knowledge and relieve their stress. Nursing

faculties are responsible for designing and

implementing appropriate internship programs to

smooth transition from student to registered nurse.

Well designed internship program facilitate interns’

entry into clinical practice, support their growth

along the continuum of expertise, and development

of essential leadership skills within the field of

health care(10,11)

.

Orientation program encourage nurse interns

to feel welcome, safe and valued, so it eases

transition and provide them with opportunities to

develop self confidence, increase job satisfaction

and chances to demonstrate competency in the

basic skills needed for So this study aimed to assess

nurse interns’ learning needs before entering

clinical practice setting and design a suitable

orientation program for covering the gabs in their

clinical and management knowledge and skills.


Vol. 2 No. 2 May 2012 138

This study also aimed to evaluate the nurse

interns’ statistical change of clinical and

management knowledge and skills after attending

the orientation program.

Aim of the study: This study aimed to apply a

designed orientation program for nurse interns

based on learning needs assessment through:

- Design, implement, and evaluate an orientation

program about clinical and management skills

needed for nurse interns based on the findings of

using learning needs assessment tool.

Materials and Method:

Study design: Cross-sectional study design was

utilizes to achieve the aim of this study.

Setting: The study was conducted at

Tanta University Faculty of Nursing.

Tanta University Emergency and Main

Hospitals Intensive Care Unites (ICUs) include

medical, anesthetic, neurological, neonatal,

pediatric, and cardiac .In addition to obstetric

and dialysis departments.

providing high quality and safe patient care (5,12,13)

.

Orientation program ensures useful transition time

if it is based on the interns’ key learning needs and

considers teaching and learning activities

grounded in practice experience, skilled and well-

supported preceptors and structured learning

framework (14)

.

LNAs are often conducted to identify

deficiencies in knowledge, skill, behavior, or

attitude in the current teaching practices, or to

anticipate deficiencies based on expected changes

in health care needs. So orientation program based

on LNA match the nurse interns’ unique learning

needs not only nursing service needs(15-18)

.

Subject

All the nursing students (384) passed the fourth

academic year (2009-2010) attended the

designed orientation program based on their

learning needs assessment and participated in

pre and post program knowledge test.

All (198) nursing students who spent their

internship year (2010-2011) at Tanta University

Hospitals were included in post program

observation after three months. Tools of the study:

to collect the data four tools were used:

1. Learning needs assessment scale, developed by

the researcher guided by Zerwekh (2006)(53)

and Fakhry (2005)(159)

and others, to assess

nurse interns’ clinical and management

learning needs immediately before starting

internship year. The sheet contained part of

demographic data, and (150) items cover


Vol. 2 No. 2 May 2012 139

clinical subscales (91) items and management

subscales (59). Responses were measured by

three points Likert Scale for clinical subscale

ranging from can do it by myself to can’t do it

by myself. And two points Likert scale

ranging from able to not able for management

subscale.

2. Nurse interns’ knowledge test, designed by the

researcher and used to collect data from nurse

interns. The test composed of (100) questions

cover both clinical and management subscales.

Scoring system represent knowledge levels of

nurse interns’ ranging from low (≤60%),

medium (>60%- ≤80%) to high (>80).

3. Nurse interns’ orientation program was

designed by the researcher based on the

findings of the learning needs assessment

scale and nurse interns' knowledge test tools

(1&2) (pre-test). At the end of the program, a

post-test was carried out used tool (2) for

sample (384) of nurse interns before starting

internship year to assess the extent to which

desired stated objectives and assumed needs

were achieved.

4. Follow up observation sheet, included the

same items in the learning needs assessment

5. scale to evaluate nurse interns' actual

performance of clinical and management skills

after three months of the orientation program

during their internship year. Researcher’s

observations to clinical skills were measured

by four points Likert Scale ranged from can do

it herself to not applicable. Management skills

were measured by two pointsLikert Scale

range from able to do to not able to do.

Method of data collection:

1. An official permission was obtained from

responsible authorities including Faculty of

Nursing and Hospitals of Tanta University to

conduct the study.

2. The learning needs assessment scale was

submitted to a jury of ten experts from different

nursing specialties to get their suggestions

about content validity and applicability of the

tool.

3. A pilot study was conducted on ten students

out of the proposed sample two times (two

weeks separated) to measure test-retest

reliability.

4. The content validity index was (93%), internal

consistency reliability was (0.9501) and the

test-retest reliability that was (0.9725).


Vol. 2 No. 2 May 2012 140

5. Nurse interns’ learning needs of clinical and

management skills were assessed by (tool 1).

6. Nurse interns’ knowledge was tested by (tool

2) pre implementation of the orientation

program.

7. The nurse interns' orientation program was

designed based on the assessment data and

literature review. The program was

implemented by the researcher and started two

weeks just before internship year; it was ten

hours duration divided into five sessions each

session two hours for five days. The nurse

interns' were divided into two groups each

group attended the five sessions.

8. Nurse interns' knowledge was tested post

program by tool (2).

9. Nurse interns’ were followed up in their

clinical areas for the first three months after the

implementation of the orientation program,

then they were reevaluated using follow up

observation sheet (tool 3).

Results

Table (1) represents demographic

characteristics of nurse interns. Nurse interns

(73.2%) were in the age group ≤ 20-22. Majority

(81%) of nurse interns graduated from general

secondary school, while minorit

(6%) graduated from secondary technical nursing

school.

About two third (65%) of the subject had

graduation level very good and (7.6%) had

excellent graduation level. NIs (71.4%) did not

have previous training. While (28.6%) had

previous training, (61.9%) of them trained during

third and fourth academic years, (20.9%) trained

during all the four academic years and (17.2%)

trained during first and second academic years.

Training mean period was (3.4 + 0.45) month.

Those trained NIs (40.9%) of them had trained in

ICUs and (34.5%) trained in medical surgical

wards.

Figure (1) shows that pre program (51%) of

nurse interns assessed themselves as cannot do,

while (49%) can do both clinical and management

skills. More than half (53%) of NIs assessed

themselves as cannot do clinical skills, while

(42%) as cannot do management skills.

Table (2) represents nurse interns’ LNA total

clinical skills scales pre orientation program. Nurse

interns’ (71.3% and 69.1%) can assess vital signs

and collect patient's data respectively. Also (65.5%,

64.5%, 64.1%, 63.3% and 60.9%) can do assess


Vol. 2 No. 2 May 2012 141

anthropometric measures, prevent immobility

complications, apply safe practice &infection

control, heat& cold therapy and perform patient

hygiene by themselves respectively. Nurse interns

(45.4 %, 43.7%, 42% and 41.8%) can not provide

by themselves elimination care, assist in diagnostic

procedures, provide gastrointestinal care and

provide cardio-respiratory care respectively.

Around one third (33.1% and 32.8%) of the nurse

interns can not provide by themselves newborn

care or apply mechanical restraining respectively.

More than quarter (29.4% and 28%) can not assess

by themselves neurological condition or provide

wound care respectively.


Vol. 2 No. 2 May 2012 142

Table (1). Demographic characteristics of the nurse interns.

Nurse Interns (n=384)

no. %

Items

73.2 281 Age (years) ≤ 20-22

26.8 103 > 22

Previous graduation school

81.0 311 General secondary school

6.0 23 Secondary Technical Nursing School

13.0 50 Health Technical Institute

7.6 29 Graduation level Excellent

65.1 250 Very Good

20.3 78 Good

7.0 27 Satisfactory

71.4 274 Previous training ( months ) No

28.6 110 Yes

17.2 19 First& second academic years

61.9 68 third &fourth academic years

20.9 23 All years

11.8 13 Training units Neonates ICU

34.5 38 Medical surgical


Vol. 2 No. 2 May 2012 143

3.6 4 Emergency Room

40.9 45 Intensive Care Units

6.4 7 Operation Room

2.7 3 Obstetric

Fig.(1) Nurse interns’ learning needs assessment for clinical and management skills pre orientation

program. (No.=384).

Table (2). Nurse interns’ learning needs assessment total clinical skills scales pre orientation program.

(No= 384).

Clinical skills scales Can do it

myself

Can do it under

supervision

Can not

do it

myself

No % No % No %

Collect patient's data 266 69.1% 83 21.4% 36 9.4%

Assess vital signs 274 71.3% 89 23.2% 21 5.5%


Vol. 2 No. 2 May 2012 144

Assess anthropometric

measures

252 65.5% 84 21.9% 49 12.6%

Assess stat of comfort 187 48.6% 137 35.7% 60 15.8%

Assess neurological

condition

131 34.1% 140 36.5% 113 29.4%

Collect samples 181 47.0% 104 27.0% 100 26.0%

Assist in diagnostic

procedures

106 27.5% 111 28.8% 168 43.7%

Safe practice &

infection control

246 64.1% 98 25.4% 40 10.5

Provide cardio-

respiratory care

94 24.4% 130 33.8% 161 41.8%

Provide gastrointestinal

care

89 23.1% 134 34.9% 161 42.0%

Provide elimination

care

100 26.1% 109 28.4% 174 45.4%

Medication

administration &IV

access

207 53.8% 86 22.3% 92 23.9

Provide wound care 159 41.3% 118 30.7% 108 28.0%

Prevent immobility

complications

248 64.5% 68 17.8% 68 17.7%

Perform patient

hygiene

234 60.9% 69 18.0% 81 21.1%

Apply heat & cold 243 63.3% 70 18.2% 71 18.4%


Vol. 2 No. 2 May 2012 145

therapy

Apply mechanical

restraining

122 31.8% 136 35.4% 126 32.8%

Provide newborn care 143 37.2% 114 29.7% 127 33.1%

Table (3). Nurse interns’ learning needs assessment total management skills subscales pre orientation

program. (No=384).

