Untitled

Minia Scientific Nursing Journal (Print - ISSN 2537-012X) (Online - ISSN 2785-9797) Vol. (8) No.
(1) December 2020

Content:
Research \ Authers Pages
1. Assessment of pediatric nurses' performance regarding intravenous Therapy 3
Nagwa Ibrahim Mohamed (1), Sanaa Mahmoud Ahmed (2), Asmaa Hamed Tawfic )3)
2. Assessment of Applying Clinical Audit for Pregnant Woman with Iron Deficiency Anemia. 15
1 Yasmeen Mohammed Badry 2 Nadia Abdallah Mohammed 3 Naglaa Mohammed Amein
3. Effect of educational nursing guideline about paracentesis procedure care on nurses' 21

performance
Eman Samir Fahmy 1, Hayah Abou Elazayiem Bayomi 2, Rokaia Fathi Mohamed 3
4. Assessment of Knowledge, Beliefs and Level of Internet Addiction among Nursing Students at 30
Minia University
Shimaa Abd El-Razek Younis1, Eman Mohamed Mahfouz 2, Yosria El-Sayed Hossien3
5. Assessment of Knowledge and Attitude among Faculty of Nursing Students Regarding Blood 39
Donation
1,Asmaa Yehia Youssef Ezeldain 2, Yosria El-Sayed Hossein3, Eman Sameh Mohammed, 4 Naglaa
Mohammed Amein 4
6. Effect of Educational Program on Women's Awareness and their health status regarding 48
antenatal Exercises
Hend Shabaan Refaey1; Ekbal Abd El Rehem Emam 2; Essa Mahmoud Mohamed 3 Amany Hassan Abd
Elrahim
7. Assessment of Pain Intensity among Preschool-age Children during Venipuncture 56

1Yahia Mohamed Sayed; 2 Soheir Abd-Rabou Mohamed; 3 Nagat Farouk Abolwafa
8. Knowledge and Performance of Mothers Having Children with Cancer Undergoing 65

Chemotherapy
1El Shaima Gamal Hasan; 2 Soheir Abd-Rabou Mohamed; 3 Sanaa Mahmoud Ahmed; 4 Khalid Fathy
Riad 5Aml Sayed Ali
9. Effect of Kegel Exercise on Improving Manifestations of Uterine Prolapse among Pre 75

menopausal Women
Shaimaa Gamal Ramadan Hassan 1, Manal Farouk Moustafa 2, Hoda Abd Elazim Mohamed 3, Ahmed
Samier Abd El-Malek
10.Relationship between Self-Esteem and Aggressive behavior among Foster Care Children at 83
Minia Governorate, Egypt
Sherifa Rabea Mohamed 1,, Nefissa Mohammed Abd El-Kader2, Hanan Ibrahim Abd EL Aziz 3, Fatma
Nagy Kotb 4
11.Early Identification of Risk Factors for Primary Postpartum Hemorrhage at Admission 90

Doaa Maged Khalf1, Hoda Abd El-Aziam Mohmed2; Abdelrahman Hegazy Abdelwahab3
12.Effect of immediate pain management on oxygenation level among early extubation patients post 96
heart surgery
Mona Sayed Elgazar, Inshrah Roshdy Mohammed, Yasser Shaban Mubarak, Marwa M. Abdelbaky,
13.Effect of Educational Program on Nurses Performance about Colostomy Care 103

Hanaa Abd El-latief shahat Ali, Jehan Sayyed Ali, Sahar Hamza Taha.
