Title: Training Program on Tuberculosis Management for Outpatient Chest Clinic' Nurses. environmental studies

Transcription

1 Title: Training Program on Tuberculosis Management for Outpatient Chest Clinic' Nurses Sahar Mohamed Soliman, PhD of epidemiology and Amel Ibrahim Ahmed, PhD of environmental studies Lecturers of Community Health Nursing, Faculty of Nursing Mansoura University. Corresponding author: Postal address: ٧, Assaad st, El-Rsaffa, Moharam-Bek, Alexandria, Egypt. E. mail address: (A. I. Ahmed) Tel: (٠٣) ٠١٠٣١٥٩٥٧٦; Fax: (٠٣) ٤٩٠١٣٦ ١ Postal address: ٣١ Amir El- Baher st, El-Rsaffa, Moharam- Bek, Alexandria, Egypt E. mail address: (S.M. Soliman) ١

2 Abstract The increasing of tuberculosis cases allover the world and in developing countries specifically, urgently demands a well trained health workforce. Nurses play an important role in controlling and preventing tuberculosis infection. The present study aimed to evaluate the impact of training program on nurses' level of knowledge concerning tuberculosis. A quasiexperimental design was used in this study, through evaluating the nurses' knowledge about tuberculosis prior to the development of the training program by using structured selfadministered questionnaire. After implementing the program the same questionnaire was used to reassess the nurses' knowledge and another structured sheet was used to estimate their opinions regarding the program. The results revealed a poor pre test level of knowledge which improved in the post test especially regarding the crucial aspects such as treatment strategy and nursing role. The study recommended that regular- base training program should be held to improve the knowledge and skills regarding tuberculosis nursing interventions. Key words: Tuberculosis, nursing role, training program Acknowledgement: The researches want to express their thanks to Prof. Dr. Nagiba Loutfi, the professor of Tropical Medicine, High Institute of Public Health, Alexandria University, and their appreciation to her efforts in facilitating the implementation of this study.

3 Introduction Tuberculosis is one of the major health tragedies among infectious diseases that threat the health and well-being of people economically productive age group (١٥ ٥٤ years). At the same time, multi-drug resistance, which is caused by poorly managed tuberculosis treatment, is a world wide. ١, Tuberculosis remains the growing problem of serious concern as a second leading killer of adults in the world ١, as one person per second is infected by the bacillus. Mycobacterium tuberculosis infects one third of the world population causing approximately ٨ million new cases and ٣ million deaths per year, therefore fighting tuberculosis is a challenge to all who are concerned about health and development., ٣ Geographical distribution of tuberculosis worldwide appears to be related to the countries socioeconomic condition. In the majority of the developed countries, the risk of mycobacterium tuberculosis infection is in the order of ٠ ١ to ٠ ٣ %, while in the countries with poor socioeconomic conditions the rate reaches ٥ ٣. More than ٩٠ of global TB cases and deaths occur in the developing world, where ٧٥ of cases are in the most global emergency public health problem in many countries throughout the world. Health care workers and other staff are also at particularly high risk of infection with TB because of frequent exposure to patients with infectious TB disease. Therefore fighting tuberculosis is a challenge to all who are concerned about health and development., ٥-٦ Nurses play a key role in ensuring the long-term implementation of the five components of the directly observed short course therapy strategy (DOTS) by undertaking TB case detection, treatment, and follow-up as well as in educating patients and the public about tuberculosis. To enable nurses to fulfill these professional functions, teaching and learning in training institutions must be adapted so that the skills and knowledge of ٣

4 graduates of basic training programmes that are relevant to the needs for implementation of the DOTS strategy. Education and training are essential elements to ensure the availability of human resources. Studies reported a lack of knowledge among nurses in relation to several issues of tuberculosis, and inefficient training skills. ١, ٦ Subjects and Methods Study design: A quasi-experimental design was used in this study. Setting: The study was conducted in ٦ chest outpatient clinics in Alexandria city, Egypt, namely; Moharam- bek, Baccous, El-Mamoura, El-Kabary, Kom-El- The professional development pathway Chokafa, and El-Gomrok. in the period described by Davidson (٠٠٥) suggests that the provision of high quality, post registration education is linked to high quality service provision. Such investment in staff is essential if nurses are to keep up to date in the ever-changing context of present day health care. ٦ Also, it was found that training intervention for clinical staff to the usual DOTs strategy executes a successful treatment of tuberculosis treatment. ٧ Therefore, it is important to study the nurses' knowledge and management to tuberculosis patient because nurses can play a crucial role in adherence due to the extent of their patient contact. ٨ from January ٠٠٦ to May ٠٠٦. Subjects: The subjects of this study included ٦٠ nurses working in the above clinics and willing to participate in the study, nine nurses excluded because they did not complete the program. Therefore the study performed on ٥١ nurses. Tools of the study: Three tools were developed by the researchers used in this study. Tool one consisted of knowledge test, the second tool is the educational program and the third tool included the session evaluation and final program evaluation sheets. Tool ١: Knowledge test: ٤