Management skills subscales Able Not able

No % No %

Interpersonal skills 222 56.9% 162 43.1%

Interpersonal relation & caring 225 58.7% 159 41.3%

Communication 223 58.1 % 161 41.9%

Conflict management 207 54.0% 177 46.0%

Organizational skills 222 57.9% 162 42.1%

Problem solving 214 55.6% 170 44.4%

Decision making 229 59.6% 155 40.4%

Time management 225 58.6% 159 41.4%

Priority setting 217 56.4% 167 43.6%

Delegation 232 60.5% 152 39.5%


Vol. 2 No. 2 May 2012 146

Table (4). Significant difference between nurse interns’ total knowledge levels on different clinical skills

subscales pre& post orientation program. (No.=384)

Total

knowledge

level

Clinical

skills subscales.

Program High Moderate Low Chi-

square

(P -

value)

No % No % No %

Pre 0 0% 87 23% 297 77% 0.000*

Post 299 78% 76 20% 9 2%

Collect patient's

data

Pre 105 27% 131 34% 148 39% 0.000*

Post 321 84% 40 10% 23 6%

Assess comfort&

neurologic state

Pre 5 1% 35 9% 344 90% 0.000*

Post 175 46% 135 35% 74 19%

Assess vital signs Pre 6 2% 96 25% 282 73% 0.000*

Post 243 63% 119 31% 22 6%

Safe practice&

Infection control

Pre 41 11% 108 28% 235 61% 0.000*

Post 285 74% 58 15% 41 11%


Vol. 2 No. 2 May 2012 147

Cardio-respiratory

care

Pre 59 15% 155 40% 170 44% 0.000*

Post 320 83% 56 15% 8 2%

Diagnostic proc&

Collect samples

Pre 16 4% 85 22% 283 74% 0.000*

Post 208 54% 129 34% 47 12%

Medication admin.

&IV access

Pre 61 16% 146 38% 177 46% 0.000*

Post 328 85% 47 12% 9 2%

Wound care Pre 57 15% 211 55% 116 30% 0.000*

Post 244 64% 125 33% 15 4%

Prevent immobility

complication

Pre 29 8% 84 22% 271 71% 0.000*

Post 221 58% 109 28% 54 14%

Gastrointestinal care Pre 14 4% 148 39% 222 58% 0.000*

Post 185 48% 158 41% 41 11%

Elimination care Pre 186 48% 156 41% 42 11% 0.000*

Post 324 84% 56 15% 4 1%

Patient hygiene Pre 69 18% 197 51% 118 31% 0.000*

Post 258 67% 112 29% 14 4%


Vol. 2 No. 2 May 2012 148

Restrain Pre 67 17% 176 46% 141 37% 0.000*

Post 254 66% 103 27% 27 7%

Newborn care Pre 61 16% 221 58% 102 27% 0.000*

Post 284 74% 83 22% 17 4%

*significant at p ≤0.05


Vol. 2 No. 2 May 2012 149

Table (5). Significant difference between nurse interns’ total knowledge levels on different management

skills subscales pre& post orientation program. (No.=384)

Total nowledge

level

Management

skills subs ale P

rogra

m High Moderate Low

X2

(P-value) No % No % No %

Pre 0 0% 32 8% 352 92% 0.000*

Post 323 84% 48 13% 13 3%

Interpersonal Skills Pre 21 6% 104 27% 259 67%

0.000* Post 293 81% 74 16% 17 3%

Interpersonal relation &

caring

Pre 16 4% 116 30% 252 66% 0.000*

Post 280 73% 91 24% 13 3%

Communication Pre 42 11% 141 37% 201 52%

0.000* Post 315 82% 57 15% 12 3%

Conflict management Pre 6 2% 53 14% 325 85%

0.000* Post 286 74% 74 19% 24 6%

Organization skills Pre 149 12% 99 18% 235 70%

0.000* Post 291 85% 52 5% 41 10%

Time management Pre 52 14% 172 45% 160 42%

0.000* Post 279 73% 89 23% 16 4%

Problem solving Pre 81 21% 0 0% 303 79%

0.000* Post 300 78% 0 0% 84 22%

Decision making Pre 16 4% 125 33% 243 63%

0.000* Post 293 76% 67 17% 24 6%

Priority setting skills Pre 78 20% 116 30% 190 49%

0.000* Post 346 90% 32 8% 6 2%

Delegation skills Pre 1 0% 76 20% 307 80%

0.000* Post 288 75% 68 18% 28 7%

*significant at p ≤0.05


Vol. 2 No. 2 May 2012 150

Fig.(2): Nurse interns’ pre orientation program learning needs assessment (for both total management

and clinical skills) and researcher’s observation3 months post program. (No.=198)

Table (6). Correlation between nurse interns’ total clinical knowledge and learning needs assessment

subscales of clinical skills pre orientation program. (No. = 384).

Clinical knowledge and learning

needs assessment subscales.

Correlation between knowledge &

learning needs assessment pre program

r P- value

Collect patient's data 0.070 0.172

Assess comfort& neurologic state -0.039 0.451

Assess vital signs 0.007 0.884

Safe practice& Infection control 0.142** 0.005

Cardio-respiratory care 0.152** 0.003

Diagnostic pros& Collect samples 0.053 0.300

Medication administration &IV

access 0.151** 0.003

Wound care 0.097 0.056

0%

20%

40%

60%

80%

100%

Pre Program 3 months Post Program

63%

86%

37%

14%

Able Not able


Vol. 2 No. 2 May 2012 151

Prevent immobility complications 0.070 0.173

Gastrointestinal care 0.048 0.353

Elimination care 0.008 0.882

Patient hygiene 0.065 0.207

Cold and heat therapy 0.104* 0.041

Applying mechanical restrain -0.058 0.255

Newborn care 0.092 0.073

*. Correlation is significant at the 0.05 level. **. Correlation is significant at the 0.01 level.

Table (7). Correlation between nurse interns’ management total knowledge and learning needs

assessment subscales of management skills pre orientation program. (No.= 384)

Management knowledge and

learning needs assessment

subscales

Correlation between knowledge &

learning needs assessment pre program

r P- value

Interpersonal skills -0.024 0.637

Interpersonal relation &

caring 0.033 0.524

Communication -0.045 0.377

Conflict management 0.120* 0.019

Organizational skills 0.089 0.081

Problem solving 0.089 0.081

Decision making 0.065 0.206

Time management 0.041 0.421

Priority setting 0.038 0.453

Delegation 0.002 0.977

*Correlation is significant at the 0.05 level .


Vol. 2 No. 2 May 2012 152

Fig.(3) Nurse interns’ LNA of total clinical skills pre program and researcher’s observation3 months

post orientation program. (No.=198)

Fig.(3) Nurse interns’ LNA of total clinical skills pre program and researcher’s observation3 months

post orientation program. (No.=198)

0%

20%

40%

60%

80%

Pre prog. Self assessment 3 months Post prog.

37%

77%

25%

9%

38%

0% 0% 14%

Can do it myself Can do it undersupervision

Cannot do it my self Not applicable

0%

20%

40%

60%

80%

100%

Pre Prog. Selfassessment

3 months Post Prog.

65% 85%

35%

15%

Able Not able


Vol. 2 No. 2 May 2012 153

Fig.(4) Nurse interns’ learning needs assessment pre orientation program and researcher’s

observation3 months post program of total management skills. (No.=198)

Fig. (5) Correlation between nurse interns’ total knowledge (clinical and management) and

researcher’s observation 3 months post program.

0%

20%

40%

60%

80%

100%

Pre Prog. Selfassessment

3 months Post Prog.

65% 85%

35% 15%

Able Not able

Clin

ica

l & M

anag

em

en

t

kno

wle

dge

Clinical & Management researcher observation post 3 months

r= 0.207*

P=0.045


Vol. 2 No. 2 May 2012 154

Discussion

Learning needs assessment guarantee a

relevant and accurate pre-internship

orientation program thus fosters a smooth

transition from nursing students to

professional registered nurse. Results of

using a well designed learning needs

assessment (LNA) tools can guide nursing

faculties to fill in the theory practice gap in

NIs’ performance and strengths the weak

points in the nurse interns’ knowledge.

The present study results revealed no

statistical significant correlation between

NIs’ learning needs self assessment and

their pre-orientation program knowledge on

clinical and management skills. Around

half of NIs assessed themselves as can do

clinical and management skills; in despite of

the incorrect answers for the majority of NIs

on basic knowledge test questions about

clinical and management skills. Most

probably this contradiction is due to their

overestimation of their abilities. So those

NIs require continuous and constructive

feedback on their abilities and progress to

identify gaps between their practice and

related basic knowledge. Khamis (2009)

study about the impact of management

program on competencies of NGs during

internship year supported results of the

present study and found a remarkable

disparity between nurse interns’ knowledge

and the level of their practical skills(19)

.

Feedback is an effective method of

improving performance because it allows

nurse interns to correct earlier

misunderstandings that developed during

learning process. Providing feedback can be

done fairly quickly, with little expenditure

of time to improve the learning process in

clinical setting and ensure interns’ master of

clinical tasks.

The results of present study revealed that

there is a statistical significant correlation

between nurse interns’ total knowledge

(clinical and management) with their

previous training, their graduation level and

their previous graduation school. Really NIs

got high graduation level and had previous

training in private hospitals specially those

trained in ICUs as well as those graduated

from institute or nursing schools got

opportunities to apply their learned skills in


Vol. 2 No. 2 May 2012 155

practical situations, helped them to interact

with more experienced healthcare staff and

improved their skills performance. Beccroft

(2009) study about “internship outcomes of

one year pilot program” supported the

present study findings, and found that high

percent of nursing interns whom had an

excellent graduation level showed high

competency level, while only low percent of

nursing interns who have a good graduation

level showed moderate level of

competency(1)

.

