Cardiopulmonary resuscitation is the emergency procedure used to salvage victims of cardiac and respiratory arrest. It should be carried out with great urgency to avoid permanent brain damage or even death that would result if the victim stays from 4 to 6 minutes without oxygen.
To assess the effectiveness of structured teaching program on the knowledge and skills of cardio pulmonary resuscitation among the nursing staff in the Khartoum Teaching, Ahmed Gasim, Omdurman Teaching, and the Khartoum North Teaching hospitals.
A quasi experimental design pretest/posttest for the same group.The study was conductedin the intensive care units in Khartoum hospitals. The study sample consisted of 100 nurses. Data was collected by a questionnaire and an observational checklist. The intervention program was in a form of lectures guidelines book. Data were analyzed using Statistical Packages for Social Sciences (SPSS).
The study showed the knowledge grades before implementation of the program were, poor in 42%; good in 22% and very good in 36% of the participants. Whereas after implementation of the program knowledge grades became, 3% poor; 16% good and 81% very good, (p value 0.001). also the study revealed that, Nurses' skills before implementation program poor (57%) good (31%) very good (12%). Nurses' skills after implementation program poor (4%) good (18%) very good (78%), (P value 0.002).
The study concluded that educational program had a significant impact related to the improvement of the nurses’s knowledge and practice post application of the program.
Keywords:Training program, Knowledge, Practice,Nurses, Intensive Care Unit.
Cardio pulmonary resuscitation (CPR) is a combination of mouth to mouth rescue breathing and chest compressions. It helps to keep blood and oxygen circulating to the heart and brain of a person whose heart has stopped beating. The term CPR is used to describe all aspects of basic life support, the initial establishment and/or maintenance of airway, breathing, circulation, defibrillation and related emergency care [1]. Cardiopulmonary resuscitation is the emergency procedure used to salvage victims of cardiac and respiratory arrest. It should be carried out with great urgency to avoid permanent brain damage or even death that would result if the victim stays from 4 to 6 minutes without oxygen [2]. According to the World Health Organization (WHO) in 2008, 17 million people (48% of all deaths) died due to cardiovascular diseases, and mainly because of cardiac arrest [3]. It has been documented that 33% to 40% of cardiac arrests in developed countries occur in the hospital setting, and of the arrests that occur in the hospital setting more than 60% are first recognized by nurses (WHO, 2009). Therefore, in order to ensure patient survival, nurses who are often the first responders in resuscitation should be adequately prepared to provide effective advanced cardiac life support (ACLS) [4]. Nurses must improve their skill with training and repeated practice. For this reason, nurses must learn this skill, especially in their first aid lectures during nursing education. This training must be repeated, as studies have shown that the current level of CPR knowledge and skills is insufficient, and that there is a significant decrease in knowledge and skill retention of skills after a while. The training must be repeated after a specific period of time. If the skills are not used frequently, they can be forgotten over a short amount of time. CPR skills need to be maintained and practiced regularly. Repeating the CPR training will prevent the loss of knowledge and skills. [5]
The methods begin by presenting the research design, followed by setting and duration of the study, sample, sample size, data collection technique and tools, phases of the study, validity and reliability of instruments and ethical consideration.
A Quasi-experimental study: pretest and posttest for the same group.
Four hospitals were (Khartoum Teaching Hospital, Ahmed Gasim Hospital, Omdurman Teaching Hospital and Khartoum North Teaching Hospital chosen for this study, Khartoum state, Sudan.
Nursing staff providing the patients nursing services in the intensive care unit in Khartoum Teaching hospital, Ahmed Gasim Hospital, Omdurman Teaching Hospital and the Khartoum North Teaching Hospital.
The recommended sample size given by the total coverage of nurses. So the total numbers of participants were 100.
Two tools were used to collect the needed data to achieve the aim of the study, they were: a self-administered questionnaire for this assessment of knowledge and an observational checklist to assess practice.
The collected data as pretest and posttest organized, categorized, tabulated using mean and standard deviation. The statistical package for social sciences (SPSS version 20) was used for analysis.
Baseline survey was conducted.
Started from (July-October, 2016), the education was given through Lectures, vides, group discussion, booklets and seminars. The contents of the program were assigned to, include basic knowledge regarding nursing care of CPR.
Posttest was done twice early post interventions and later after three months’ post interventions. She was using the same tools to compare between pre and post intervention program which were conducted to evaluate the effect of the program on respondents.