5 The essential knowledge assessment tool was developed to assess the nurses' knowledge for tuberculosis care in outpatient clinics. The total score of the test was ٤٩, covering four topics namely; the nature of the tuberculosis, ١٦ scores (definition of tuberculosis, causative agent, risk factors, types of tuberculosis, modes of transmission and manifestations), the treatment strategy ١٧ scores, (types of treatment, duration, side effect and DOTs), component of patient' assessment ٨ scores, component of follow up ٣ scores and nursing role ٧ scores. Open ended questions were used to avoid gassing. Tool : Educational program: The educational program included all topics of tuberculosis. Tool: ٣: Program evaluation sheet The program evaluation sheet with three - lickert scale were developed to assess the satisfaction of the participants regarding their expectation from the program and its objectives, the illustrated topics and scientific materials, time and duration, organization and coordination of the program, the competency of the of trainers and finally the place where the program was held in. Also three open questions included to predict their verbal satisfaction, dissatisfaction and suggestions. Methods: ١-Administrative process: a- Official approval was obtained from the ministry of health -Development of the study tools: a- The researchers developed the tools after reviewing of recent literatures. b- Validity of tools was tested by experts in that field c- A pilot study was carried out on ١٥ nurses were chosen randomly from outpatient chest clinics to ensure the clarity of the knowledge test and session evaluation and final program evaluation sheets. d- Reliability of the session evaluation and final program evaluation sheets was statistically tested by using alpha model test and the unrealistic questions were omitted. ٣-Progm development: The result of pre test was used as needs assessment of the target group. The ٥

6 educational program covered all topics of tuberculosis but it focused on their weak points that gained scores ٥٠ namely; types of tuberculosis, causative agent, risk factors, types of treatment, definition of DOTS strategy, components of initial assessment, components of follow up and nursing role. The program consisted of ٦ sessions divided on two days. The program was implemented in the conference hall of the "Tuberculosis is a Curable Disease Network." The program was repeated three times through out three weeks for three groups of nurses, each group included ١٧ nurses. A variety of interactive teaching techniques that encourage group discussions, were used namely; interactive lectures, brainstorming, and role-play. Trainers used power point presentation, flip chart and structured scenarios and patient assessment sheets as educational materials. Post-test was used to assess participant progress in knowledge. Statistical analysis: SPSS package (version ٠ ٩) was used for the statistical analysis of the obtained data. Paired T-test was used to estimate the difference in knowledge pre and post the implementation of the program. Results: Table (١) illustrates the distribution of nurses according to their job characteristics. The majority of nurses are staff nurses. Three quadrants hold diploma degree, ١٣ ٧ technical diploma and ١١ ٨ hold bachelor degree. Only ٥٨ ٨ attended training programs concerning tuberculosis issues. Regarding to the years of experience ٣٩ practicing nursing in chest clinics for less than ٥ years and only one quadrant expend more than ١٠ years in chest clinics, with overall Mean± S.D of ٨ ٨± ٨ ١ years. Table () revealed a statistical significant difference (P ٠ ٠٥) between nurses mean scores of knowledge pre and post implementation of the educational program regarding to the most areas of knowledge. The percentage of gained knowledge in post-test knowledge, was١١٤ ٣, in definition of tuberculosis diseases, ٣٤٠٠ in identification of causative agent, ٣٦ ٤ ٦