Findings of present study showed that more

than half of NIs assessed themselves as

cannot do both clinical standard and

management skills. Those NIs’ clinical

knowledge test preprogram showed that

they had poor knowledge level regarding

both clinical and management skills.

The fact is that those NIs’ knowledge were

poor about ten out of eighteen skills

understudy including assess state of

comfort, assess neurological condition,

collect samples, assist in diagnostic

procedures, apply safe practice and infection

control measures and apply mechanical

restrain. Besides, they had poor knowledge

level regarding cardio-respiratory,

gastrointestinal, elimination, wound, and

newborn care skills.

The results of LNA revealed that around

forty percent of nurse interns assessed

themselves as being not able to carryout all

the management skills. Those NIs were not

able to carryout interpersonal skills,

organizational skills, priority setting and

delegation skills. Majority of those interns

showed low level of management

knowledge and minority were at moderate

level of knowledge.

These results may be because at the

beginning of their transition NIs suspect

their management knowledge and skills,

they still not have any refreshing courses or

orientation program. Nurse interns look for

internship years as the sparkling beginning

of their professional carrier, and they will be

treated as a trainee, they dream with

practicing under supervision of highly

experienced nursing staff, whom will

provide them with direction. Those interns

need specific job description that clarify

their role and are in need of pre-internship


Vol. 2 No. 2 May 2012 156

orientation program to support their skills

and refresh their knowledge.

The present study findings confirmed

by Morrow (2009) whom found that novice

nurses were inadequately prepared in the

areas of critical thinking skills, decision

making and problem solving(20)

. Also

Greenwood (2000) reported that novice

nurses had poor time management skills and

prioritization, and a general inability to

convert theoretical training to real-world

situations(21)

.

Those NIs were not able to do interpersonal

relation& caring, communication and

conflict management skills. Their lack of

interpersonal management skills knowledge

is the apparent cause for their inability to

carryout these skills. Contradicting to the

present study findings Arthur (2008)

studied assessing nursing students’ basic

communication and interviewing skills

found that nurse interns rated themselves as

able to provide good therapeutic

interpersonal relations and communication

skills while providing practical care(22)

.

Present study LNA revealed that nurse

interns assessed themselves as being not

able to carryout conflict management skills.

This can be interpreted as the pre-graduate

education did not sufficiently prepare those

interns for managing conflict. They studied

lectures on conflict resolution; but they did

not have enough chance to apply theory into

practice. Even during their undergraduate

practice in healthcare setting the instructors

try to overly protect their students and

resolve any conflict with patients, nurses,

doctors, or even with their colleagues.

Obied (2008) study about management of

workplace violence against nurses

confirmed present study and found that NIs’

lack of conflict resolution strategies and

interpersonal skills constitute one of the

main reasons behind NIs’ experience of

workplace violence(23)

.

The results of the LNA of present study

showed that nurse interns assessed

themselves as being not able to carryout

organizational skill. They were not able to

do each of solve problems, make decisions,

or even mange their time. Those interns

showed low knowledge regarding

organizational skills. Those NIs lacking of

organizational knowledge and skills make


Vol. 2 No. 2 May 2012 157

them to feel inadequate and increase their

fear of harming patients or miss any care.

They have to learn how to group

simultaneous interventions to master their

own time, skills, and be able to provide care

independently with no external guidance. So

those NIs require orientation program on

management organization knowledge to

support them to regain self confidence.

Based on the findings of LNA of present

study the nurse interns assessed themselves

as being not able to carryout interpersonal

skills.

Findings of LNA illustrated that nurse

interns assessed themselves as being not

able to carryout decision making skills.

Most probably this result reflects their lack

of decision making skills knowledge. They

answer incorrectly about questions related

to timing of decision making, steps of

decision making process and personal

barriers of decision making. So it is

suggested that a formal orientation program

that enhance critical thinking and decision

making ability should be given to NIs to

improve their knowledge and skills pre-

internship year. Consequently they will be

clinically effective in making decisions and

reduce the risk of committing errors.

Gillespie & Peterson (2009) study about

helping novice nurses make effective

clinical decisions supported the present

study findings and reported that many

novice nurses fall in different errors as they

lack critical thinking and decision making

skills. They stated that novice nurses with

limited experience in the care settings, in

which they work, tend to view decision-

making as nearly responding to patient

complaints and following protocols or

documented care plans. As they make

decisions, their focus leans toward doing,

rather than on thinking and reflecting(24)

.

LNA findings of present study revealed that

nurse interns assessed themselves as being

not able to carryout time management skills.

Those interns were not able to manage

distractions, use time saving strategies,

avoid doing others’ work, or even refuse

responsibility they cannot manage. They

cannot finish most of things they start or

being sensitive for others time. The fact is

that those NIs’ lack knowledge about each

of how to manage their time, prioritize


Vol. 2 No. 2 May 2012 158

competing tasks in a way that best serves

patients needs, respects the team, and

maintains energy and focus throughout the

shift. So they need pre-orientation program

include educational materials on prober time

management.

Smith & Crawford (2003)

supported

present study results and found that novice

nurses is delayed in patient care, due to their

failure to administer in a timely manner,

failure to recognize and failure to intervene

in relation to patient care(25)

.

However most NGs lack the judgment,

confidence, and experience to act

decisively, until they fully develop their

clinical judgment, they must follow the

rules. If the rules don’t cover a particular

situation, they must rely on more

experienced team members for advice and

support. Further confusion may arise when

new nurses are called to help teammates

while operating within the multiple time

demands of a shift.

Saintsing et al. (2011) study about novice

nurse’s clinical decision-making and how to

avoid errors support the present study

results and found that the issues of time

management and critical thinking are two

items that are potentially dependent upon

each other. Novice nurse is likely to make

judgment errors regarding critical thinking

related to real or perceived time

constraints(26)

.

LNA results showed that NIs assessed

themselves as being not able to carry out

delegation skills. Those NIs do not trust

others to carryout their duties and do not

have the courage to take responsibility for

their delegated skills. They cannot select

and organize tasks to be delegated, cannot

select appropriate person for delegation, or

even maintain reasonable control for

delegated tasks. Those NIs got low level of

knowledge regarding delegation skills. Ruff

(2011)

study about delegation skills:

essential to the contemporary nurse

supported the present study and found that

ineffective delegation was cited by nursing

staff as one reason for missed care(27)

.

LNA revealed that NIs assessed themselves

as being not able to carry out priority setting

skills, which matches their low level of

knowledge regarding priority setting. Those

nurse interns cannot write pros and cons for


Vol. 2 No. 2 May 2012 159

options or priorities tasks according to

goals. In addition, they cannot do each of

put clear goals and objectives, organize their

thoughts or even take time to plan their

activities. Most probably those NIs also

lack experience of early detection and

intervention for priority cases which nursing

care can prevent its deterioration.

Immediate post implementation of the

present study well design pre-internship

orientation educational program, NIs

changed significantly from being with low

to be with high level of knowledge on

clinical skills standards procedures; related

to collect patient’s data, cardio-respiratory

care, medication administration, elimination

care, prevent immobility complications,

wound care, diagnostic procedures and safe

practice and infection control; statistically

significantly improved post orientation

program. As well as, an improvement in

management knowledge level showed for

interpersonal, organizational, priority setting

and delegation skills. But still some NIs had

low knowledge level regarding clinical and

management skills, whom need to study

their learned materials.

The findings of the present study is also

supported by Roussel et al. (2006) study on

management and leadership for nurse

administrators asserted that educational

program helped nurses in keeping up to data

with new concepts, increasing knowledge

and competences, modifying their attitudes

and developing their abilities to deal with

patients and problems(28)

.

The present study researcher’s followed up

NIs during their first three months of

internship year to direct them for proper

skill acquisition and socialization. The

researcher arranged that NIs attend simple

orientation at the first three morning shifts

at the beginning of each rotation, to help

them to be familiar with the unit

environment, procedures and staff this was

carried out in cooperation with the HN of

each unit. Each NI was assigned to care for

one patient with experienced RN for first

week. The TUH HNs and number of RNs

were invited to attend with NIs their the pre-

internship orientation program implemented

by the researcher, to be sure for refreshing

their knowledge and to facilitate the future

interns’ socialization and support.


Vol. 2 No. 2 May 2012 160

The researcher intended to help NIs

socialization process by which they will

acquire the specialized knowledge, skills,

values, norms and interests needed to

perform their roles acceptably. Beside the

facilitation for professional socialization

process that integrates the cognitive and

affective domains of professional

performance governs their behavior. The

researcher believes the importance that

learning process takes place in a social

environment, so that the learning occurs

through interaction with their actual work

units. Really the attention and the clinical

supervision which NIs received at the

follow up period of internship orientation

program enhanced their sense of confidence

and improve their competence. As well as

improved their performance to role,

responsibilities and patients care quality.

Data analysis of follow up observation sheet

three months post orientation program

revealed significant improvement of NIs’

ability to carryout all clinical skills, in

comparison with their learning needs self

assessment pre-orientation program.

Researcher’s observation also revealed that

majority of nurse interns can by themselves

assess vital signs, state of comfort, collect

samples, provide cardio-respiratory care,

apply mechanical restrain and provide

newborn care. As well as NIs can by

themselves prevent immobility

complications, provide wound care, assess

neurological condition and carryout safe

practice and infection control measures.

According to the researcher’s observation

three months post orientation program nurse

interns’ ability to carryout management

skills of interpersonal, organizational,

priority setting and delegation skills were

significantly improved, in comparison with

their learning needs self assessment pre-

orientation program. So nurse interns should

attend immediate pre-internship orientation

programs to help them to refresh their

knowledge, memorize the basic clinical and

management standards needed to be applied

during their internship year. Learning needs

assessment is very important to meet nurse

interns’ individual needs and to address the

skills required for specific practice areas.

Beside their knowledge must be tested to

identify their actual educational needs.