14.Nurse’s knowledge and Practice regarding Medication Errors in Critical Care Units: Descriptive 111
study
Al Shaimaa Moustafa Fathy1, Nahla Shaaban Khalil2, Naser Mohamed Taha3, Marwa M.Abd-elbaky4
15.Application of Modified Ventilator Bundle and Its Effect on Weaning Among Mechanically 121
Ventilated Patients
Amany Sayed Eweas1, Sahar Yassien Mohammad 2, Jehan Sayyed Ali Sayyed 3, Marwa Mohammad Abd
Elbaky 4 Magda Mohammad Bayoumi 5
P a g e |1
Minia Scientific Nursing Journal (Print - ISSN 2537-012X) (Online - ISSN 2785-9797) Vol. (8) No. (1) December 2020
Research \ Authers Pages
16.Effect of Preoperative Nursing Protocol on Pain and Daily Activities for Post Inguinal Hernia 130
Repair Patients
Eman Abdelmobdy Ali 1, Islam Ibrahim Ragab 2, Mohammed Abdel Shafy Mohammed3, Rokaia Fathi
Mohamed 4
17.Correlation between the patients with Hepatitis C Virus and their Health-Related Quality of Life 139
Ola Omer Abd ElHamied 1; Hala Ibrahem Mohamed 2; Hend Elham Mohamed 3; Eman Fadl Abd
Elkhalik 4
18.Effectiveness of Teaching Program on Awareness Regarding the Minor Discomfort Problems 147
among Pregnant Women
1Hager Abdalalla Hashem; 2Ekbal Abdel Reheem Emam; 3Amany Hassan Abd Elrahim
P a g e |2
Assessment of pediatric nurses' performance regarding intravenous Therapy
Nagwa Ibrahim Mohamed (1), Sanaa Mahmoud Ahmed (2), Asmaa Hamed Tawfic )3)
1. Bsc.inNursing,FacultyofNursing,MiniaUniversity
2. Assistant Professor of Pediatric Nursing, Faculty of Nursing– Minia University
3. Lecturer of Pediatric Nursing, Faculty of Nursing Minia University–MiniaUniversity
Abstract
Background: Intravenous therapy is an important part of the treatment of many hospitalized patients. Fluid and
electrolyte therapy is an essential component of the care of hospitalized children. The aim of this study is to assess
pediatric nurses' performance regarding intravenous therapy in Minia University hospital and Minia General Hospital.
Design: Descriptive research design was used for this study. Setting: This study was conducted at Minia University
for Pediatrics and Obstetrics Hospital and Minia General Hospital affiliated to the Ministry of health and population.
Subjects: A convenient sample consisting of 58 nurses who were divided into 29 nurses from the pediatric and
emergency department at Minia University Pediatrics and Obstetrics Hospital as well as 29 nurses from the pediatric
and emergency department at Minia General Hospital over six months were included. Tools of data collection: Three
tools were included for data collection; Tool І: A structured interview questionnaire sheet in an Arabic language. It
consisted of two parts: Part 1: personal data of nurses as age, qualifications, years of experience, and previous
training courses. Part 2: Knowledge assessment sheet: it contained 30 close-ended questions to assess nurse's
knowledge about nursing care regarding insertion, maintenance, and removal of the intravenous line. Tool II:
Observational checklist sheet was developed by the researcher to assess the nurses' practices for intravenous therapy it
contained 12 procedures (149 steps) Tool III: Nurses' attitude regarding intravenous therapy. More than half of nurses
in Minia University Hospital (MUH) and 44.8% of them in Minia General Hospital (MGH) had incomplete
knowledge regarding intravenous therapy with high statistical significance differences P-value .006. Also, more than
two-thirds of nurses in MUH and 51.7% of them in MGH had incomplete practice regarding intravenous therapy with
no statistical significance differences P-value .117. Conclusion: These results concluded that one third of nurses
worked in Minia University Hospital had very good knowledge and 10.3% of them had complete practice than a few
of nurses worked in Minia General hospital but more than three quarters of nurses in Minia general hospital had
positive attitude regarding intravenous therapy with statistically significant difference which P-value 0.04.
Recommendations The education program should be applied and repeated every 3 months in the same study setting
and adopted in other similar settings with necessary modifications, the provision of continuing education programs is
suggested regularly to refresh and update the knowledge of nurses, as well as to reinforce appropriate practices in
pediatric units related to intravenous therapy with continuous supervision.
