Effect of Intervention Program on Critical Nursing Management Regarding Hepatic Encephalopathy
Amira Sabry Mohammed1, Nadia Mohammed Taha2, Fatheia Attia Mohamed3, Naglaa Abd El Kareem Moghazy4
1Assistant lecturer, Medical Surgical Nursing Department, Faculty of Nursing, Zagazig University, Egypt, Email: [email protected]
2Prof. of Medical Surgical Nursing, Faculty of Nursing, Zagazig University, Egypt, Email:
3Assist. Prof. of Medical Surgical Nursing, Faculty of Nursing, Zagazig University, Egypt, Email: [email protected]
4Lecturer of Medical Surgical Nursing, Faculty of Nursing, Zagazig University, Egypt, Email: [email protected]
Corresponding author: Amira Sabry Mohammed, Email: [email protected]
Abstract
Background: Hepatic encephalopathy (HE) a syndrome of neuropsychiatric manifestations in patients with cirrhosis due to the accumulation of toxins in the blood. This study aimed to evaluate the effect of intervention program on critical nursing management regarding HE. A quasi experimental research design was utilized. Data were collected from Medical Intensive Care Units at Zagazig University Hospitals. The study was conducted on (30) nurses who working in the above setting. Two tools were used for collection of data, first a structured interview questionnaire for nurses to collect demographic characteristics of them and assess nurses' knowledge regarding HE, critical nursing care and suitable nutrition for HE. Second tool was an observational checklist to assess nurses' practice regarding HE.
Results of this study showed that, more than half (53.3%) of studied nurses, age above thirty years and more than three quarters (76.7%) of them were married& females. More than half (56. 7%) of them having a diploma and experience above 10 years. There was a statistical significant improvement in total nurses' knowledge and practice after application of program.
There is statistically significant positive correlation between nurses' knowledge score, their practice score, their age and years of experience pre and post intervention (p<0.05).
Conclusion all knowledge and practice dimensions of nurses were improved after program. It is recommended that further studies should be done on a large sample size and in various settings for generalization.
Keywords: Critical, Nursing Management, Hepatic Encephalopathy, Patients' Outcomes.
Introduction
Hepatic encephalopathy is a syndrome of neuropsychiatric symptoms and signs, including coma, observed in patients with cirrhosis due to the accumulation of toxins in the blood (1).
It can be divided into minimal (covert) hepatic encephalopathy and overt hepatic encephalopathy, depending on the severity (2). HE symptoms typically include confusion, personality changes, disorientation, and a depressed level of consciousness. The earliest
stage is often characterized by an inverted sleep-wake pattern where in patients are found to be sleeping during the day and awake throughout the night. Throughout the intermediate stages, patients tend to experience worsening levels of confusion, lethargy, and personality changes. In the advanced stages, HE may eventually lead to coma and ultimately to death (3- 5). Hepatic encephalopathy (HE) is a common, severe complication of advanced chronic liver disease (CLD) and has a devastating impact on the patient’s quality of life, prognosis, morbidity, hospitalization, and mortality (6). Health-related quality of life (HRQOL) in cirrhosis, indicating a negative impact of HE. HRQOL abnormalities span daily functioning, sleep-wake cycle changes, and the ability to work. Of these, sleep-wake cycle changes have a major effect on HRQOL, which remains challenging to treat. The impact of HRQOL impairment is felt by patients, caregivers and families. Caregivers of patients with HE bear a major financial and psychological burden, which may affect their personal health (7). The major precipitating factors of HE were infection [pneumonia, UTI, spontaneous bacterial peritonitis, cellulitis, sepsis of unknown source], GIT bleeding and electrolyte imbalance [hypokaelemia and hyponatremia]. Dehydration, constipation and unknown precipitants are considered (8). Management of HE include controlling of precipitating factors, medical treatment and liver transplantation. Standard medical treatment of HE comprises non-absorbable disaccharides as lacunose and antibiotics as rifaximin. Newer drugs that act on serum ammonia level have a vital role in management of HE, as l-ornithine- l-aspartate, sodium phenyl butyrate and sodium benzoate (9). Optimal outcomes rely on active participation of a knowledgeable caregiver and strong partnership with outpatient and inpatient teams. Nurses are a critical link in helping patients and caregivers understand and in supporting their efforts to manage problems (10). Specificity of HE patient healthcare encompasses nursing interventions and diagnosis. Through continuous education, respecting previous knowledge, it is necessary to focus on specific diseases such as HE for providing healthcare excellence (11).
