Effect of educational nursing guideline about paracentesis procedure care on nurses' performance

Introduction

Paracentesis is a procedure in which a needle or catheter is inserted into the peritoneal cavity under sterile conditions in order to; drainage fluid from abdominal cavity in ascites condition, relieve pressure on the abdominal and chest organs, and to study chemical, bacteriological and cellular composition of the peritoneal fluid for the diagnosis of diseases.( Saberifiroozi, 2017).

However Paracentesis has been shown to be a safe and efficient method for treating patients with severe ascites that is resistant to nutritional and diuretic therapy, it can cause severe problems to the patient, and associated with some risks or complications. These complications can be divided into; systemic, local and intra-peritoneal complications. Systematic complications as (severe hypotension and infection), local as (abdominal wall hematoma and localized infection at the puncture site), and intra-peritoneal as (perforation of vessels and viscera, peritonitis) (Biecker, 2011). Several national and international studies showed that nursing adherence rate to paracentesis guideline is correlated with positive patient's outcomes, patient's safety, and reducing the risks for either local or systemic complications. (Saberifiroozi, 2017).

Hence the successful Paracentesis procedure mainly depends on skillful practitioner, highly strict aseptic technique, good preparation and carefully monitoring for the patients throughout the procedure, nurses have a major responsibilities toward patients undergoing Paracentesis because in order to minimize of intraperitoneal fluid without intravascular volume depletion, preventing injury, and inhibit infection of peritoneal cavity (Gines et al., 2014).   

Nursing role toward patient undergoing paracentesis classified into pre, during and post procedure. Pre-procedure care is beginning with (assessment for patient condition, vital sings, taking consent, providing explanation about procedure, gathering needed supplies, preparing patient as emptying bladder, and positioning), while during procedure actions include (maintaining aseptic technique and closely monitoring for the patient throughout the procedure for any abnormalities) (Watkins et al., 2015). Post procedure interventions include; applying a sterile dressing and a pressure bandage at the puncture site to prevent leakage of fluid, continuing to monitor vital signs, assessing for hypovolemia, electrolyte shifts, and changes in mental status, giving prescribed albumin intravenously after large volume paracentesis and documenting the procedure (National clinical Paracentesis guidelines, 2015)

Significance of the study

The flow rate of ascetic patients (from 2016 to the end of 2017) was nearly about 250 patients in Qena university hospital (Statistical unit of Qena university hospital, 2017). Researcher viewed from working experience that there was a gap between the actual practice and expected paracentesis care according to the adopted guideline of care for ascetic patients undergoing Paracentesis. 

Several conducted studies revealed that a high percent of ascetic patients undergoing paracentesis suffering from either local or systemic complication as a result of malpractice (Saberifiroozi, 2017). One of these studies is that conducted in Mansura university hospital by (El-Sayed et al., 2018) and found that 32% of patients had signs and symptoms of hypovolemia after paracentesis because of lack of monitoring, rapid and increased drainage of ascetic fluid, as well as 11% suffering from peritonitis due to breaking down of aseptic technique.

Furthermore in our geographical area at Qena hospitals nurses considered that the physician is the only responsible one for performing paracentesis procedure, and there is a lack of awareness that they have a major role in assessing, preparing and monitoring patient from the beginning until finishing, as well as after the procedure. There for this study was conducted to investigate the effect of educational nursing guideline regarding paracentesis care on nurses' performance.

Aim of the study

The aim of this study was to evaluate the effect of educational nursing guideline about Paracentesis procedure care on nurses' performance

Research Hypotheses

Application of standardized nursing guideline of care about paracentesis procedure will improve nurses' performance

Research Design

A pre/post quasi-experimental research design was utilized to meet the aim of this study.

Subjects 

A convenient sample of 40 nurses (25 nurses from Qena University hospital and 15 nurses from general hospital).

Inclusion criteria

All available nurses at tropical medicine department of Qena University Hospital and in the tropical department of Qena general hospital who accept to participate in the current research.

Setting of the study

                The study was conducted at the tropical medicine departments in Qena University Hospital and Qena General Hospital, Qena governorate, Egypt.

Study Duration

Data collection for this study was carried out through six months, from the beginning of January 2019 till the end of June 2019.

Tools of data collection

Two tools were utilized in order to fulfill this study:

1.  First Tool:

A structured questionnaire was designed by the researcher after reviewing of the recent related literature (James and solove, 2016, El-Sayed et al., 2018) consists of two parts:-

Part (1): Demographic data: as (name, age, marital status, place of residence, qualification, years of experience, previous training programs).

Part (2): Knowledge assessment sheet

Self-administered knowledge sheet was filled by participants nurses about abdominal paracentesis procedure include; (definition and causes of ascites, definition of paracentesis, its indications, contraindications, possible complications and how to prevent them, needed supplies, nurses role before, during and after paracentesis procedure). It consists of 20 multiple choices questions and used for nurses before and after the implementation of educational nursing guidelines through three follow up phases.