Keywords: Pediatric Nurses, Nurses' Performance, Intravenous Therapy
Introduction Nurses play a vital role in the administration of

Intravenous therapy (IV) is an important part of the intravenous therapy. Most of the interventions and prevention
treatment of many hospitalized patients. IV solutions are strategies such as insertion, monitoring and assessing peripheral
medications. Administration of medications is part of the venous catheter (PVC) sites are part of routine nursing care.
controlled acts authorized to nursing. It is the nurse’s Nurses should have accurate knowledge of the preparation and
responsibility to ensure that the patient receives the ordered administration of the IV Infusion and IV device. In addition, they
solution and additives at the ordered rate. The extravasation of any should also know about the prevention, treatment, and
IV fluid can cause serious permanent harm. Hourly checks are to management of local and systematic complications supported by
identify extravasation early (Hoste et al., 2014). dynamic evidence‐based practice guidelines. One of the major
Intravenous solutions often have similar packaging; risks for phlebitis incidence is due to the placement and
therefore, great care is required in selecting the right intravenous maintenance of PVC by insufficiently trained staff
solution. Particular care is required if the patient has more than one (Mohammed & Ahmed, 2017).
IV line or pump to ensure that lines are not mixed up. When an IV
bag is changed or if medications are being added to one of the Significance of the study
lines, the line must be tracked right back to the solution container Peripheral intravenous (PIV) therapy is one of the most
to verify that the additive is being added to the correct line frequently used therapeutic interventions in the acute care setting.
(Palomo et al., 2015). In the acute care pediatric setting, starting and monitoring
Intravenous infiltration can lead to problems like intravenous (IV) therapy is challenging and poses a significant risk
discomfort, the need for reinsertion of the intravenous catheters to small infants and children (De Lima Jacinto, et al., 2011),
which associated with pain and anxiety from repetitive failed (PIV (Walsh &Schad, 2012).
) insertion attempts, or compartment syndrome, which can A vein cannula has direct access to the patient vascular
increase not only the period of hospitalization and medical system and is a potential route for micro-organisms to enter
expenses for treatment but also permanent damage in children. bypassing the skin and in connection with drugs and /or fluids
These problems can lead to prolonged hospitalization, increased given. Despite this factual information, Studies indicated that
medical costs, higher mortality, and greater morbidity nurses do not regularly assess the peripheral intravenous cannula
(Flippo & Lee, 2011). and are frequently unaware of complications (Zhang et al,
2016). Peripheral intravascular (PIV) complications were reported
P a g e |3 Nagwa I., et al
at rates as high As 28% in children compared to 8.5% in adults.
Furthermore, infants and children pose challenges to optimal PIV Scoring system of nurses' knowledge:
management because of their limited communication abilities, Scoring system for knowledge of the studied nurses
unpredictable behavior and activity levels, and small vessel sizes was calculated as the following:
(Flippo & Lee, 2011) All knowledge variables were weighted as (2) for the
Children are particularly vulnerable to these PIV- complete correct answer and (1) for an incomplete correct
induced complications. Several studies have suggested that a answer and, (0) for choosing don’t know or incorrect answer.
dedicated IV therapy team may reduce catheter-related The total score of nurses’ knowledge was 60.
complications by standardizing catheter insertion technique, The nurses’ total knowledge score was classified as
inspecting catheter sites daily, and rotating catheter sites within 72 the following:
hours of placement (CDC 2013).  Very good: (≥75%)
 Good: (50 - < 75%)
Aim of the study  Poor: (<50%).
This study aimed to
Assess pediatric nurses' performance regarding Tool II
intravenous therapy at Minia University Hospital and Minia Observational checklist sheet was developed by the
General Hospital. researcher that was adopted from Terese and Marlene,(2010),
Patricia and Anne,(2008) to assess the nurses' practices for
Research questions intravenous therapy it contained 12 procedures (149 steps) as
 What is the nurses' performance as regards insertion, infection control (10 steps), hand washing (19 steps), wear
maintenance, and removal of intravenous line to personal protective gloves (32 steps), insertion I.V
children in Minia university hospital and general cannulation (16 steps), removal I.V cannulation (9 steps), I.V
hospital? fluid preparation (9 steps), administration of I.V fluid drug
 What are the differences between pediatric nurses' infusions (7 steps), administration of blood products (7
performance at Minia University Hospital and Minia steps), flushing of PIVC's (9 steps), IV fluid considerations
General Hospital? via peripheral IV line (12 steps), change of PIVC dressing and
securing of cannula (11 steps), and management of I.V
Research Design therapy complications (8 steps).