Significance of the study
Hepatic encephalopathy occurs in up to 80% of patients with cirrhosis (12). HE imposes a significant economic burden on the patient, caretaker, health system, and society. Not only does it have a negative impact on the morbidity and mortality of the patient, but it also affects his or her psychologic and social functioning, as well as quality of life, in general. (13).
Nurses are critical in the delivery of essential health services and are core in strengthening the health system (14). The role of the nurse in recognizing symptoms of HE is critical.
Assessment by the nurse may prevent symptoms from progressing from minor non-life- threatening to life-threatening issues requiring urgent intervention (15). Thus, education for nurses on the management of HE is important, as well as education needed for patients and families to support them through the treatment and follow-up (10).
Aim of the study
This study aimed to evaluate the effect of intervention program on critical nursing management regarding HE
Research Hypotheses
H1: The mean knowledge scores of nurse's post implementing program will be higher than that of their pre- program scores.
H2: The mean practice scores of nurse's post implementing program will be improved than that of their pre program.
Subjects and methods Research design:
A quasi experimental research design was used.
Study setting
This study was conducted in Medical ICU at Zagazig University Hospitals.
Study subjects:
The study sample was convenience sample which includes all available nurses (30) working in the above mentioned setting.
Tools of data collection
Two tools were used for data collection:-
Tool I: A structured interview questionnaire for nurses:
It was developed by the researcher based on literature review. It was designed in Arabic language which applied as pre and post test. It consists of 84 questions and four parts as the following:-
Part 1: Nurse's demographic characteristics:-
This part included data about demographic characteristics of nurses consisting of (9) close ended questions as their age, gender, social status, qualification, years of experience.
Part 2: nurse's knowledge about HE:
It consisted of 20 MCQ questions such as (definition of HE, precipitating factors, signs and symptom, stages, laboratory and diagnostic tests, treatment, complications and prevention of HE).
Part 3: Nurse's knowledge about critical nursing care for HE: It included 40 MCQ questions as: critical care, observation, feeding methods, safety precaution, skin care, medication administration, action and side effects of lacunose, LOC assessment.
Part 4: Nurse's knowledge about suitable nutrition for HE: It consisted of (15) true or false questions as: protein intake, preferable type of protein, carbohydrates intake, salt added, necessary vitamins and minerals, smoking and alcohol, eating garlic, drinking green tea, dietary history, anthropometric measurements, physical examination and a daily dietary intake.
Scoring system regarding knowledge: The complete correct answer was taken two score while one score for incomplete correct answer and incorrect or don't know was taken zero.
The total score was calculated for each nurse by adding the score items of questionnaire. The nurse had satisfactory level of knowledge when the total score equal or above 80%, and unsatisfactory when it below 80%.
Tool II: Observational Checklists for Nurses:
Observational checklist included practical skills as: enema administration, insertion of NGT, gastric lavage and enteral feeding, administering medications through NGT, removing NGT,
or pharyngeal suctioning, oral and skin care, applying an extremity restraint and fall prevention measures, prevention strategies to skin damage, finally anthropometric measurements.
Scoring system regarding practice
For observational checklist consisted of given score one for done step with correct way and score zero for the not done. The nurses had satisfactory level of practice when the total score equal or above 80 % and unsatisfactory if it below 80% based on statistical analysis.
Critical nursing management program and booklet: it was developed according to assessment levels and needs of nurses and patients and designed as a booklet in Arabic language by the researcher based on the related literature and expertise opinions. It covered both theoretical and practical parts (20 sessions) as the following:
Theoretical part : it covered the following items in 5 sessions:
anatomy of the liver, liver functions, signs and symptoms of liver failure, definition of HE, precipitating factors, signs and symptoms, stages, diagnostic and laboratory tests, treatment, complications, prevention, suitable nutrition, feeding methods, asterixis test, LOC assessment tests, critical nursing care for HE.