Ethical Consideration
An official letter was taken from the National Al Ribat University to hospitals administrators for permission to carry out the study. Participants provided verbal consent to participate they have also been assured of confidentiality and of freedom to withdraw without conditions.
Total numbers of respondents were 100. The results of the present study are shown in figures and tables respectively:
| Statements |
|
|
|
|||||||
|
|
|
|
|
|
|
|
|
|||
| Verbally asked the patient “are you okay, shake gently | 50(50.0) | 0.50±0.50 | 91(88.0) | 0.91±0.29 | 0.06 | -0.52 | -0.30 | -7.1 | 198 | 0.002 |
| Call for help or activate emergency response system | 51(51.0) | 0.51±0.50 | 92(92.0) | 0.92±0.27 | 0.06 | -0.52 | -0.30 | -7.2 | 198 | 0.001 |
| Turn victim on to back while supporting head and neck. Place the victim on the floor | 50(50.0) | 0.50±0.50 | 95(95.0) | 0.95±0.22 | 0.05 | -0.56 | -0.34 | -8.2 | 198 | 0.003 |
| Use a head tilt and chin lift Maneuver | 50(50.0) | 0.50±0.50 | 76(76.0) | 0.76±0.43 | 0.07 | -0.39 | -0.13 | -3.9 | 198 | 0.001 |
| Place his/her ear over victim's mouth and observed the chest for rising with respiration | 42(42.0) | 0.42±0.50 | 92(92.0) | 0.92±0.27 | 0.06 | -0.61 | -0.39 | -8.8 | 198 | 0.005 |
| Listen, look and feel for breathing for 3-5 seconds | 40(40.0) | 0.41±0.49 | 92(92.0) | 0.92±0.27 | 0.06 | -0.63 | -0.41 | -9.2 | 198 | 0.003 |
| Pinch the victim's nostrils with thumb and index finger of the hand holding the forehead | 41(41.0) | 0.41±0.50 | 92(92.0) | 0.92±0.27 | 0.06 | -0.62 | -0.40 | -9.0 | 198 | 0.002 |
| Take a deep breath and place mouth around the client's moth with a tight seal | 47(47.0) | 0.47±0.50 | 94(94.0) | 0.94±0.24 | 0.06 | -0.58 | -0.36 | -8.5 | 198 | 0.006 |
| Ventilate two slow breaths. Each breath took 2 seconds to deliver | 50(50.0) | 0.50±0.50 | 94(94.0) | 0.94±0.24 | 0.06 | -0.55 | -0.33 | -7.9 | 198 | 0.002 |
| Pause between breaths allow for lung deflation and to take another deep breath | 49(49.0) | 0.49±0.50 | 93(93.0) | 0.93±0.26 | 0.06 | -0.55 | -0.33 | -7.8 | 198 | 0.003 |
| If the victim is breathing but still unresponsive turn on to side (recovery position) | 41(41.0) | 0.41±0.49 | 92(92.0) | 0.92±0.27 | 0.06 | -0.62 | -0.40 | -9.0 | 198 | 0.002 |
|
|
|
|
| Poor | 18 | 18 % |
| Good | 10 | 10 % |
| Very good | 72 | 72 % |
| Total | 100 | 100 % |
| Statements |
|
|
|
|||||||
|
|
|
|
|
|
|
|
|
|
||
| Method to open airway | 32(32.0) | 32(32.0) | 73(73.0) | 0.73±0.44 | 0.07 | 0.01 | 0.23 | 1.28 | 198 | 0.073 |
| The immediate responsibilityof the nurse after identifying cardiac arrest | 36(36.0) | 36(36.0) | 76(76.0) | 0.76±0.43 | 0.08 | 0.03 | 0.23 | 1.89 | 198 | 0.065 |
| Position of nose whileproviding mouth to mouth ventilation | 39(39.0) | 39(39.0) | 77(77.0) | 0.77±0.39 | 0.05 | 0.05 | 0.25 | 3.0 | 198 | 0.013 |
| Statements |
|
|
|
|||||||
|
|
|
|
|
|
|
|
|
|
||
| Observations by the nurse while providing mouth to mouth ventilation | 46(46.0) | 46(46.0) | 71(71.0) | 0.71±0.42 | 0.19 | 0.08 | 0.30 | 3.48 | 198 | 0.011 |
| The rate of breathing given fora minute during passive ventilation | 48(48.0) | 48(48.0) | 72(90.0) | 0.72±0.44 | 0.18 | 0.07 | 0.29 | 3.32 | 198 | 0.021 |
| Content of rescuer's exhaled air | 42(42.0) | 42(42.0) | 68(83.0) | 0.68±0.49 | 0.15 | 0.03 | 0.27 | 2.49 | 198 | 0.014 |
| The rate of artificial ventilationto prevent stomach inflations | 32(32.0) | 32(32.0) | 66(89.0) | 0.66±0.41 | 0.23 | 0.12 | 0.34 | 4.03 | 198 | 0.011 |
| The indication for pausebetween breaths | 36(36.0) | 36(36.0) | 74(86.0) | 0.74±0.39 | 0.12 | 0.01 | 0.23 | 2.13 | 198 | 0.034 |
| Statements |
|
|
|
|
|
|
|
|||
|
|
|
|
|
|||||||
| The correct location for placementof hands for chest compression | 51(51.0) | 0.51±0.50 | 70(70.0) | 0.70±0.48 | 0.17 | 0.06 | 0.28 | 2.98 | 198 | 0.013 |
| The correct position to bemaintained for giving prompt chest compression | 50(50.0) | 0.50±0.50 | 73(73.0) | 0.73±0.45 | 0.19 | 0.09 | 0.29 | 3.63 | 198 | 0.012 |