The descriptive study design was used for this study
Scoring system of nurses' practice
Setting: Scoring system for practicing nursing care was
This study was conducted in pediatric and emergency calculated as the following:
departments at Minia University for Pediatrics and Obstetrics Performances step was weighted as 0 for not done, 1
Hospital and Minia General Hospital affiliated to the Ministry for incomplete done, and 2 for completely done. The total
of health and population. score of nurses’ practice was 298.
Subjects The nurses’ total practice score was classified as:

A convenient sample consisting of 58 nurses (29 of  Complete: (≥75%)
nurses were from the pediatric and emergency departments in  Incomplete: (50- < 75%)
Minia University for Pediatrics and Obstetrics Hospital and 29  Not done: (<50%).
of them were from the pediatric and emergency departments at
Minia General Hospital and over six months. Tool IIІ
Nurses' attitudes regarding intravenous therapy: it
Data Collection Tools contained 10 items by using the Likert scale includes three
Three tools were included for data collection points as agree, uncertain, and disagree. Their attitude as the
Tool I first line of nursing management for intravenous therapy, wear
A structured interview questionnaire sheet in the gloves is the first step in the insertion of the cannula, if
Arabic language to gather data of the studied sample and intravenous cannula inserted incorrectly, removed it and try
designed by the investigator after an extensive review of again, etc.
related literature and the consultation of the experts in the
field of pediatrics and pediatric nursing. Scoring system of nurses' attitude
Scoring system Nurses' attitude regarding
It consisted of two parts intravenous therapy was calculated as the following:
 Part 1: Personal data of nurses: it contained 4 items All attitude variables were weighted as (0) score for
of selected personal items about nurses as age, disagree, (1) score for uncertain, and (2) score for agreeing.
qualifications, years of experience, and previous The total score of the nurses’ attitude was 20.
training courses. The nurses’ total attitude score was classified as the
 Part 2: Knowledge assessment sheet: it contained 30 following:
questions. Questions in form of close-ended to assess  Positive: > 60%
nurse's knowledge about nursing care as regards  Negative: ≤ 60%
insertion, maintenance, and removal of the
intravenous line to children and the different
intravenous therapy complication which might occur
to children.
Validity and Reliability informed that the information obtained will be confidential
The content validity of the data collection tool was and will be used be only for the study. Each assessment sheet
examined by five experts who were affiliated to the Faculty of was coded and nurses’ names didn’t appear on the sheets for
Nursing, Minia, and Assuit University at the Pediatric Nursing anonymity and confidentiality.
Department. The tool was examined for content coverage,
clarity, relevance, applicability, wording, length, format, and Data Collection Procedure
overall appearance. Based on experts` comments and Administrative approval was obtained from the ethics
recommendations; minor modifications had been made such committee, faculty of nursing, Minia University. Official
as rephrasing and rearrangements of some sentences. permission was obtained from the concerned hospital
Internal consistency was measured to identify the authorities to conduct the study after explaining the aim and
extent to which the items of tools measure the same concept nature of the study. The researcher was interviewing with
and correlated with each other. Internal consistency estimate nurses. At that time, the purpose and nature of the study were
reliability by grouping questions in the questionnaire that explained by the researcher through direct personal
measure the same concept. Cronbach’s alpha for reliability communication before starting to participate in the study and
testing internal consistency was performed for each section of then the data collection.