Practical part: it covered the following items in 15 sessions:
enema administration, insertion of NGT, gastric lavage and enteral feeding, administering medications through NGT, removing NGT, or pharyngeal suctioning, oral care, skin care, applying an extremity restraint, fall prevention, prevention strategies of skin damage and finally anthropometric measurements.
Content validity and reliability
It was used to modify the tools and design booklet. It ascertained by 5 jury of expertise (3 professor nursing and 2 professor medical staff), who were reviewed the tools for clarity, relevance, comprehensiveness, understandable and applicability. Cronbach's Alpha was used to measure the reliability of the tool. It was 0.95 for knowledge, 0.87 for observational checklist for nurse's practice.
Field work
Field work of the present study was executed in 23 month from July, 2019 to May, 2021.
Distribution of the questionnaire was done every day at morning and afternoon shift. The time required for completion the questionnaire was ranged from 30- 45 minutes. Observation was done every day during the previous procedures before filling the questionnaire.
Pilot study
A pilot study was carried out on 5 (15%) of nurses to test clarity, relevance comprehensiveness, understanding, applicability. Simple modifications were done based on pilot results as rephrasing and rearrangement. The pilot study was excluded from the study sample.
Administrative considerations
An official permission for data collection in Zagazig University Hospitals was obtained from the hospital administrative personnel by the submission of a formal letter from the Dean of the faculty of Nursing.
Statistical analysis
All data were collected, tabulated and statistically analyzed using SPSS 20.0. t test and Paired t test and Wilcoxon signed ranks test were used for comparison. Percent of categorical variables were compared using Chi-square test or Fisher's exact test. Mc nemar test or Marginal Homogeneity Test was used to compare. Spearman correlation coefficient was used
to assess relationship. P-value < 0.05 was considered statistically significant (S).
Results
Table (1): clarifies that more than half (53.3%) of studied nurses, age above thirty years and more than three quarters (76.7%) of them were married& females. Regarding qualification, more than half (56. 7%) of them having a diploma degree and experience above 10 years.
Neither nurses attending training or hospital had guidelines about HE. Table 2: indicates that all knowledge dimensions were improved after application of intervention program by range from 24.71% regarding nurses' knowledge about suitable nutrition for patients with HE to 43.82 % regarding nurses' knowledge about HE. In general there was a statistical significant improvement in total nurses' knowledge after application of intervention program by 41.84
%. Table 3: demonstrates that all practice dimensions were improved after application of intervention program by range from 14.17% regarding nurses' practice about administering medications to 76.41% regarding nurses' practice about anthropometric measurements. Table (4): illustrates that there is statistically significant positive correlation between nurses' knowledge score, their practice score, their age and years of experience pre and post intervention (p<0.05).
Discussion
Hepatic Encephalopathy (H.E), defined as a spectrum of neuropsychiatric abnormalities in patients with liver dysfunction after exclusion of brain disease, is a common complication of advanced liver disease with significant morbidity and mortality (16).Patients with HE may require nursing care anywhere in the healthcare system. Therefore it is beneficial for all nurses to have a basic knowledge and practice about HE (17). Education is vital to increasing knowledge, improving prevention and care practices (18). The results of present study clarified that more than half (53.3%) of studied nurses, age above thirty years and more than three quarters (76.7%) of them were married& females. Regarding qualification, more than half (56. 7%) of studied nurses having a diploma degree and having experience above 10 years. These findings are agree with (11) who mentioned that the majority of nurses are female (91.4%) and had only secondary medical school and according to working experience, more than half of them had over 20 years of experience.