Scoring system: If nurses have score 60 % and more this was considered ''satisfactory" level of knowledge and if they had less than 60% it will be considered ''unsatisfactory" level of knowledge.

2. Second Tool: Observational checklist adopted from (National Clinical Paracentesis Guideline, 2015) was used as a pre and post- test for assessing the nurses' practices pre, during and post paracentesis procedure. The steps of care categorized into (not done, incompletely done, and completely done).

Scoring system

If the nurses was done more than 70% from practices it will be considered ''high performance'', if they had less than 70% it will be considered ''low performance''.

Educational booklet was given to each nurse included in the study in order to provide educational nursing guidelines about paracentesis procedure. It is divided into two parts: Theoretical part included (definition and causes of ascites, definition of paracentesis, its indications, contraindications, possible complications and how to prevent them, needed equipment, right sites of needle insertion) and practical part included (how to prepare patients undergoing paracentesis, aseptic and right technique of needle insertion, patient's positioning, care during paracentesis and monitoring, nursing actions after finishing the procedure).

Tools Validity:

The tools were tested for content validity by a jury of five experts in the field of the study and necessary modifications were done. The tools were tested for internal consistency.

Tools Reliability

Internal consistency was evaluated using Cronbach's Alpha coefficient test which revealed that tools of the study were reliable as indicated by the value of (0.87 and 0.91) for knowledge and practice respectively

Pilot study

A pilot study was conducted on 4 nurses (10% of the total sample) to test clarity, completeness and to determine the time involvement. They included in our actual sample because no modifications needed to be performed.

Ethical Considerations

                A written initial approval was obtained from the research ethical committee of the faculty of nursing, Minia University. The purpose of the present research was explained for every nurse and each nurse has had the right to agree or refuse participation in the study and written consent was obtained from nurses who participated in this study. They also informed that the information obtained would be confidential and would be used only for the purpose of the study. Each assessment sheet was coded and nurses' name didn't appear on the sheets in the purpose of anonymity and confidentiality.

Data Collection Procedure

Phase I: Preparatory and administrative phase: Administrative approval was obtained from the dean of Faculty of Nursing, Minia University to the managers of selected hospitals before implementation of the study, and then an official permission to conduct the proposed study was obtained by the researcher from the manager of Qena University Hospital and Qena General Hospital. Also the official approval for data collection was obtained from the medical consultant of the study setting after explanation of the purpose of the study. Moreover written consent was obtained from each nurse participated in this study.

Phase II: Implementation phase: Once the permission was obtained to conduct the study, the researcher initiated data collection. Collection of data was started from the beginning of January 2019 to the end of June 2019, through 4 days weekly during 2 shifts, the first shift is from (8 am: 2 pm), and the second shift is from (2 pm: 8 pm).

At initial interview the researcher introduced herself to initiate communication, explained the nature and purpose of the study and the nurses were persuaded by the importance of their role in providing a safe paracentesis procedure and preventing its complication. Then each nurse was involved in a pre-test, she/ he was assessed for his or her baseline knowledge using (tool I), this tool was filled individually by the nurses within about  15 min, then each nurse was assessed individually by the researcher during her/his routine care in paracentesis procedure to determine their baseline of practice using (tool II).

Nurses were divided into groups according to shifts and time available, each group contain 2 to 7 nurses and each group of nurses selected the suitable time for receiving the teaching sessions whenever they have minimal workload. Two teaching sessions were conducted at the prepared training places for each group using the prepared teaching aids and media (booklets, power point and videos ), in order to cover the following items (definition and causes of ascites, definition of paracentesis, it's indications, contra-indications, complications, equipment, the sites of needle insertion, patient positioning, nursing role before, during, and after paracentesis procedure. Each session took around 40 minutes. Each nurse obtained a booklet that included all the training contents.The application of nursing guidelines was performed by researcher then by nurses until the researcher became sure that nurses were applying these steps perfectly. The education of the standardized nursing guidelines carried out at morning, and after noon shifts from 1/2/2019 to 28/2/2019. 

Phase III: Evaluation phase: One month after providing of the educational intervention, the 1^st post test was conducted for evaluating the nurses' knowledge and practice; the knowledge was evaluated by allowing each nurse to refill tool (I) individually, while the practice was evaluated by the researcher through observing each nurse while performing paracentesis procedure care individually and rechecking each step if done completely, incompletely or not done through using guidelines check list tool (II). The 1^st posttest was conducted at morning, and after noon shifts from 1/4/2019 to 30/24/2019. 

One month later (from 1/5/2019 to 31/5/2019), the 2^nd posttest was done using the same technique and the last third posttest was performed by the same way after another month (from 1/6/2019 to 30/6/2019).  Post-tests were conducted by interviewing and observing each participant alone.

Limitations/difficulties of the study

1. Work load of nurses was an obstacle as the researcher was waiting for a long time to start the session with participants, also this make some participants to be tired to listen and has low concentration and need continuous repetition, which required a lot of time and effort.
2. Interruptions during conducting sessions by other staff members.