the structured interview questionnaire and the results were Nurses' knowledge, practice, and attitude regarding
0.750, 985, and 0.70 for nurses' knowledge, practice, and intravenous therapy were assessed by using the structured
attitude regarding intravenous therapy respectively. interview questionnaire and observational checklist. The
interview took place in the pediatric and emergency
Pilot study departments at Minia University for Pediatrics and Obstetrics
Random selection of 10% (5 nurses) of the total Hospital and Minia General Hospital. The interview
number of nurses to investigate and ensure the feasibility, conducted for all nurses to fill the personal data and to assess
objectivity, applicability, clarity, adequacy, and to determine their knowledge regarding intravenous therapy by using a
possible problems in the methodological approach or structured interview questionnaire. The time taken to conduct
instrument. The results of the pilot study were used to test the the structured interview questionnaire for each nurse was
proposed statistical and data analysis methods. The tools were ranged from 20 to 30 minutes and nurses' practice done by the
completed without difficulty, adding support to the validity of observational checklist and consumed 30- 45 minutes at a rate
the instrument. Little modification was done e.g. rephrasing of 3 to 5 nurses/ week. Data collection was conducted over six
and rearrangements of some sentences. The time required for months extending from May 2019 up to October 2019.
completion of the interview questionnaire didn’t exceed 30
minutes. Nurses involved in the pilot study were included in Statistical analysis
the main study sample. Pilot testing helped the investigator The collected data were tabulated & statistically
plan for data collection. analyzed using the software program and statistical package
for social science (IBM SPSS 25.0) to evaluate nurses under
Ethical consideration study. The statistical analysis included percentage (%), mean,
For ethical consideration, and approval was obtained stander deviation (SD) and Chi-square ( ).Chi-square ( )
from the faculty of the nursing ethical committee and official was used to test the association between two qualitative
permission was obtained from the director of the Minia variables. Fisher's exact test used to test the association
University for Pediatrics and Obstetrics Hospital and Minia between two qualitative variables and the sample size is small.
General Hospital, and permission from the head of pediatric Quantitative continuous data were compared by using a t-test
and emergency departments after explaining the aim and in case of comparisons between the mean scores of the two
nature of the study. Nurses’ were interviewed on an individual groups. Graphs were done for data visualization using
basis to explain the nature and purpose of the study. Microsoft Excel. The P-value of ≤ 0.05 indicates a significant
Oral informed consent was obtained by the researcher from result while P-value of > 0.05 indicates a non-significant
the nurses before data collection after full explanation for the result
aim of the study, benefits, and rights for privacy. They also
Results
Table (1) Number and Percentage Distribution of The Studied Nurses According to Their socio-demographic data (n= 58).
MUH MGH Total
Personal data (n= 29) (n= 29) (n= 58)
No. % No. % No. %
Marital status
Single 6 20.7 8 27.6 14 24.1
Married 20 69.0 18 62.1 38 65.5
Divorced 3 10.3 3 10.3 6 10.3
Age/ years
Less than 20 6 20.7 1 3.4 7 12.1
20- < 30 16 55.2 23 79.3 39 67.2
30- 40 7 24.1 5 17.2 12 20.7
Mean ± SD 25.4 ± 6.0 25.7 ± 5.3
Educational level
Secondary nursing school 11 37.9 6 20.7 17 29.3
Health institute 13 44.8 11 37.9 24 41.4
B.Sc 5 17.2 8 27.6 13 22.4
Master 0 .0 4 13.8 4 6.9
Years of experience
MUH MGH Total
Personal data (n= 29) (n= 29) (n= 58)
No. % No. % No. %
Less than 5 years 8 27.6 16 55.2 24 41.4
5-< 10 12 41.4 6 20.7 18 31.0
10- <15 9 31.0 7 24.1 16 27.6
Mean ± SD 6.2 ± 3.9 6.4 ± 4.0
Attendance previous training
Yes 14 48.3 9 31.0 23 39.7
No 15 51.7 20 69.0 35 60.3
Table (1) shows that 69.0 % of the studied nurses in MUH and 62.1% of them in MGH were married. Regarding the age
group from 20 - < 30 the table shows that 55.2 %, 79.3% of nurses in MUH, and MGH with mean ± SD 25.4 ± 6.0 and 25.7 ± 5.3
years respectively. As the educational level, 44.8% and 37.9% of the studied nurses in MUH and MGH are technical institute nurses.
Less than half 41.4 % of nurses in MUH had experience from 5 < 10 years while 55.2% of them in MGH had experienced less than 5
years. In addition, 51.7% of nurses in MUH and 69.0% of them in MGH didn't attend previous training about intravenous therapy.