While these results are disagree with (19) who showed that the majority of the studied nurses were at age group (20 to less than 30), more than half of them were male and single, less than half of them were technical nursing diploma and one third of them had experience ranged between one to less than three years. Furthermore, (20) who revealed that more than half of the studied nurses, their age was between 18 to 30 years old, less than half of the them were graduated from nursing institute, and less than half of them are less than 5 years of experience. The current study reported that studied nurses had not attending training course about nursing care for HE. This result is supported by (21) in Assuit University who revealed that most of group hadn't training for emergency or for hepatic diseases with percentage
92.5% and 87.5% respectively. The present study reported that the hospital had not guidelines about nursing care for HE. (22) They found that implementing nursing guidelines on patients with haematemesis was significantly effective in outcomes of these patients with significant difference between both groups this indicate improvement of patient condition when applying guidelines for study group. The results of this study indicated that all knowledge dimensions were improved after application of intervention program by range from 24.71% regarding nurses' knowledge about suitable nutrition for patients with HE to 43.82 % regarding nurses' knowledge about HE. In general there was statistical significant improvement in total nurses' knowledge after application of program by 41.84 %. The result of this study is in harmony with study conducted by (23), their study revealed that significant improvement in knowledge of the Health Care Providers; physicians and nurses after implementation of the educational intervention program (P < 0.05). Likewise (24) in their study who pointed that the highest mean knowledge score was after implementation of the nursing intervention protocol in study group compared to control group and show high statistical significant differences in the study group. Furthermore, (25) their findings revealed a statistically significant improvement in the total mean knowledge scores of nurses in all items of the study after implementing the standards (P=0.000) as compared with the pre implementation period. Also this result is consistent with (26) in their study, their results indicated that the knowledge scores improved significantly before (141.89 ± 20.40) and after (182.72 ± 10.27) educational intervention (P <
0.0001).The current study demonstrated that all practice dimensions were improved after application of intervention program by range from 14.17% regarding nurses' practice about administering medications to 76.41% regarding nurses' practice about anthropometric measurements. The present study showed improvement in administering medications, (27) stated that nurses constitute the largest group of health professionals who work in the hospital setting and most of the medications in the setting are administered by nurses. This result of the current study go in line with (28) who clarified that there was statistically significant difference between pre and post implementation of training program as regard total scores of knowledge and practice about nursing intravenous medication errors. Also (29) who found that educational program on medication safety improves the knowledge of critical care nurses regarding intravenous medication errors. This study recommends that medication errors should be periodically assessed by improving clinical guidelines of medication administration. Likely, (30) who revealed that implementing the practice guidelines program was effective in improving nurses’ knowledge and their total practice scores were excellent immediately and good after three months regarding reducing medication administration errors and (31) their study concluded that improving nursing staff’ knowledge and practice about safe medication administration is evident by decreasing frequency of the errors after intervention than pre intervention.The current study demonstrated that improvement in anthropometric measurements. This finding is similar to (32), they showing that a targeted nutritional assessment teaching program that highlights both the importance and techniques of anthropometrical measurements has successfully been implemented in a PICU. It managed to improve staff knowledge and nutritional practice and (33)who reported that the study highlights large gaps in measurement techniques for the newer anthropometric measurements, though general practitioners GPs’ skills showed slight improvement after
training. It is clear from the results of the present study that there is statistically significant positive correlation between nurses' knowledge score, their practice score, their age and years of experience pre and post intervention (p<0.05). On the same hand, (34) represented the correlation coefficient between the total of knowledge and total of practice during three program phases and (35) illustrated that there were a positive correlation between knowledge, procedural intervention and general performance after program. Also (36) stated that there are positive correlations were found between mean knowledge scores and mean practice scores; age and years of experience. Moreover, (37) demonstrated that there was statistically significant correlation between knowledge, practice and educational level. On the other hand, the result of study conducted by (20), revealed that there was no statistically significant between total level of knowledge, attitude and practice among the studied nurses.
Conclusion
On the light of the present study, it can be concluded that all knowledge and practice dimensions were improved after application of intervention program, there was a statistical significant improvement in total nurses' knowledge after application of intervention program by 41.84 %. There was statistically significant difference (p<0.001) and improvement of nurses' practice post intervention program compared to pre intervention program to be 45.87%.
Recommendations
Based on the results of the present study the following recommendations are suggested:-
A standardized HE assessment tool should be available.
Hospital should have policies and guidelines for HE management.
Periodic refreshing training and educational programs to nurses.
A specific procedure book and information resources about HE in Arabic should be available.
Nurses should be encouraged to attend workshops, training and conferences.
Further studies should be done on a large sample size and in various settings for generalization.
Ethical considerations
The research approval was obtained from ethical committee of faculty of nursing before starting the study. Also the researcher was clarified the objective of the study to studied nurses. The researcher was assured maintaining anonymity and confidentiality of subjects' data. Furthermore nurses were informed that they are allowed to choose to participate or not in the study and that they have the right to withdraw from the study at any time.