Vol. 2 No. 2 May 2012 161

Designing, implementing the orientation

program and using different teaching

methods helped to evoke nurse interns

maximum benefits and to overcome their

individual differences. Really present

experience assured that at the beginning of

the internship year NIs need to be

supported, encouraged and mentored by the

faculty staff members until they became

confident in their clinical and management

practice.


Vol. 2 No. 2 May 2012 162

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Vol. 2 No. 2 May 2012 165

Life Style Profile of School Age Children Suffering From Pathological Stuttering

Rahma Soliman Bahgat

Professor of Pediatric Nursing, Faculty of Nursing, Tanta University

Dr. Mohammed El-Sayed Darwish

Lecturer of Phonetics E.N.T Department, Faculty of Medicine, Head of Speech Therapy Center

Mervat Ali Abdo Said Ahmed

B. S. C. Nursing, Faculty of Nursing Tanta University

Abstract

Stuttering as a speech event that contains intraphonemic disruption, part-word repetitions,

monosyllabic whole word reputations, prolongation and silent fixations (blocks).The present

study aimed to investigate the lifestyle profile of children suffering from pathological stuttering

and to identify the factors that worsen or improve the child with pathological stuttering. This

study followed a descriptive design. The study was conducted on 60 children who were attending

the speech therapy in Tanta University. Data were collected by using two tools: questionnaire

sheet, observation checklist. The results revealed, a mean age of stuttering children, it was found

that 63.3% of children with stuttering had a mean age of 8.17+ 1.66 years. Significant difference

was found between the mean age of stuttering children and his socialization. Significant

difference was found between the mean age of stuttering children and response to treatment.

From the present study it can be concluded that the pathological stuttering as disease is easy to

diagnose, difficult to treat has many negative impact on physical, psychological, social and

spiritual aspect of children life. This study recommends that searching for the causation of

stuttering. Health education and counseling of stuttering children and their mothers includes

follow up to speech therapy, family

Introduction


Vol. 2 No. 2 May 2012 166

School-age period characterized by

cognitive and language development

progresses rapidly. Vocabulary expands, and

Sentence structure becomes more

complex.(1)

The assessment of the progress

in language development includes

examination of three interactive components

of language itself: phonics, or speech sound;

syntax or grammar and semantics or

meaning in language forms such as word

and sentence. Usually, speech is fluent,

fluent speech is free of any interruption,

blockage but disfluency is defined as a

breakdown or blockage in the forward flow

of speech. The occurrence of disfluency is

not the same of stuttering though stuttering

is characterized by an excessive amount of

disfluency(2,3)

One of the most common

speech disorders is stuttering. This disorder

is state mixed of theses of item as; word

break, protracted telling, repeating the first

sound and lock or stopping but none of these

items are lonely defined stuttering.

It can

also be defined as speech have difficulty

speaking because of repetition, protraction,

or involuntary lock.(4,5)

Stutter is a complex,

multi-dimensional. Stuttering can range in

frequency and intensity from mild to severe.

Stress can sometimes make it worse. The

struggle to speak may be accompanied by

physical gestures or movements (6)

Prevalence of stuttering how many

people stutter at a given point in time appear

to be somewhat lower than 1 % (according

to Craig; 2002 (7)

the actual incidence is

approximately 5% with onsets. Occurring

mainly at the age Pre School (Andrews

Harris, 1964; Manson, 2002) is about 2,

5%that is, about 1in 20 children now stutter

incidence is about 5% or 1in 20 children at

same point in childhood(8).

Males stutter than

females. People who stutter make up about

1%in the West Indies, 3-4%of population

stutters. African countries seen to have the

highest prevalence of the stuttering with

about 8-9% of population stuttering (9)

Causes of stuttering in children are not

surely known, but most researchers believe

that the stuttering occurs as the result of a

variety of factors. They may include one or

more of the following First; Genetic plays

role sixty percent of all people who stutter

have close family member who also stutters

(zerbroswki, 2003). Scand; Developmental


Vol. 2 No. 2 May 2012 167

stuttering beginning at the age of 18 months

to 2 years, as they hone their speech and

language skills. Third; neurological factors

researchers has found in some cases, there

seems to be a problem in the way language

is transmitted through the brain. Scientists

don’t know exactly why this occurs (10, 11)

Language and communication skills an

essential of school life is the use of a system

of symbols for communication and thought.

Early in school life judgments are made

intuitive on superficial appearance with

increasing experience and language at his

disposal. The child can image complex

situation think out the most appropriate

solution and anticipate the outcome. The

child has developed logical thinking from

assimilating experience into schemes (2, 3)

Life style is a way of living including

behaviors that promote or impair good

health and longevity, the young child with

stuttering must learn how to adapt their self

care and minimize any disruption of their

lifestyle (12)

so, the contents of life style

profile program of the stuttering child

should focus on the needs and capabilities of

the learners to ensure the three main

categories including survival skills, health

maintenance skills and health promoting

skills (13, 14, 15)

Stuttering education can be

divided into three main categories survival

skills, health maintenance skills and health

promotion skills

Health maintenance

preserves the present state of health and

health promotions skills maximize the

optimal level of functioning and health

hazard are reduced. The care program of

those children must invade also every aspect

of patient's life including home &school.

These skills comprise the necessity for

scheduled speech therapy, regular physical

activities, normal communication with

others.(16)

Stuttering impact in their

academic performance at school and

relationship with teacher and classmates;

according to the study of klompas and Rass(

2004) on life experience of individually with

stuttering(17)

The nurse play an important role

for the care of stuttering children which help

in improving the quality of life and

facilitating the children and family's

adaptation to this problem. She encourages

the child to adjust himself to live a

satisfactory life and to be a productive


Vol. 2 No. 2 May 2012 168

number in the society it is very important for

nurse to study the life style of stuttering

children to be able to achieve her role

efficiency (18)

Aim of the study:

1-To investigate life style profile of school

age children suffering from pathological

stuttering.

2- Identify the factor that worsen or

improves the child with pathological

stuttering.

Materials and Method

Research design

A descriptive design was used in this study

Setting: The study was conducted at the

Speech Therapy Center of Tanta University

Hospital

Subjects:

Composed of 60 school age children

suffering from pathological stuttering and

their mothers or caregivers who attended the

previous setting were included. The

children had the following criteria: -

Both sex, Age ranged from 6-15years. Free

from any other speech problem. Started

speech therapy.

Tools of data collection:

Two Tools Were Used In Data Collection:

Tool (I): Structured Questionnaire sheet

It was developed by the researcher after

reviewing of literature to obtain the

following information:

a) Biosocial data of both pathological

stuttering children Such as:

Age, sex, birth order, educational level

Development history such as first defines of

family, sitting, walking, talking, control of

bladder, delay of language.

b) Biosocial data of mothers Such as:

Age, educational level, occupation, family

size, number of siblings, Family history of

stuttering, presence of parental

consanguinity.

c) The three main categories of health

promoting life style Profile:

Survival skills.

Health maintenance skills.

Health promotion skills.

1) Survival skills

Entailed The Following Items:

Items related to the need for speech

therapy

Relation between speech therapy and speech

production


Vol. 2 No. 2 May 2012 169

Items related to children communication

with others.

Information about speech therapy per week

and its effect.

Schedule for speech therapy.

Psychological assessment was done to

assess psychological state of school age

children during speech session such as

(anxiety, anger, and avoidance)

(2) Health maintenance skills

They entailed The Following Items:

- Physical exercise such as different

types of sports.

-Social relations of the stuttering child

as making friendly relationship with

classmates, neighbors and participation in

activities with others, playing in groups,

school or in the club.

3) Health promoting skills

They entailed the following items: Ask

mothers about some information, if not

they should be given in counseling:

Counseling of the school age children

suffering from pathological stuttering and

their mothers

-Counseling is a kind of experience that will

help them to change their attitude, which

includes: -Help the child in every possible

way to feel that he is normal

Be ready to make reasonable change in the

environment to facilitate verbal

communication

Reduce communication stress

Be good listener

Allow time for the child to speak

-Don’t ask the child to talk when he is very

emotional stressed especially when crying

Don’t allow others to tease, ridicule,

interrupt or joke about the child's speech

Follow up visits for speech therapy and its

recording in a certain file of the outpatient

clinic

Tool (II): Observation checklist

It was developed by the researcher after

reviewing the literature to observe school

age children suffering from pathological

stuttering and their mothers during speech

therapy.

Method

1-AdministrativeProcess

An official permission was obtained

from the head of speech therapy department

for caring out this study.


Vol. 2 No. 2 May 2012 170

- Children and their mothers were

selected by using simple random

method.

- Based on reviewed literature, the tool

of study was developed.

- - Data for this study covered a period

of five months from August 2012 to

December 2012.

- Both nurses and other working in the

clinic were informed about the role

of the researcher to gain their

cooperation and secure proper

communication.

- Children and their mothers' consents

were obtained to participate in this

study.

2- Development of the Study Tools:

Two tools were designed and used in

this study: a questionnaire sheet and

observation checklist was developed after

reviewing recent literatures.

3- Ethical consideration:

Privacy and confidentiality of data

and results were considered. Also the study

samples were informed that they can with

draw from the study at any time.

4- Pilot Study:

A pilot study was carried out on a

sample of 10 children and their mothers/

caregivers to verify the applicability,

feasibility and test the clarity of the

questions and estimate the time required for

each interview. The necessary modification

was carried out. The data obtained from the

pilot study was analyzed then some

questions were restated and some items were

added.

5- The Actual Study

- Children and their mothers'/

caregivers were interviewed using a

questionnaire sheet in the outpatient

speech therapy to assess their

knowledge. Every child and his or

her mother /caregivers was

interviewed for 20-30 minutes.