7 in mode of transmission, ٦٣ % in manifestation, ٣ ٦ in types of treatment, ٥٤ ٥ in duration of treatment, ١٦٦ ٦ in side effect of treatment, ٨٠ in identification of DOTS strategy, ١٧٥ in components of initial assessment, and ٤ ٣ nursing role in managing patient with tuberculosis. Furthermore, the overall mean of knowledge scores were ١٨ ١± ٤ ٥ before implementation of the educational program compared to ٣١ ١±٧ ٦ after implementation of the educational program, with increasing of ٧١ ٨. This difference was found to be statistically significant (P ٠ ٠٥). Table (٣) reveals that percentage of nurses with satisfactory level of knowledge pre the program ranged from ١ ٩-٦ ٧ compared to ١٣ ٧-٩٠ ١ after attending the program. Their was a significant increase in the number of nurses who identified the component of nursing role in assessing the patient (socio-demographic, contact, health history and finalizing lab investigations) ١١ ٧ in pre- test compared to ٦٨ ٦ of nurses in post test. In addition, a significant increase in the number of nurses who identified nursing role in the follow up phase (monthly follow up, ensuring visit appointment and monitoring of treatment side effects) from ١٧ ٦ in pre test compared to ٦٤ ٧ in post- test Table (٤). Table (٥) shows the satisfaction level of participants regarding the program that was totally ranked as very good (٨ ١%). Two thirds of participants were strongly agreed that the program fulfilled their expectations, and achieved its intended objectives. Most of trainees strongly agreed that trainers are competent, the program was well organized, and the scientific materials and the place are appropriate. Discussion: The expansion and strengthening of DOTS requires an adequate and well-trained workforce. Currently, the needs for such an effective TB workforce outstrip the supply of trained personnel at all levels of service delivery. Staff development program can be linked to both theory and practice and ٧

8 the resulting award benefits the nurse and the clinical areas. It was found that patient outcome positively correlated to the level tuberculosis patient and the nursing role especially in the first visit. This lack of knowledge may lead to decrease the of nurses' training ١٠, ١١. The present patient's adherence to the treatment, as study revealed a significant improvement in the knowledge level of nurses after implementing the training program. This improvement mainly observed in the basic knowledge concerning types of tuberculosis and causative agent. This result in agreement with this study was in Delhi, India shows that there is a general lack of knowledge among nurses regarding to causative agent of TB, importance of sputum examination, doses of short course chemotherapy, health education for patient and family members ٥. In addition, a study conducted in the U.S.A indicated that educational program improve nurses attitudes and level of knowledge toward patient diagnosed with tuberculosis. ١ It considered a danger sing that a minority of nurses have a satisfactory knowledge level about treatment side effect especially the minor manifestation. In addition to the component of initial assessment for nurses usually are directly contacted either with patient's first contact or during the follow up phase. This low adherence may occurs due to underestimated nursing role either in informing the patient about the treatment course and nature of his disease during the first visit and/ or the undetected treatment side effect during the follow up phase. However, this percentage of nurses obviously increased after implantation of the training program. Dick J et al (٠٠٤), who reported that many tuberculosis patients fail to complete their treatment as prescribed poor rapport between health care providers and patients with tuberculosis, but educational intervention had positive reflection on their work. ٩, support this view of the present study. ١٣ The majority of nurses were highly satisfied with the different aspects of the implemented training program, and they recommended repeating such program in a ٨

9 regular base to refresh their knowledge. In addition to their interest in holding several program for each topic to strength their - Clinical guidelines for tuberculosis nursing intervention should be developed to be a close memorial for nurses and to clinical skills. This result in agreement regulate the nursing performance with several studies that indicate that nurses seek learning opportunities as a way of remaining motivated within their professional careers ١١, ١٣. Also it was reported that educational intervention facilitate critical reflection on nurses work; encourage problem-solving; and heighten awareness of communication with patients and with colleagues. ١٣ Conclusion and recommendations The study concluded that training program is important for nurses who are working in tuberculosis management. This program positively improved ether knowledge especially regarding the aspect of nursing roles. The nurses who attended the program were highly satisfied with it and recommended to repeat such one regularly. The study recommended that: ١- Holding special programs on nursing role in tuberculosis management concerning tuberculosis. Referrences ١-Thomas Setefane Moloi, ٠٠٣. The provision of tuberculosis patient care: A Sociological perspective on primary health care nurses in the Qwa- Qwa district of the Free State. University of Pretoria etd- Moloi TS. - Ruth Carusa. ٠٠٣. Tuberculosis elimination and control: The role of primary care providers. Public Health Update. ٣- Ethel Leonor Noia Maciel, Maria Carmen Viana, Regina Celia Gomes Zeitoune, Ilce Ferreira, Gesisa Fregona and Reynaldo Dietze. ٠٠٥. Prevalence and incidence of mycobacterium tuberculosis infection in nursing students in Vitoria, EspiritoSanto. Revista da Sociedade Brasileira de Medecina Tropical ٣٨(٦):٤٦٩-٤٧. ٩