| The correct site of fingers duringperformance of external chest compressions | 50(50.0) | 0.50±0.50 | 73(73.0) | 0.73±0.45 | 0.19 | 0.09 | 0.29 | 3.63 | 198 | 0.023 |
| The pressure applied whileperforming external chest compression | 42(42.0) | 0.42±0.50 | 76(76.0) | 0.76±0.40 | 0.19 | 0.09 | 0.29 | 3.94 | 198 | 0.010 |
| The recommended externalchest compression for a minute | 40(40.0) | 0.40±0.48 | 59(59.0) | 0.59±0.50 | 0.17 | 0.04 | 0.30 | 2.60 | 198 | 0.020 |
| The length to which the sternummust be compressed downward during external chest compression in adults | 41(41.0) | 0.46±0.49 | 60(60.0) | 0.60±0.49 | 0.23 | 0.11 | 0.35 | 3.71 | 198 | 0.014 |
| The ratio of chest compression andpassive ventilation for 1 rescuer technique | 47(47.0) | 0.47±0.50 | 60(60.0) | 0.60±0.49 | 0.23 | 0.11 | 0.35 | 3.71 | 198 | 0.023 |
| The means to perform externalchest compression in CPR stimulates or improve of circulation | 50(50.0) | 0.50±0.50 | 73(73.0) | 0.73±0.42 | 0.1 | -0.02 | 0.22 | 1.71 | 198 | 0.089 |
| The amount of blood ejected fromthe heart by external chest compression in CPR | 49(49.0) | 0.49±0.50 | 71(71.0) | 0.71±0.49 | 0.16 | 0.05 | 0.27 | 2.82 | 198 | 0.015 |
|
|
|
|
|
||
|
|
|
|
|
||
|
|
57 | 57% | 8 | 8% |
|
|
|
31 | 31% | 22 | 22 % | |
|
|
12 | 12% | 70 | 70 % | |
|
|
100 | 100% | 100 | 100 % | |
In this study 100 nurses were selected to participate in the program. At baseline average level of knowledge about CPR of the participants was found to be very low (37%) due to their younger age and recent duration of graduation. This percentage increased to 86% at posttest (Figure 1) with slight decrease at late post program test to 72% (table16). The baseline ―poor‖ grade (42%) at increased posttest by 81% as very good (Figure 2), then the ―very good‖ grade of knowledge slightly declined to (72%) (table 2). This study is similar to study conducted at Botswana in 2014 assessing the cardiopulmonary resuscitation knowledge and skills[6]. The meaning of the overall knowledge score of 0.63 increased to 0.86 indicating significant differences (p < 0.05) in the level of knowledge of the participants regarding all items of CPR after the carrying out of the program; this in turn demonstrated that the program had good outcome on the studied nurses. Nevertheless, the slight decrease in the overall knowledge of the participants (86% to 72%) observed at the late post program test was not significant (p > 0.05) (Tables 3-5). This finding could be explained by the fact that at an early implementation program the information given to the participants were still fresh and at the late post program test the participants may be engaged in other activities that contribute to this slight decrease in their knowledge regarding the dimensions of CPR. Many of the previous studies proved the effectiveness of conduction of educational programs to provide the nurses with knowledge about many of the medical issues related to critical cases and chronic disease that in turn increased their competence and abilities to know more and more about the cases under their nursing supervision. An Egyptian study[7] by revealed that the mean knowledge scores of nurses are increased immediately after implementation of the program with a significant statistical difference. This increased level slightly decreased post three months of program application. Another study from Basra[8] proved that application of teaching program significantly increased the nurses' knowledge about issues of cardiac arrest. However, a study in Bahrain [9] showed that the cognitive knowledge was not adequately retained. Fifty-eight per cent of respondents perceived recalling CPR information as easy or extremely easy. The last study unlike our study where the program only improved the knowledge of minor proportion of the studies nurse. Concerning Practices: At baseline average level of practices of the participant toward patients with CPR was reported by (42%) of them and their overall grade were poor (57%), which increased at the early post program test to (82%) and (78%) respectively (Figures 3 and 