- The researcher observed children

and their mothers /caregivers while

taking speech therapy regarding the

following:-

a) Speech production of school age

children such as:

- Frequency of occurrence of

stuttering.


Vol. 2 No. 2 May 2012 171

- Duration and consistency of

stuttering.

- The child uses a speech rate that is

either too fast or too slow.

- The child repeats the beginning

sound of words.

- The child repeats whole words.

- The child repeats whole phrases.

- The child uses interjections.

- The child engages in additional

behavior when speaking.

- Presence of any other speech

disorder and symptoms appear

during therapy.

- Observe mothers when

demonstrating instruction provided

by the doctors.

b) Communication Skills

To assess the following information:

Verbal and non verbal abilities

1) Vocalization such as:

-The child has difficulty to remember and

use content area terms

The child uses immature vocabulary

- The child has difficulty making word

association or comparisons

2) Social pragmatics such as:

- The child is cooperative and attentive.

- The child uses poor eye contact.

- The child is easily distracted or has short

attention.

- The child is easily frustrated or

impulsive.

- The child has difficulty using language

for the purposes.

- The child prefers structure routine and

prefers to spend more time alone rather

than in-group.

Statistical design:

The collected data were organized,

tabulated and statistically analyzed using

SPSS statistical package version 19.

Numerical variables were presented as mean

and standard deviation. for comparison of

mean values, student’s t test was used for

categorical variables , the number and

percent distribution was calculated and

difference were tested using Monte Carlo


Vol. 2 No. 2 May 2012 172

exact test. Chi square was not used

because of small sample size and presence

of small observations in some categories

which is one of the limitations of the use of

chi square. Spearman’s correlation was used

to test association between stuttering and

total socialization score. The level of

significance was adopted at p<0.05.

Results

Table (1) shows the percentage

distribution of mothers/caregivers according

to their biosocial characteristics. It is

observed that the highest percentages of

mothers (40%) were aged 30 years, with a

mean age of (34.92+5.56) years. Illiteracy,

reading and writing prevailed in (13.4%)

and university grades in (35%) while

primary and secondary grades had more

percentage than others (51.7%). More than

half of the samples (63.3%) were

housewives but (36.7%) are employees.

Also this table shows that more than half of

the sample (55%) have 3-4 members in the

family with a mean of (3.60+1.62).

Regarding the family residence, it is clear

that about more than half 58. 3% of the

samples live in urban area and about

(41.7%) of the samples live in rural area.

Table (2) shows the percentage

distribution of children characteristics

according to family history. The positive

family history of stuttering constituted

(25%) of the sample distributed as follows:

uncles (40%) ante (33.3%) and (26.7%)

cousins. It is noticed that the start of

stuttering at three years occurred in (35%)

also gradual illness in (63.4%) This table

shows also positive parents consanguinity in

(25%) while positive sibling history of

stuttering in (16.7%).A reason for stuttering

was found in 28.3%

Table (3) shows the percentage distribution

of children according to response to

treatment. It is noticed that more than half of

the sample (61.7%) had disturbance of

normal speech. It is clear that (93.3%) had

impact of irregular speech therapy. Children

with stuttering taking therapy constituted

(53.3%), maintenance follow up at home

(11.7%) compared to those taking oral

treatment is (1.7%).


Vol. 2 No. 2 May 2012 173

According to psychological state of

children during session, it is clear that about

half of the sample (50%) had anxiety state,

less slightly than one third of the sample

(31.7%) had anger and avoidance was found

in (18.3%).

Table (4) shows the correlation between

children response to treatment and their age

in years. A significant difference is observed

between children age in years and having

response to speech therapy (P= 0.017). No

significant differences were observed

between disturbances of a normal speech,

impact of irregular speech therapy, type of

impact, stage of treatment, function of

speech session, needs for speech per week,

content of speech session, psychological

state during speech session ( P = 0.811,

0.567, 1.000, 0.083, 1.000, 0.833, 0.317,

0.983 respectively).these findings are

illustrated in figure (4-10).

Table (5): shows the correlation between

children response to treatment and mothers'

educational level. A significant difference

was observed between mothers educational

level and having need for speech therapy

session and response to speech therapy

treatment (P= 0.05, 0.033). The table

illustrates that no significant differences

were observed between mothers educational

level and disturbance of a normal speech ,

impact of irregular speech therapy, type of

impact, stage of treatment, function of

therapy, content of speech session,

psychological state during session( P =

0.683, 0.817, 0.550, 0.500, 0.767, 0.450,

0.567 respectively ).

Table (6): illustrates the comparison of

total socialization score in relation to

language delayed. No significant difference

between socialization and delayed language

development was found (p= 0.691) and (t

test = 0.399).


Vol. 2 No. 2 May 2012 174

Table (1): percentage Distribution of stuttering children according to mothers' characteristics

Characteristics of mothers of stuttering

children

(n=60) %

No

Age in years:

25- 11 18.3

30- 24 40.0

35- 13 21.7

40- 9 15.0

45+ 3 5.0

Mean+SD 34.92+5.56

Educational level:

Illiterate or read and write 8 13.4

Primary and preparatory 16 26.7

Secondary or technical institute 15 25

University 21 35.0

Occupation:

Housewife 38 63.3

Employee 22 36.7

Family size:

1-2 14 23.3

3-4 33 55.0

5-6 9 15.0

7+ 4 6.7

Mean+SD 3.60+1.62

Accommodation type:

Shared house 6 10.0

Private house 40 66.7

Rented house 14 23.3

Residence:

Urban 35 58.3

Rural 25 41.7


Vol. 2 No. 2 May 2012 175

Table (2): percentage Distribution of stuttering children according to family history

Family history (n=60)

% No

Positive family history for stuttering

Yes 15 25.0

No 45 75.0

Relationship to family history: (n=15) 25.0%

Positive Uncle 6 40.0

Positive Ante 5 33.3

Positive cousins

Negative

4

45

26.7

75

Start of stuttering:

<2 years 17 28.3

2- years 12 20.0

3- years 21 35.0

4+ years 10 16.7

Start of illness:

Gradual 38 63.4

Sudden 22 36.7

History of Parents consanguinity

Yes 15 25.0

No 45 75.0

Sibling history of stuttering

Positive 10 16.7

Negative 50 83.3

Causes of stuttering

Yes 17 28.3

No 43 71.7


Vol. 2 No. 2 May 2012 176

Table (3): percentage Distribution of stuttering children according to response to treatment

Response to treatment: (n=60)

% No

Disturbance of normal speech 37 61.7

Impact of irregular speech therapy 56 93.3

Relationship with teacher 7 12.1

Relationship with other student 9 15.5

School action

Family relationship

10

32

17.2

55.2

Stage of treatment :

Follow up at home 7 11.7

Taking therapy 32 53.3

Taking oral treatment

Maintenance therapy and follow up

at home

1

20

1.7

33.3

Function of speech therapy :

Ability to cooperate with others 47 78.3

Don’t know 13 21.7

Child need for speech therapy

session per week

Follow up( every 3 months) 14 23.3

Once per week 13 21.7

Twice per week 28 46.7

Thrice per week 5 8.3

Response to speech therapy

treatment:

52 86.7

Ability to interaction with

society

10 17.2

Psychological status improved 13 22.4

Interaction with family and

School

6 10.3

Improved action in school

Improved interaction with other

children during session

5

24

8.6

41.4


Vol. 2 No. 2 May 2012 177

Percentage Distribution of children according to response to treatment (continued)

Response to treatment: (n=60) %

No

Content of the speech session:

Educate child same exercise 7 11.7

Educate caregivers same exercise 6 10

Encourage child to communicate with others

Educate child, caregivers same exercise

12

35

20

58.3

Psychological state of children during speech

session:

Anxiety 30 50

Anger 19 31.7

Avoidance 11 18.3

Table (4): Correlation between children response to treatment and children’s age

Response to treatment

Children’s age in years

(n=60)

p 6-<8

(n=38)

8-12

(n=22)

No % No %

Disturbance of normal speech 23 60.5 14 63.6 0.811

Impact of irregular speech therapy: 1.000

Relationship with teacher 4 10.8 3 14.3

Relationship with other student 6 16.2 3 14.3

School action 6 16.2 4 19

Relationship with family 21 56.8 11 52.4

Stage of treatment for children with stuttering 0.083

Follow up at home 7 18.4 0 0

Taking therapy 19 50 13 59.1

Taking oral treatment 0 0 1 4.5

Maintenance therapy and follow up at home 12 31.6 8 36.4


Vol. 2 No. 2 May 2012 178

Function of speech therapy session : 1.000

Ability to cooperate with others 30 78.9 17 77.3

Don’t know 8 21.1 5 22.7

Need for speech therapy session per week 0.833

Follow up ( every 3 months) 10 26.3 4 18.2

Once per week 7 18.4 6 27.3

Twice per week 18 47.4 10 45.5

More than thrice per week 3 7.9 2 9.1

Correlation between children response to treatment and children age (continued)

Response to treatment

Children’s age in years

(N=60)

p 6-<8

(n=38)

8-12

(n=22)

No % No %

Response to speech therapy treatment: 36 94.7 16 72.7 0.017

Types of response: 0.300

Ability to interact with society 5 13.5 5 23.8

Psychological status improved 11 29.7 2 9.5

Interaction with family and school 3 8.1 3 14.3

Improved in school 2 5.4 3 14.3

Improved interaction with other children

during session 16 43.2 8 38.1

Content of the speech session: 0.317

Educate child same exercise 4 10.5 3 13.6

Educate caregivers same exercise 4 10.5 2 9.1

Encourage child to communicate

Educate child, caregiver

same exercise

5

25

13.2

65.8

7

10

31.8

45.5

Psychological state of children during

speech session: 0.983

Anxiety 18 47.4 12 54.5

Anger 13 34.2 6 27.3

Avoidance 7 18.4 4 18.2


Vol. 2 No. 2 May 2012 179

**Significant at level 0.05

Table (5): Correlation between children response to treatment and mothers’ education