10 ٤- US Agency for International Development. ٠٠٥. Expanded Response to Tuberculosis Updated. ٥- WHO. ١٩٩٩. Tuberculosis infection control in the era of expanding HIV care and treatment.addendum to WHO Guidelines for the Prevention of Tuberculosis in Health Care Facilities in Resource-Limited Settings. ٦- Singla N, SharmaPP, Jain RC. Awareness about tuberculosis among nurses working in a tuberculosis hospital and in a general hospital in Delhi, India. IntJ Tuberc LungDis, ١٩٩٨Dec;(١):١٠٠٥-١٠ ٧- Julie Davidson and colleagues describe the use of the nominal group to obtain staff nurses' views of a two-year rational development programme. Staff nurse Africa.. Bull World Health Organ. ٠٠٥Apr; ٨٣(٤): ٥٠-٩ ٩- Beckford-Ball J. ٠٠٦. NICE guidelines to improve TB management and prevention. Nurs Times, ١٠(١٩):١٩-٠ ١٠- Claudia M, Smith RN. Contemporary problems in community health nursing In: Community Health Nursing Theory and Practice.١٩٩٥; ٥٩. Published in Philadelphia, London, Toronto, Sydney, Tokyo ١١- Louwagie GM, Bachmann MO, Reid M. ٠٠. Formal clinical primary health care training. Does it make a difference? Curationis, ٥(٤):٣-٧. ١- MessmerPR, JonesS, MooreJ, TaggartB, ParchmentY, HollomanF, QuinteroLM. ١٩٩٨. Knowledge, perceptions, and practice of nurses toward HIV\AIDS patients diagnosed development programme:evaluation. with tuberculosis, J Contin Edu Nurs.. Pediatric Nursing vol ١٧ no ٨ October ٠٠٥. ٨- Lewin s, Dick H, Zwarenstein M, LombardCJ. Staffing and ambulatory tuberculosis treatment outcomes: a cluster randomized controlled trial in South ;٩(٣):١١٧-٥. ١٣- Dick J, LewinS,Rose E, Zwarenstein M, Walt. H. ٠٠٤. Changing professional practice in tuberculosis care: An educational intervention. J Adv Nurs.:٤٨(٥);٤٣٤-٤. ١٠

11 Table١: Distribution of nurses according to their job characteristics Item Number ٥١ % Position Staff nurses ٤٥ ٨٨ Nursing supervisors ٦ ١١ ٨ Qualification Diploma ٣٩ ٧٦ ٥ Technical ٧ ١٣ ٧ Bachelor ٦ ١١ ٨ Years of experience Less than ٥ years ٠ ٣٩ ٥ to ١٠ years ١٨ ٣٥ ٣ More than ١٠ years ١٣ ٥ ٥ ٨ ٨± ٨ ١ Attending training program Yes ٣٠ ٥٨ ٨ No ١ ٤١ ٣ ١١

12 Table: Mean scores of nurses' knowledge regarding tuberculosis pre and post implementation of training program Item P Total scores Pre- test N=٥١ Post- test N=٥١ Definition of tuberculosis ٠ ٧± ٠ ٦٩ ١ ٥± ٠ ٧ ١١٤ ٣ Types of tuberculosis ١ ٠٠±٠ ٣ ١ ١±٠ ٤ ١٠ Risk factors of tuberculosis ١ ٠٠± ٠ ٤ ١ ١± ٠ ٧ ١٠ Causative agent ٠ ٠١٩±٠ ١ ٠ ٧± ٠ ٥ ١ ٣٤٠٠ Mod of transmission ١ ١± ٠ ٥ ١ ٥± ٠ ٦ ٣٦ ٤ Manifestation ٣ ٨± ١ ٦ ± ١ ٤ ٧ ٦٣ Types of treatment ٠ ٩٨± ٠ ٥ ١ ٣± ٠ ٦ ٣ ٦ Duration of treatment ١ ١± ٠ ٧ ١ ٧± ٠ ٦ ٥٤ ٥ Side effect of treatment ٧± ١ ٥ ٧ ± ٤ ١ ١ ١٦٦ ٦ Definition of DOTS strategy ٠ ٥± ٠ ٥ ٠ ٩± ٠ ٣ ١ ٨٠ Components of initial ١ ± ١ ٠٠ ٣ ٣± ١ ٩ assessment ٨ ١٧٥ Components of Follow up ٠ ٩± ٠ ٧ ٠ ٩± ٠ ٨ Nursing role ٦± ١ ٤ ٣ ٧± ١ ٨ ٧ ٤ ٣ Total knowledge scores ١٨ ١± ٤ ٥ ٣١ ١±٧ ٦ ٤٨ ٧١ ٨ Paired N=١٠ Paired T-test ٠ ٧٦± ٠ ٨١ ٦ ٧ ٠ ٠٠٠ ٣ ٩± ٠ ٥ ٠ ٥٣ ٠ ٥٩ ١ ٩± ٠ ٨١ ٠ ١٧ ٠ ٨٦ ٠ ٦٨± ٠ ٤٧ ١٠ ٥ ٠ ٠٠٠ ٠ ٤١± ٠ ٧٧ ٣ ٧ ٠ ٠٠٠ ٣± ١ ٧ ٩ ٧ ٠ ٠٠٠ ٠ ٣١±٠ ٧١ ٣ ١ ٠ ٠٠٣ ٠ ٦± ٠ ٨٥ ٤ ٥ ٠ ٠٠٠ ٥ ٥± ٤ ١ ٧ ٧ ٠ ٠٠٠ ٠ ٤± ٠ ٦٤ ٣ ٠ ٠٠ ١± ٧ ٣ ٠ ٠٠٠ ٠ ٠± ١ ١ ٠ ٠٠١ ٠ ١٠ ١ ١± ١ ٠٠ ٣ ٨ ٠ ٠٠٠ ١ ٩±٧ ١ ٨ ٠ ٠٠٠ ١