4). Slight decrease in both score and grade of practice were reported by 77% correct practice and 70% very good grade of practice at late post program test (table 6). This study is similar to the study conducted at Al Basra (Iraq) General Hospital[8]. Regarding the practices of the participants on the initial steps in care of the patients with cardiac arrest, the findings of our study detected significant increase (p < 0.05) (Tables1) in the level of the practices of the nurses after attendance of the program, that means the program showed positive impact on the participants, which was reflected on the clear improvement in their correct application of the initial steps and procedures of compression for the patients with cardiac arrest. The results of this study were in the same line with other previous studies, one study from India (10). showed that practices of nurses on CPR was significantly improved with training based on educational program. Two other studies in Egypt [7]. Showed significant improvement in our nurses` practices regarding application of initial steps of care of patients with cardiac arrest as well as procedures of compression. Being at the heart of the health care delivery is an enormous challenge for nursing, but it is also a golden opportunity to save the life of the patient. A high level of knowledge and skill of CPR is expected from all participants to save the lives of the unfortunate victims of cardiac arrest.
According to the study findings the researcher concluded that: An early evaluating post training program test revealed a significant improvement of both knowledge and practice of the participating nurses. A late (three months) post program assessment to assess the retention of the already gained knowledge and practice demonstrated a little drop in their level.
We thank the administration and staff of the four hospitals, Khartoum Teaching Hospital, Ahmed Gasim Hospital, Omdurman Teaching Hospital and the Khartoum North Teaching Hospital for their enthusiastic support and cooperation throughout this study.
Chew DP, fcsanza cna, fracpb pea, kelly a-m, mclined f, white hd. 2011 addendum to the national heart foundation of australia/cardiac society of australia and new zealand guidelines for the management of acute coronary syndromes (acs). Clinical trials. 2006, 2011, 4, 2006, 6.
Dwood SB, Al-Mosawi HS, Khudhair AS, Al-Mussawi AA. Evaluate of effectiveness of planned teaching programmer regarding basic life support (BLS) among Nursing Staff in Basra General Hospital. Int J Nurs. 1(2), 2014, 155-66.
Dal U, Sarpkaya D. Knowledge and psychomotor skills of nursing students in North Cyprus in the area of cardiopulmonary resuscitation. Pakistan Journal of Medical Sciences. 29(4), 2013.
Bennett D, Bion J. ABC of intensive care: organisation of intensive care. BMJ: British Medical Journal. 318(7196), 1999, 1468.
Hamilton R. Nurses‘ Knowledge and skill retention following cardiopulmonary resuscitation training: a review of the literature. Journal of advanced nursing. 51(3), 2005, 288-97.
Rajeswaran L, Ehlers VJ. Cardiopulmonary resuscitation knowledge and skills of registered nurses in Botswana. curationis. 37(1), 2014, 1-7.
Chaudoir SR, Dugan AG, Barr CH. Measuring factors affecting implementation of health innovations: a systematic review of structural, organizational, provider, patient, and innovation level measures. Implementation Science. 8(1), 2013, 22.
Neuendorf KA. The content analysis guidebook: Sage; 2016.
Barnes S, Gardiner C, Gott M, Payne S, Chady B, Small N, et al. Enhancing patient professional communication about end-of-life issues in life-limiting conditions: a critical review of the literature. Journal of pain and symptom management. 44(6), 2012, 866-79.
Waters D, Theodoratou E, Campbell H, Rudan I, Chopra M. Optimizing community case management strategies to achieve equitable reduction of childhood pneumonia mortality: An application of Equitable Impact Sensitive Tool (EQUIST) in five low–and middle–income countries. Journal of global health. 2(2), 2012.