Table (2): Relation Between Studied Nurses in Minia University Hospital (MUH) and Minia General Hospital (MGH)
According to Their Total and Subtotal Knowledge Regarding Intravenous Therapy (n= 58).
MUH MGH Total
Total knowledge levels (n= 29) (n= 29) (n= 58) X2 P-valu e
No. % No. % No. %
General knowledge
Very good 15 51.7 7 24.1 22 37.9
5.195 .05*
Good 10 34.5 18 62.1 28 48.3
Poor 4 13.8 4 13.8 8 13.8
Preparation for cannulation
Very good 10 34.5 5 17.2 15 25.9
Good 14 48.3 12 41.4 26 44.8
4.703 .05*
Poor 5 17.2 12 41.4 17 29.3
During cannulation
Very good 18 62.1 8 27.6 26 44.8
Good 9 31.0 19 65.5 28 48.3
Poor 2 6.9 2 6.9 4 6.9 7.418 .025*
After cannulation
Very good 11 37.9 6 20.7 17 29.3
Good 13 44.8 6 20.7 19 32.8
Poor 5 17.2 17 58.6 22 37.9 10.595 .005**
Prevention and Complications of Intravenous Therapy
Very good 19 65.5 11 37.9 30 51.7
Good 10 34.5 18 62.1 28 48.3 4.419 .036*
**Highly statistical significance differences
Table (2): shows that 51.7% of nurses in MUH and 24.1% of nurses in MGH nurses had poor general knowledge regarding
intravenous therapy, 34.5% of nurses in MUH and 17.2% of nurses in MGH nurses had poor knowledge about how to prepare for
cannulation, 62.1% of nurses in MUH and 27.6% of nurses in MGH nurses had poor knowledge related to cannulation, 37.9% of
nurses in MUH and 20.7% of nurses in MGH nurses had poor knowledge about steps after cannulation and 65.5% of nurses in MUH
and 37.9% of nurses in MGH nurses poor in how to prevent complications of intravenous therapy with statistical significance
differences P-value .05, .05, .025, .005, .036 respectively.
51.7%
60.0% 44.8% 44.8%
34.5%
40.0%
20.7%
20.0% 3.4%
0.0%
Poor Good Very good
MUH MGH
Figure (1): Between the Studied Nurses in Minia University Hospital (MUH) and Minia General Hospital (MGH) According
to Their total Knowledge Regarding Intravenous Therapy (n= 58).
Figure (1): illustrates that 3.4% of nurses in MUH compared to 34.5% of them in MGH had poor knowledge regarding
intravenous therapy with highly statistical significance differences P-value .006
Table (3): Relation Between Studied Nurses in Minia University Hospital (MUH) and Minia General Hospital (MGH)
According to Their Practice Regarding Correctly performance (n= 58).
MUH MGH Total
(n= 29) (n= 29) (n= 58) X2/ Fisher P-value
Items No. % No. % No. % test
1. Infection control 3 10.3 8 27.6 11 19.0 2.831 .243

2. Hand washing 3 10.3 3 10.3 6 10.3 .719 .698
3. PPE (gown & gloves) 23 79.3 15 51.7 38 65.5 4.884 .087
4. I.V cannulation 4 13.8 4 13.8 8 13.8 8.420 .015*
5. I.V fluid 15 51.7 8 27.6 23 39.7 3.551 .169
6. Blood products 16 55.2 14 48.3 30 51.7 2.333 .311
7. Flushing of PIVC’s 12 41.4 9 31.0 21 36.2 2.518 .284
8. Fluid Considerations via Peripheral IV line 9 31.0 7 24.1 16 27.6 .404 .817
9. Change of PIVC dressing and securement of 18 62.1 12 41.4 30 51.7 3.771 .152
cannula
10. Management of I.V therapy complications 21 72.4 15 51.7 36 62.1 2.933 .231
* Statistically significance differences **Highly statistical significance differences
Table (3) presents that, 10.3% of studied nurses in MUH and 27.6% of studied nurses in MGH applied infection control
during I.V preparation. 10.3% of studied nurses in MUH and 10.3% of nurses in MGH wash hands before I.V preparation. 79.3%,
51.7% of studied nurses in MUH, and MGH applied PPE. 13.8%, 13.8% of studied nurses in MUH, and MGH applied I.V
cannulation with statistically significant differences which P-value 0.015.