Response to treatment:

Mothers’ educations

(n=60)

P Primary

(n=24)

Secondary

(n=15)

University

(n=21)

No % No % No %

Disturbance of a normal speech 13 54.2 10 66.7 14 66.7 0.683

Impact of irregular speech

therapy 23 95.8 15 93.3 20 90.5 0.817

Types of impact : 0.550

Relationship with teachers 4 17.4 0 0 3 15

Relationship with other

students 2 8.7 2 13.3 5 25

School action 4 17.4 3 20 3 15

Relationship with family 13 56.5 10 66.7 9 45

Stage of treatment for child with

stuttering 0.500

Follow up at home 2 8.3 3 20 2 9.5

Taking therapy 15 62.5 5 33.3 12 57.1

Taking oral treatment 1 4.2 0 0 0 0

Maintenance therapy and

follow up at home

6 25 7 46.7 7 33.3

Function of speech therapy

session 0.767

Ability to cooperate with others 18 75 13 86.7 16 76.2

Don’t know 6 25 2 13.3 5 23.8

Child need for speech therapy

session per week

0.050

*

Follow up ( ever3months) 10 41.7 1 6.7 3 14.3

Once per week 7 29.2 2 13.3 4 19

Twice per week 7 29.2 10 66.7 11 52.4


Vol. 2 No. 2 May 2012 180

More than three time per week 0 0 2 13.3 3 14.3

Correlation between children response to treatment and mothers’ education (continued)

Response to treatment :

Mothers’ education

(n=60)

p

Primary

(n=24)

Secondary

(n=15)

University

(n=21)

No % No % No %

Response to speech therapy

treatment: 21 75 13 86.7 21 100 0.117

Types response: 0.033**

Ability to interact with the society 8 36.4 1 6.7 1 4.8

Psychological status improved 4 18.2 3 20 6 28.6

Interaction with family and school

Improved interaction with other

children during session

4

5

18.2

22.7

0

9

0

60

2

10

9.5

47.6

Content of the speech session: 0.450

Educate child some exercise 5 20.8 1 6.7 1 4.8

Educate caregivers some exercise 3 12.5 1 6.7 2 9.5

Encourage child to communicate

Educate child, caregivers same

exercise

6

10

25

41.7

3

10

20

66.7

3

15

14.3

71.4

Psychological state of child during

speech session: 0.567

Anxiety 13 54.2 7 46.7 10 47.6

Anger 9 37.5 5 33.3 5 23.8


Vol. 2 No. 2 May 2012 181

Avoidance 2 8.3 3 20 6 28.6

Table (6): Comparison of total score of socialization in relation to delayed language

development

Total socialization

Score

Delayed Language development

Yes No

Range 12-20 13-21

Mean 15.15 15.37

SD 2.21 1.98

T test = 0.399, p = 0.691

Discussion

Stuttering as a problem is full of

controversies. It has several definitions and

several theories of a etiology. The line of

treatment of stuttering also differs greatly

and produces variable degrees of

improvement. The aim of the treatment of

stuttering is not only to reduce dysfluency,

but also to replace stuttering with natural

speech production having normal rate.

(19)Lifestyle means the manner or way of

acting. Style is a particular from of behavior

directly associated with an individual. The

first 18 years are the period during which the

most profound change occurs in physical,

cognitive and social development. The

contents of the lifestyle care program of the

affected children should focus on the need

and capabilities of the stuttering children to

ensure the three main categories: Survival

skills, Health maintenance skills and Health

promotion skills. (13,14,15)

The sample used

for this study met the incidence and

prevalence of stuttering. The male to female

incidence in this study was 65%: 35%. This

result is in agreement with Mansson (2000)

who found that the boy to girl ratio is 1.65: 1

%. Also this result disagrees with Yaruss


Vol. 2 No. 2 May 2012 182

(2006), Bloodstein (2002) and Stackhouse

(2001). They found ratio of 3 males to one

female 3:1. Boys generally have more

speech disorders because girls are speak

earlier than boy's and they are better speech

and language and specially at using speech

and language for social purposes. (21, 16,22, 23)

As regards the biosocial characteristics of

mothers according to mothers' age, the

present study revealed that the mean age

was 34.92 years. Less than half of the

sample mothers had high education, so they

are more aware to be involved in child care

and dealing with their problem, in addition

they seek earlier consultation and engage

their children in speech therapy. Regarding

family size, the present study revealed that

the mean family size was 3.60 children. In

the present study, high a percentage of

stuttering children live in urban areas (Table

1), while a low percentage (41.7%) live in

rural ones. This is in disagreement with the

study of Yaruss (2001), who revealed that

rural inhabitation was found in 55% and

urban in 29% respectively when

investigating 1818 people at two villages in

Upper Egypt. This result is due to the fact

families of children living in urban area did

not allow them to play outside the house

which prevents early communication with

peers.( 24)

As regards the family history of stuttering

children, the present study revealed parent

consanguinity was found in 25%of children

while 16.7% of them had positive sibling

history (Table 2). Consanguinity is a social

phenomenon. These results explain the

importance of counseling for the prevention

and early detection of stuttering among

children especially in positive family

history. This finding is in agreement with a

study of Andrews and Harries (2008) who

found that 25-60% of stutterers had relatives

who stuttered. (25)

Stuttering is a problem

interfering with the normal life of the

children. There are three main categories of

health promoting life style profile: Survival

skills, health promoting skills, and health

maintenance skills. Survival skills entail the

items related to the need for speech therapy

and speech production and communication

with others. Information about speech

therapy and psychological assessment

(anxiety, anger and fear) is so accurate, and


Vol. 2 No. 2 May 2012 183

adequate knowledge is necessary to help

these children understand the nature of their

problems, therapy administration, treatment

of stuttering, child's daily activity, . These

may help them to reduce dysfluency, replace

stuttering with natural speech production

having normal rate and to improve

communication, social adjustment and self

fulfillment as much as possible Bloodstein

(2002) 20)

The results showed that the

therapy led to improvement in all

parameters. (Table 3) The improvement of

all perceptual prolongation, repetition,

blocks, went parallel with increased speech

rate, which indicates stability of the results.

Although this improvement was associated

with improvement of psychological

assessment, improvement did not reach

significant level after therapy. This was

expected because this study was conducted

for a short term evaluation and the

psychological changes need is in a long

period of therapy and follow up to show

improvement. This result is in agreement

with Cooper and Bloom (2002) who found

that speech therapy greatly improves

prognosis and extends the life span. (26)

The

present study revealed that the majority of

the sample (Table 3) suffered from the

impact of irregular speech therapy sessions;

this means that the child who maintains

regular speech therapy improves but the one

who has irregular speech therapy sessions

does not progress. Irregular speech sessions

have a major relationship with family but a

less impact on school action and relation

with others students (both of them less than

quarter of the sample). These results are in

agreement with Andrews, Craig (2002) and

Lincoln (2006) who found that the stuttering

frequency decreased to very low level post

treatment and also improvement in stuttering

frequency at least in 85% to 90% across all

assessment contexts for 9-14 year olds

stutterers. So the earlier treatment of stutter

gives the better prognosis. (27,28)

According

to psychological status, the results showed

that there was a positive linear association

between presence of anxiety and stuttering

(Table 3). Although all children therapy in

this study improved, this improvement did

not reach the significant level. This result is

in agreement with Bloodstein( 2002) who

found that the stutter scores were higher in


Vol. 2 No. 2 May 2012 184

social anxiety than in a normal speaking.

However, negative findings were obtained

by Denial, Brutten who reported that there

was a similarity between some stuttering

characteristics as shame, avoidance, denial

and addiction. The stutterers needed as the

addicts need support and structured

recovery, from others with the same

problems. So the rule of helping group was

very important. (21)

There was a significant

difference between child age and child

response to treatment (Table 4).Young

children respond better to speech therapy

because they are still unaware about their

problem. As regards mothers' education it

had a significant positive impact on response

to speech therapy session among stuttering

children (Table 5)Those who were illiterate

and primary educated school mothers were

less competent than other groups

(secondary, university). The present study

showed that the severity of stuttering had a

significant negative effect on total

socialization. This result is in agreement

with Miller and Watson who reported that

the young stutterers had significant negative

attitudes toward speech communication and

the negative attitudes increased with age.

The present study showed that child

socialization had a positive effect on the

child with delayed language development

(Table 6). Moreover, Riley (2004) reported

that 30% of young stutterers have

simultomeonsly language difficulty.


Vol. 2 No. 2 May 2012 185

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Vol. 2 No. 2 May 2012 188

Establishing Basic Standards of Nursing care protocol at Neonatal

Intensive care unit.

*Sabah Mohamed El sayed **Prof. DR. Yomn Y. Sabry.

*** Prof. DR. Hamed M. sharkawy *Dr. Ebtisam M. elsayed and* Dr.Thanaa Ali .

Faculty of nursing,* Tanta and** Alexandria University,***Faculty of medicine, Tanta University

Abstract

The advancements in intensive care in recent decades have enabled better survival of full

spectrum of newborns. The management of neonates at NICU is based on various modalities

of support and application of fundamental principles of neonatal care. The aim of this study

was to establish basic standards of care for nurses working at Neonatal Intensive Care Unit.

The subjects of the present study consisted of 70 nurses working in Neonatal Intensive Care

Unit and responsible for providing direct care for newborn. Two tools were used to collect

data:. Knowledge assessment sheet and observation checklist to assess nurses' knowledge

and actual performance of nurses providing direct care for neonates in Neonatal Intensive Care

Unit before, immediately, and after three months from the standard application. The results.

showed that, before the standard application the total scores of knowledge for nurses were

good (3o %) and poor with percentages of 63%. It was improved immediate, and after three

months later of the standard application. There was significant difference in nurses'

performance before, immediate, and after three months of the standard application.