13 Table ٣: Distribution of nurse according to their satisfactory level of knowledge concerning tuberculosis Pre Post Item Number % Number % ٥١ ٥١ Definition of TB ٣ ٤٥ ١ ٣١ ٦٠ ٧ Types of TB ٥ ٩ ٨ ٧ ١٣ ٧ Risk factors ٧ ١٣ ٧ ١٥ ٩ ٤ Causative agent ١ ١ ٩ ٣٦ ٧٠ ٥ Mod of transmission ٩ ٥٦ ٨ ٤٠ ٧٨ ٤ Manifestation General manifestation ٣ ٦ ٧ ٤٦ ٩٠ ١ Chest manifestation ٤٣ ١ ٤ ٨ ٣ Treatment Types ٧ ١٣ ٧ ١٨ ٣٥ ٣ Duration ٠ ٣٩ ٣٩ ٧٦ ٥ Treatment Side effect Minor side effect ٩ ١٧ ٦ ٣ ٦ ٧ Major side effect ١٥ ٩ ٤ ٣٠ ٥٨ ٨ Definition of DOTS strategy ٧ ٥ ٩ ٣٦ ٧٠ ٥ Components of initial assessment ٨ ١٥ ٦ ٣ ٤٥ ١ Components of Follow up ٣ ٤٥ ١ ٦ ٥٠ ٩ Nursing role Initial visit ٧ ١٣ ٧ ٠ ٣٩ Follow up ١٦ ٣١ ٤ ٤ ٤٧ ١ ١٣

14 Table ٤: Distribution nurses of according to their knowledge concerning nursing role in tuberculosis management Before program After program Item Number Number X P % % ٥١ ٥١ Assessment ٦ ١١ ٧ ٣٥ ٦٨ ٦ ٩ ٣ ٠ ٠٠٠ Implementation of ٧ ٥ ٩ ٣٦ ٧٠ ٥ ٣ ٣ ٠ ٠٦٧ DOTs Health education ٤٤ ٨٦ ٣ ٤٥ ٨٨ ٠ ١٣ Follow up ٩ ١٧ ٦ ٣٣ ٦٤ ٧ ٣ ٣ ٠ ٠٠٠ ١٤

15 Table ٥: Satisfaction of nurses regarding the program Item Level of satisfaction Total N=٥١ (%) scores Disagree Agree Strongly agree Program achieved their expectations ١ (١ ٩ ) ١٩ (٣٧ ٣) ٣١ (٦٠ ٧) ١ ٥± ٠ ٥٤ (٧٥ V.G) Achieving Program objective ١(١ ٩ ) ٠ (٣٩ ) ٣٠ (٥٨ ٨) ١ ٥± ٠ ٥٤ (٧٥ V.G) Enough time ٥ (٩ ٨ ) ٣ (٤٥ ١) ٣ (٤٥ ١) ١ ٣± ٠ ٦٥ (٦٥% G) Coordinators competent ٠ ٩ (١٧ ٦) ٤ (٨ ٤) ١ ٨± ٠ ٣٨ (٩٠ E) Appropriate organization ٠ ١ (٣ ٥) ٣٩ (٧٦ ٥) ١ ٧± ٠ ٤ (٨٥ E) Appropriate scientific materials ٠ ١٣ (٤ ٥) ٣٩ (٧٦ ٥) ١ ٧± ٠ ٤٤ (٨٥ E) Appropriate place ٠ ١٤ (٥ ٥) ٣٦ (٧٠ ٥) ١ ٧± ٠ ٥ (٨٥ E) Total program evaluation ١٤ ١١ ٥± ٣ (٨ ١% V.G) Less than ٧٥ % = Good (G) ٧٥ = Very Good (V.G) ٨٥ = Excellent (E) ١٥