51.7%, 27.6% of studied nurses in MUH, and MGH administered I.V fluid correctly. 55.2% of studied nurses in MUH and
48.3% of nurses in MGH administered blood products correctly. 41.4%, 31.0% of studied nurses in MUH, and MGH flushed of
PIVC's. 31.0% of studied nurses in MUH 24.1% of nurses in MGH done completely fluid considerations via Peripheral IV line.
62.1%, 41.4% of studied nurses in MUH and MGH changed of PIVC dressing and securement of cannula correctly and 72.4% of
studied nurses in MUH and 51.7% of nurses in MGH managed of I.V therapy complications
69.0%
70.0%
51.7%
60.0% 44.8%
50.0%
40.0%
20.7%
30.0%
10.3%
20.0%
3.4%
10.0%
0.0%
Not done Incomplete Complete
MUH MGH
Figure (2): Comparison Between the Studied Nurses in Minia University Hospital (MUH) and Minia General Hospital
(MGH) According to Their Total Practice Levels Regarding Intravenous Therapy (n= 58).
Figure (2): illustrates that 69.0% of nurses in MUH and 51.7% of them in MGH had incomplete practice regarding
intravenous therapy with no statistical significance differences P-value .117
Table (4): Relation Between the Studied Nurses in Minia University Hospital (MUH) and Minia General Hospital
(MGH)According to Their Attitude Regarding Intravenous Therapy in (n= 58).
MUH (n= 29) MGH (n= 29) Total (n= 58) X2/ fisher P-value
Attitude Agree Disagree Agree Disagree Agree Disagree
No. (%) No. (%) No. (%) No. (%) No. (%) No. (%)
1-Explaining the patient's nursing 26(89.7) 3(10.3) 28(96.6) 1(3.4) 54(93.1) 4(6.9) 1.074 .30
procedure is the first step in introducing
the peripheral vein line?
2- Wearing gloves is the first step in 20(69.0) 9(31.0) 21(72.4) 8(27.6) 41(70.7) 17(29.3) .083 .773
cannula preparation.
3- When preparing to insert the needle 16(55.2) 13(44.8) 9(31.0) 20(69.0) 25(43.1) 33(56.9) 3.445 .063
into the skin, should the cross out be
down?
4- If you tried to enter the cannula and 21(71.4) 8(27.6) 17(58.6) 12(41.4) 38(65.5) 20(34.5) 1.221 .269
were not sure of the appropriate place,
would you remove the catheter and try
again?
5- After two failed attempts to enter IV, 14(48.3) 15(51.7) 13(44.8) 16(55.2) 27(46.6) 31(53.4) .069 .792
the best thing you can do is continue to
try until you get the vein?
6- It is very important when securing the 27(93.1) 2(6.9) 26(89.7) 3(10.3) 53(91.4) 5(8.6) .219 .640
axis of the cannula on the skin to ensure
that the tape does not cover the insertion
site?
7- The most important step when 24(82.8) 5(17.2) 23(79.3) 6(20.7) 47(81.0) 11(19.0) .112 .738
stopping intravenous therapy is
documenting the date and time and those
professionals who removed cannula from
the patient?
It is not necessary to wear gloves when 22(75.9) 7(24.1) 11(37.9) 18(62.1) 33(56.9) 25(43.1) 8.507 .004**
stopping IV because there is no risk of
exposure to blood or body fluids?
9- By maintaining sterilization, can acute 23(79.3) 6(20.7) 21(72.4) 8(27.6) 44(75.9) 14(24.1) .377 .539
IV complications be prevented?