Table 1: Demographic characteristics of studied nurses (n=30)
Demographic parameters No %
Age
< 30 year 14 46.7
≥ 30 year Mean ±SD Median(range)
16 53.3
31.3±6.4 30 (22-45)
Sex
Male 7 23.3
Female 23 76.7
Social status
Single 7 23.3
Married 23 76.7
Education
Diploma 17 56.7
Technical institute 10 33.3
Bachelors 3 10.0
Experience years
<10 year 13 43.3
≥10 year Mean ±SD Median(range)
17 56.7
11.2±6.7 10(2-25) Training about HE
No 30 100.0
Presence of hospital guidelines about HE
No 30 100.0
Table 2: Mean nurses, knowledge regarding critical nursing management for studied patients throughout study phases (n= 30)
Nurses' knowledge items
Study Phases
Mean difference
% of
improve ment
W P
value Pre
Intervention
Post
intervention Mean ± SD Mean ± SD Nurses’
knowledge about HE*
8.8± 3.9 16.5±3.2 7.26 43.82 4.6 <0.001 Nurses’
knowledge about critical nursing care for patients with HE*
19.1± 9.6 35.4±4.6
15.43 43.59 4.7
<0.001
Nurses’
knowledge about suitable nutrition for patients with HE*
10.4±2.7 14±1.1
3.46 24.71 ^8.1 <0.001
Total nurses' 27.6 41.84 4.9
knowledge* 38.3±15.1 65.9±8.7 <0.001 W=Wilcoxon Signed Ranks Test
^ paired t test p<0.05 statistically significant
Table 3: Mean nurses' practice regarding management of studied patients throughout study phases (n= 30)
Nurses' practice items
Study Phase Mean
differenc e
% of improv ement
W P
Pre
Intervention
Post
Intervention Mean ± SD Mean ± SD Nasogastric Tube
Insertion
17.4±3.9 25.4±1.4
8.06 31.65 ^11.3 <0.00 1
Irrigation of
Nasogastric Tube
14.5±3.1 19.4±1.4
4.86 25.05 ^9.4 <0.00 1
Enteral Feeding 12.8±5 22.6±1.6
9.8 43.36 4.9 <0.00 1 Administering
Medications
20.7±2.4 24.2±1.3
3.43 14.17 ^7.6 <0.00 1 Removing Nasogastric
Tube
11.5±2.7 17.2±1.4
5.73 33.19 ^12.9 <0.00 1 Oropharyngeal
Suctioning
23.8±5.1 32.3±1.8
8.46 26.16 ^8.5 <0.00 1
Oral Care 9.3±3.9 16.3±0.5
7 42.77 4.7 <0.00
1
Skin care 13.4±10.7 35.2±1.2
21.76 61.76 4.6 <0.00 1 Fall Prevention 7.6±7.5 22.8±1.1
15.16 66.39 4.7 <0.00 1 Applying an Extremity
Restraint
4.4±5.3 15.8±1.5
11.4 71.85 4.8 <0.00 1 Anthropometric
Measurements
8.1±15.7 34.4±5.7
26.26 76.41 4.4 <0.00 1 Total Nurses' practice 144.2±60.3 266.5±14.5
122.23 45.87 4.8 <0.00 1 W=Wilcoxon Signed Ranks Test
^ paired t test p<0.05 statistically significant
Table (4): Correlation matrix between nurses' knowledge score, their practices score, their age and years of experience throughout study phases (n=30)
Parameter
knowledge score Practice score
Pre
Intervention
Post
Intervention
Pre
Intervention
Post
intervention
(r ) P (r ) P (r ) P (r ) P
Age /yrs 0.45 0.013 0.34 0.068 0.54 0.002 0.68 <0.001
Experience /yrs
0.47 0.008 0.39 0.032 0.53 0.002 0.72 <0.001 Nurses'
knowledge score
pre intervention 1 . 0.45 0.012
Nurses'
knowledge score
post intervention 1 - 0.52 0.003
(r) correlation coefficient significant p<0.05
No statistical significant correlation between other demographic characteristics such as sex, education, social status, training and policy
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