Conclusion: it can be concluded that all the nursing activities presented in the initial standard

as basic nursing responsibilities was enhanced. Recommendations: The developed standards

should be translated into Arabic and disseminated to the managers of health organizations.


Vol. 2 No. 2 May 2012 189

Introduction:

The neonatal period is defined as the

first four weeks subsequent to birth Some

newborns require observation and care that

is beyond the scope of a normal newborn

nursery, these are called high risk neonates

(1,2). High risk neonate can be defined as a

newborn, regardless of gestational age or

birth weight, which has a greater-than-

average chance of morbidity or mortality,

requiring early intervention that should be

delivered at neonatal intensive care unit(3).

It provides care to full spectrum of

newborns ranging from extremely

premature infants, to high-risk and

critically ill babies, to less critically ill

babies who are recovering and maturing

with increased emphasis is being placed on

the need for standards of care, as well as

mechanisms which address the barriers to

provision and use of quality care(4). The

first step in

improving quality of nursing care is an

articulation of standards of care that

provide a mean for determining quality of

care as well as accountability of the

nurses(5). A standard is defined as a

professionally agreed level of performance,

it provides the required knowledge and

skills that can be used to orient new staff

and to guide nurses in clinical practice (6).

Nurses are the key elements in critical

care. They are required to keep pace with

the rapid changes in health care, and

provide quality of patient's care in a cost-

effective manner (7)

Aim of the study: was to assess actual

performance of nurses working in Neonatal

Intensive Care Unit at Tanta University

Hospital.1

Subjects and Method:-

Research design: -

A quasi-experimental research design was

used to accomplish this study.

Setting:

This study was carried out at the Neonatal

Intensive Care Unit of Tanta University

Hospital.

Sample:

Consisted of all bedside nurses

working in NICU responsible for

providing direct care for neonates with

any health problems in the previously

mentioned setting. Their number was

70.

-Tools:

1-A Structured questionnaire sheet for


Vol. 2 No. 2 May 2012 190

Neonatal Nursing management

competences: This tool was developed

to assess nurses' knowledge and skills

related to the basic competences needed

for neonatal care. It covered three parts;

biosocial data of the nurses, Nurses'

knowledge assessment questionnaire

2- Nurses practice observational checklist.

Method:

- All nurses were observed during

different nursing procedure at different

shifts (morning, afternoon and night

shifts).

- The questionnaire was answered on an

individual basis in the presence of the

researcher. The time needed to answer the

questionnaire ranged from thirty minutes

to one hour. Data collection of this tool

lasted approximately ten months.

- Preparation of suitable media for teaching

the nurses including; lectures, data show,

poster, video, doll for remonstration, and

book notes.

- Determining the framework of the

standards; The Donnabedian model (8)

(structure, process and outcome) was used.

Implementation of the standard care

strategies.

- Nurses were divided into ten groups,

seven nurses in each group.

-The standard of care was discussed for all

nurses included in the study; it includes 13

sessions; adequate (basic assessment,

hygienic care, sensory stimulation,

infection control, support for respiratory

effort, caloric intake and knowledge about

High Risk palliative care.)

Evaluation was done immediately and

three month later.

Part (A):-Knowledge of the

nurses regarding care of neonates

at NICU was evaluated and

classified as:

Every item was evaluated as

follow:

Correct and complete

answer was scored (2)

Correct and incomplete

answer had been scored (1)

incorrect and incomplete

answer had been scored (0)

Total score of knowledge items was

calculated in percentage and a score

of 70% or more is considered good,

60-69% fair & less than 60% was

considered poor.


Vol. 2 No. 2 May 2012 191

Part (B):-Practice of the nurses

regarding care of neonates at NICU with

evaluated and classified as:

Every item evaluated as follow:

Competent (Correct and complete

done) had been scored (1)

incompetent (Correct and

incomplete done) had been scored

(0)

incorrect or not done had

been scored (0)

The total score of every item had been

calculated in percentage and classified as

follow:

85 and more had been considered good

70-84 % had been considered

fair.

Less than 70% had been considered

poor.

Results:

Table (1) illustrates the general

characteristics of nurses included in the

study. It was observed that, nearly two

third (60%) of the nurses were 30 to less

than 40 years old, with mean age were 31

± 6.Regarding their education, 67.1% of

nurses are secondary nursing school

graduates while 24.3 % of them have

completed their university nursing

education and only 8.6 % of them have a

technical nursing institute certification.

Unfortunately, the same table indicates that

only 12.9 % of nurses have attended

specific course/ training in neonatology,

and the majority of them (87.1%) did not

attain any course or training. It was

observed that most of them (85.7) were

married and 14.3% were single. In relation

to their years of experience in NICU, the

result reveals that the mean years of

experience in NICU were 11.6±5.8 years.

Table (2): shows the correlation between

nurses' knowledge before and immediately

after application of the standard, and

between before and three months after

application of the standards of care. It was

observed that, the nurses' levels of

knowledge regarding high risk neonates,

infection control, oxygen therapy, control

of body temperature, kangaroo care,

nutrition, re-lactation, tactile stimulation,

and support of parents (19%, 13%, 34%,

46%, 100%, 37%, 100%100%, and

99%,)respectively were incompetent

before application of the standard, while

after application of the standards either

immediately or three months later , the


Vol. 2 No. 2 May 2012 192

nurses ' knowledge regarding the

previously mentioned topics completely

improved, With significant differences

p<0.001.Table (3): shows the correlation

between nurses' performance before,

immediately after application of the

standards, and between before and three

months later from application of the

standards. It was reveals that, the total

scores of nurses' performance regarding

control of infection were 96% incompetent

before standard compared to 61% and 69%

were incompetent immediately and after

application of the standard

respectively.Table (4) and fig. (1, 2):

represents the total score for the nurses'

knowledge and practice according to their

level of performance. It was observed that,

the total scores of nurses' knowledge were

poor with percentage 63%, where as,

immediately and after three months of the

standard application ,the total score of

knowledge improved as the majority of

them (89%) and (81%) obtained good and

fair scores respectively. As regards the

total score of practice, 80% of nurses'

performances were poor before the

standard, while after application of the

standard either immediately or after three

months, the nurses' performance improved.

statistically significant difference was

observed (p<0.001).

Table (5) and Fig (3, 4): Illustrated

the total score of nurses' performance

according to their competences. It was

observed that 63% of the nurses'

knowledge was incompetent before

standard application, compared to (8%

and10%) immediately and three months

later respectively. As regards nurses'

practices the total scores were 80%

incompetent before standard and decreased

to 30% and 36% respectively immediately

and three months later from application of

the standards. There were statistically

significant differences (p<0.001).


Vol. 2 No. 2 May 2012 193

Table (1): Distribution of the Nurses According to Their General Characteristics.

Characteristics No. = 70 %

Age in years

20 –

30 –

40 –50

24

42

4

34.3

60

5.7

Total 70 100

X ± SD 31±6

Education

•Baccalaureate degree

Technical nursing institute

Secondary nursing school.

17

6

47

24.3

8.6

67.1

Total 70 100

Attending special courses/training in neonatology.

Yes

No

9

61

12.9

87.1

Total

70

100

Marital status:-

●Married.

●Single.

60

10

85.7

14.3

Total 70 100

Years of experience:

1 -

5 –

10 –

15 –

20 –25

18

10

12

26

4

25.7

14.3

17.1

37.2

5.7

Total 70 100

X ± SD 11.6±5.8


Vol. 2 No. 2 May 2012 194

Table (2): the correlation between nurses' knowledge before and immediately after

application of the standard, and between before and three months after application of

the standard

P2 P1

After Immediate Before

In Competent In Competent In Competent

% No. % No. % No.

.0..1> .0..1

> . . . 0 11 11

1- High risk

neonates

.0..1> .0..1

> . . . . 11 9

2- Infection control

.0..1> .0..1

> . . . . 13 43

Oxygen therapy-3

.0..1> .0..1

> 13 1. . . 91 31

4- Suction

.0..1> .0..1

> 41 16 4. 13 9. 19

5- Ventilator

.0..1> .0..1

> . . . . 36 14

6-Control body

temperature

.0..1> .0..1

> . . . . 1.. 0.

7- Kangaroo care

.0..1> .0..1

> . . . . 10 46

8- Nutrition

.0..1> .0..1

> . . . . 1.. 0.

9- Relactation

.0..1> .0..1

> . . . . 1.. 0.

10- Tactile

stimulation

.0..1> .0..1. . . . 11 61 11- Support parents


Vol. 2 No. 2 May 2012 195

P1: Comparing between before and immediate.

P2: Comparing between before and after three months.

Table (3): correlation between nurses' performance before and immediately after, and

between before and three months after application of the standards of care.

>

.0..1> .0..1

> 01 99 01 9. 1.. 0.

12- Palliative care

1. 0 8 9 61 33 Total P2 P1 After Immediate Before

Items In Competent In Competent In Competent


Vol. 2 No. 2 May 2012 196

.0..1

>

.0..1

>

% No. % No. % No.

.0..1

>

.0..1

> 69 48 61 43 96 67

1- Infection control

.0..1

>

.0..1

> 23 16 5.5 4 57 45

2- Daily care.

.0..1

>

.0..1

> 78.5 55 78.5 55 100 70

3- Measurement.

.0..1

>

.0..1

> 38 27 35 25 73 51

4- Phototherapy

.0..1

>

.0..1

> 63 44 63 44 76 53

5- Intravenous

therapy

.0..1

>

.0..1

> 29 20 21 15 96 67

6- Gavage feeding.

.0..1

>

.0..1

> 11 8 7 5 23 16

7- Oxygen

therapy.