Statistical Analysis of Data

Data entry was done using compatible personal computer. The statistical analysis was done using SPSS–20 statistical software package. Data were collected, revised, coded, analyzed, and tabulated using number and percentage distribution. Data were presented using descriptive statistics in the form of frequency and percentages for quantitative continuous data which were compared by using student T–test in case of comparisons between the mean scores of the two studied groups. For multiple groups F–test or (ANOVA) was used. Person correlation analysis was used for assessment of the interrelationships between knowledge and practices pre\post\follow up program. Statistical significance was used at p. value < 0.05.

Results

Table (1): Frequency distribution of the participants according to their demographic data (n=40).

Table (1) Illustrated frequency distribution of the participants according to their personal data. It was found that (85%) were females; their ages ranged from 18-32 years, with a mean age of 23.22±3.91 years, more than half of them were living in rural areas, and almost of them were married. As regards the nurses' years of experience, it was noticed that (72.5%) had less than 7 years of experience. Regarding educational qualifications of the nurses, it was found that (80%) of them had technical institute of nursing. Concerning attendance of training courses about paracentesis and its peri procedural care, all of the studied nurses (100%) did not attend any previous courses.

Figure (1):  Comparison between total level of nurses' knowledge about paracentesis procedure at pre and post guidelines implementation (n=40)

Figure (1): Illustrated that there was a significant improvement in nurses' knowledge regarding paracentesis procedure with a percentages of (92.5%, 85%, and72.5%) at the three follow up phases after implementation of educational guidelines compared with unsatisfactory level  of knowledge (22.5%)  at the pre implementation phase.

Figure (2):  Comparison between total level of nurses' Practice regarding paracentesis procedure at pre and post guideline implementation (n=40)

Figure (2): Demonstrated that there was a significant increase in total practice scores of nurses regarding paracentesis procedure after implementation of teaching guidelines at the three follow up phases represented by (92.5%, 85% and 82%) respectively when comparing with only 17.5% before implementation of teaching guidelines.

Table (2):  Comparison between the mean scores of nurses' knowledge and practice regarding paracentesis care at pre and post the educational nursing guidelines (n=40)

NB: (P1; between pre and post1 after intervention; P2 between pre intervention and post2 intervention, P3, between pre intervention and post 3 intervention; p4 between post1 intervention and post2 intervention; p5 between post1 intervention and post3 intervention.p6  between post 2 intervention and post 3 intervention . P ≤0.05 is significant   and **P≤0.01 is highly significant.

Table (2): Represented mean scores of nurses' knowledge and practice regarding paracentesis care at pre and post implementation of educational guideline. Regarding knowledge; it illustrated that nurses' mean scores were significantly improved through the three follow up phases compared to pretest phase, as their knowledge mean scores was (8.60±0.92) at pretest and became (15.35±2.04), (14.60±2.72) and (13.67±3.45) at post1, post2 and post3 respectively, with a very highly significant difference (p<0.001). Furthermore there was a highly significant improvement in nurses' practice afterimplementation of educational nursing guideline in all follow up phases compared to the pretest phase, it was (14.75±13.9) at pretest phase and became (53.80±7.85), (51.42±9.91) and 48.87+5.60at post1, post2 and post3 respectively, with a very highly significant difference (p<0.001).  

Table (3):  Relation between total nurses' knowledge and practice regarding paracentesis at pre and follow up phases of guideline implementation

NB:  (**P.0.01, highly significant)

Table (3): It reflected that there was there were highly statistically significant improvements in nurses’ practice in relation to improvement in nurses’ knowledge after implementation of educational nursing guideline (P≤0.01) as compared with before.

Table (4):  Relation between total level of nurses' knowledge about paracentesis procedure and their personal data at pre and post guideline implementation (n=40)

Table (4) Displayed that there was a significant relation between nurses' knowledge and their ages; in which nurses older than 24 years had  more satisfactory level of knowledge at the third follow up phase with P value(.022*). Also, a highly significant relation was detected between nurses' knowledge and their gender; as female nurses had more satisfactory level of knowledge at post 1 phase with (p value 0.009). Moreover, a highly significant relation was detected between nurses' knowledge and their qualifications; in which bachelor degree nurses had more satisfactory level of knowledge at pretest phase (p 0.004). However, nurses' years of experience, residence, marital status and previous training had no influence on their knowledge score

Table (5):  Relation between total level of nurses' practices about paracentesis procedure and their personal data at pre and post guidelines implementation (n=40)      

Table (5) Showed thatthere was a highly significant relation between nurses' practice and their gender; as female nurses had higher performance level than males at post 1 phase (p 0.009). Also, nurses' qualifications had a significant relation with their practice in which bachelor degree nurses had higher performance level at pretest phase (p 0.046). However, nurses' age, years of experience, residence, marital status and previous training had no influence on their knowledge scores.