.0..1

>

.0..1

> 14 10 14 10 83 58

8- Pulse oximetery

.0..1

>

.0..1

> 0 0 0 0 100 70

9- Suction

.0..1

>

.0..1

> 29 20 14 10 100 70

10- Resuscitation

.0..1

>

.0..1

> 43 30 31 22 100 70

11-Ventilator

.0..1

>

.0..1

> 30 21 28 19 61 43

12- Communication

.0..1

>

.0..1

> 36 25 30 21 80 56

Total


Vol. 2 No. 2 May 2012 197

P1: comparison between before and immediate after application of the standard

P2:-comparison between before and after three months application of the

standard

Table (4): the Total Score of Nurses’ Knowledge and Practice according to

Their Level of performance.

Before Immediately Three months later

P

value

Comp. In comp. Comp. In comp. Comp. In comp.

No. % No % No % No % No % No % <0.001

Knowledge 46 10 43 61 65 92 5 8 63 90 7 10

Practice 14 20 56 80 49 70 21 30 45 64 25 36 <0.001


Vol. 2 No. 2 May 2012 198

(Fig. 1) : Total Score for the Nurses' Knowledge according their level of performance.

befor

e

Imme

diatel

y afte

r the

stand

ard

Three

mon

ths a

fter th

e

stand

ard

Good

Fair

poor

63

7%10%7

4% 9%

30

89

81%

0

10

20

30

40

50

60

70

80

90

Total score of nurses knoweldge

Good

Fair

poor

Total practices of nurses

12%

45%43%

41%

14%

45%

14%

6%

80%

0

10

20

30

40

50

60

70

80

90

Before

sta

ndard

Good

Fair

Poor

Imm

ediate

ly af

ter t

he sta

ndard

Good

Fair

Poor

Three m

onths

after t

he sta

ndardG

oodFai

rPoor


Vol. 2 No. 2 May 2012 199

(Fig 2) :Total Score for the Nurses' Practice according their level of performance

Table (5): the Total Score for the Nurses' Knowledge and Practice according to their

competence.

Total knoweldge according to their competence

26%

65% 63%

0

0.10.2

0.3

0.4

0.50.6

0.7

befo

re

sta

ndard

s

imm

edia

tely

com

pete

nt

thre

e

month

s

knoweldge

Before

standard

Immediately after

the standard

Three months after

the standard

Fisher exact

test P value

no % No % No %

p<0.001 Knowledge

Good 21 30 62 89 57 81

Fair 5 7 3 4 6 9

Poor 44 63 8 7 7 10

Total 70 100 70 100 70 100

Practice

Good 10 14 32 45 30 43

p<0.001 Fair 4 6 9 14 8 12

Poor 56 80 29 41 32 45

Total 70 100 70 100 70 100


Vol. 2 No. 2 May 2012 200

(Fig 3): Total Score for the Nurses' knowledge according their competences.

(Fig 4): Total Score for the Nurses' Practice according their competences

-DISCUSSION:

Maintaining and improving neonatal

care requires active involvement of

everyone in health care system, in order to

meet the needs for evaluating health care in

its totality as well as to identify whether

effective and appropriate care has been

provided. Education and training are

potential means for implementing effective

nursing care at Neonatal Intensive Care

Unit (NICU), as they alter perception,

increase knowledge, and in turn change

work practice.(9) "The current study is

figuring out that, most of nurses didn't

attend any previous in-service training

program related to neonatal care at NICU

.This finding may be owing to the shortage

of nurses' number, absence of continuing

education department in the hospital and

lack of motivation for training, as well as

increased workload in Neonatal Intensive

Care Unit. The findings of the current

study are in line with ". The British

Association of Perinatal medicine (BAPM)

(10) which stated that "a lack of trained

staff may lead to care that is unsafe.'' and

Jeffery et al (11), Vidal et al (12), stated

Total practices according to their compeences

14%

49%45%

0%

10%

20%

30%

40%

50%

60%

befo

re

sta

ndard

s

imm

edia

tely

com

pete

nt

thre

e

month

s

practices


Vol. 2 No. 2 May 2012 201

that the implementation of effective

training programs for health care providers

in hospital settings followed by moderate

improvement in Essential Newborn Care

(ENC) is a must .While the finding was

incongruent with another study (13), who

revealed that the nurses' factors related to

in-service training had no effect on both

nurses' knowledge and performance. The

current study revealed that about two third

of nurses' knowledge was incompetent

about neonates in intensive care unit before

standards application, while immediately

and after three months application of the

standards, nurses' knowledge highly

improved . On the other hand, it was found

that ,most of them demonstrated

incompetent level of performance before

standards, which improved also

immediately and three months later. This

moderate level of competencies could be

related to the improper working

environment and unclear cut-

responsibilities among nurses, as well as

the inadequate attendance of continuous

pre-service and in-service training

programs. This finding is supported by

Salem (14) who showed that, half of the

studied nurses gave correct responses when

assessing their level of knowledge, while

none of them attained the competent level

in their performance. Another study carried

out by El-Sayed (15) who reported that, a

score of more than half of studied nurses

was unsatisfactory regarding care provided

for neonates. Fair performance was

observed among more than half of nurses

as mentioned by El-Mommani (16).

In addition WHO (2006), (17), which

stated that, there was inadequate nurses'

knowledge and performance and attributed

this deficiency to one or more of the

following reasons as mentioned; lack of

orientation program prior to work as well

lack of nursing care conference during

work, invariability of procedure, and books

especially in the studied area, lack of

supervision, and nurses' evaluation against

identified standards of patient care. On the

contrary, this finding disagreed with Al-

Sharkawy (18). Who reported that, almost

three-quarters of nurses had good scores of

performance.

The present study showed that few of

nurses have competent level of

performance about infection control,

before standards, which increased


Vol. 2 No. 2 May 2012 202

immediately and after three months

application of the standards. This low level

of performance may be due to shortage of

staff, absence of continuous observation

from health professionals and lack of work

motivation either verbal or financial .This

result is congruent with Abd-alla (19). who

found inadequate nurses knowledge and

practice related to nosocomial infection,

principle of disinfectant, sterilization, and

standard infection control precautions and

he interpreted that by the lack of nurses'

awareness with importance of infection

control and safe health practice. Attia (20)

and El-Shenawy (21) revealed that control

of infection in ICU was considered a total

responsibility of the nurse as stated by the

entire expert group included in their

studies.

A large number of premature infants

require prolonged ventilatory support. In

order to provide this support an artificial

airway must be inserted. This airway can

be established in one of two ways, either

with an end tracheal tube or by the means

of a tracheotomy tube. Regardless of which

method is used, the neonate’s upper airway

is by passed, thus reducing the neonate’s

ability to clear secretions spontaneously.

Additionally, the presence of the tube may

lead to an increase in sputum production.

For these reasons neonates with an

artificial airway in place will require

airway suctioning (22). Endotracheal

intubation may be necessary for the

ventilation process. The nurse must

constantly ensure tube placement, stability

and patency. End tracheal intubation and

subsequent oxygen therapy decrease ciliary

activity and accelerate mucus production.

Appropriate suctioning of the end tracheal

tube is required to aid in the outflow of

pulmonary secretions and assure patent

airway. (23,24-5)

The present study revealed that half

of nurses were competent in performing

suctioning before standard application and

it increased to include all of them

immediately and after three months

application of standards. . Increased

awareness that suctioning is one of nurses'

own responsibilities could be the reason

behind this competent level of

performance, in addition to the

understanding of the danger of

accumulation of these secretions in the

neonates' airway. The Finding of the

present study was in-accordance with El-


Vol. 2 No. 2 May 2012 203

Mommani (16) who reported that ,more

than half of nurses demonstrated poor level

of performance in suction procedure, and

another(13) who reported that ,suction was

satisfactory in only few numbers of nurses.

The result of the current study is in the line

with Salman (7) who revealed that, three

quarter of nurses gave competent answers

about assisting pediatricians during end

tracheal tube insertion. Moreover, most of

nurses scored competent in performing

suctioning.

Anthropometric measurements help

in assessing neonates' growth and

development. When combined with other

measurements, they are used to form an

index that becomes useful (WHO 2009)

(26). Anthropometric indices such as

height for age, weight for age and weight

for height can be compared to recognized

standards of growth to decide if the

individual or populations under

investigation are within the normal for

size, proportion or composition. (27) As

regards this aspect, the present study

revealed that, the majority of the studied

nurses demonstrated incompetent level of

performance in taking the neonates'

general measurements. This could be

attributed to the fact that pediatricians

usually do the measurements on admission

as a part of their physical examination.

Weight is an important measurement

which should be performed by the nurses

and couldn't be measured, in spite of the

fact that weighing the neonate is

considered as a part of their routine nursing

care which should be performed every

night shift, this could be attributed to

unawareness of the nurses that weighing

should be done regularly to protect rapid

decrease in body weight which may result

from dehydration or insufficient caloric

intake.

The findings of the current study are

in harmony with a study carried out by El-

Sayed (15) who reported that none of the

studied nurses had taken the general

measurements for the neonates.

Furthermore, El-Mommani (16) stated that

the lowest scores were assigned to taking

general measurements, and Mahmoud (28)

reported that approximately two-thirds of

nurses were unsatisfactory in this aspect. In

addition Al-Sharkawy (18) found that only

few numbers of the studied nurses were

good in taking general measurements for

neonates. Mohamed (13) found that the


Vol. 2 No. 2 May 2012 204

majority of nurses did not take the length,

the head and chest circumferences, while

weighing the neonates was done by more

than one-quarter of nurses.

Conclusion: Recommendations:-

Conclusion: it can be concluded that there

was an enhancement in nurses' knowledge

and moderate improvement in performance

after application of the standard.

Recommendations: The developed

standards should be translated into Arabic

and disseminated to the managers of health

organizations

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