10- The intravenous cannula must be 12(41.4) 17(58.6) 14(48.3) 15(51.7) 26(44.8) 32(55.2) .279 .597
removed according to the hospital's
policy without regard to any patient-
related reasons
* Statistically significance differences **highly statistical significance differences
Table (4): shows that, there were no statistically significant differences between nurses who are working in Minia University
Hospital (MUH) and those who are working in Minia General Hospital (MGH) regarding their Attitude about Intravenous Therapy
except statement about "not necessary to wear gloves in stops I.V therapy" about 75.9% of nurses who are working in Minia
University Hospital (MUH) compared to 37.9% of them in Minia General Hospital (MGH) said that they agree about this statement
with statistically significant differences which P-value .004
75.9%
80.0% 58.6%
60.0% 41.4%
24.1%
40.0%
20.0%
0.0%
Negative Positive
MUH MGH
Figure (3): Comparison Between the Studied Nurses in Minia University Hospital (MUH) and Minia General Hospital (MGH)
According to Their Total Attitude Levels Regarding Intravenous Therapy (n= 58).
Figure (3): illustrates that more than three quarters of nurses in Minia general hospital had positive attitude regarding
intravenous therapy with statistically significant difference which P-value 0.04.
Table (5): Relation between Personal Data of The Studied Nurses with Their Total Knowledge Levels Regarding Intravenous
Therapy in Minia University Hospital (MUH) and Minia General Hospital (MGH) (n= 58).
Total knowledge levels
MUH (n= 29) MGH (n= 29)
X2/ Fisher
Very good Good Poor Very good Good Poor P – value
test
Personal data No.(%) No. (%) No. (%) No.(%) No. (%) No. (%)
Marital status
Single 4(66.7) 2(33.3) 0(.0) 2(25.0) 5(62.5) 1(12.5)
Married 6(30.0) 13(65.0) 1(5.0) 4(22.2) 6(33.3) 8(44.4) 3.266 .514
Divorced 3(100.0) 0(.0) 0(.0) 0(.0) 2(66.7) 1(33.3)
Fisher (P - value) 6.732(.151) 3.760 (.439)
Age/ years
< 20 4(66.7) 2(33.3) 0(.0) 0(.0) 1(100.0) 0(.0)
20- < 30 7(43.8) 8(50.0) 1(6.3) 6(26.1) 7(30.4) 10(43.5) 11.458 .02*
30- 40 2(28.6) 5(71.4) 0(.0) 0(.0) 5(100.0) 0(.0)
Fisher (P - value) 2.795(.593) 9.311(.054)
Education
Secondary nursing
8(72.7) 3(27.3) 0(.0) 2(33.3) 4(66.7) 0(.0)
school
Health institute 5(38.5) 8(61.5) 0(.0) 3(27.3) 4(36.4) 4(36.4) 16.563 .011*
B.Sc 0(.0) 4(80.0) 1(20.0) 1(12.5) 2(25.0) 5(62.5)
Master 0(.0) 0(.0) 0(.0) 0(.0) 3(75.0) 1(25.0)
Fisher (P - value) 11.355 (.023*) 8.115 (.230)
Years of experience
Less than 5 years 4(50.0) 3(37.5) 1(12.5) 4(25.0) 5(31.3) 7(43.8)
5-< 10 7(58.3) 5(41.7) 0(.0) 2(33.3) 1(16.7) 3(50.0) 16.379 .003**
10- <15 2(22.2) 7(77.8) 0(.0) 0(.0) 7(100.0) 0(.0)
Fisher (P - value) 5.916 (.206) 11.760(.019*)
Attendance previous
training
Yes 5(33.3) 9(60.0) 1(6.7) 5(25.0) 8(40.0) 7(35.0)
1.179 .555
No 8(57.1) 6(42.9) 0(.0) 1(11.1) 5(55.6) 3(33.3)
Fisher (P - value) 2.261(.323) .919(.632)
Table (5): presents that, 6.3% of nurses aged between 20 – 30 years in Minia University Hospital and 43.5% of nurses aged
between 20 – 30 years in Minia General Hospital had very good knowledge regarding intravenous therapy with statistically
significance differences which p – value .02 and 20.0% of bachelor nurses in Minia University Hospital and 62.5% of bachelor nurses
in Minia General Hospital had very good knowledge regarding intravenous therapy with statistically significance differences which p –
value .01. Also, 12.5% of nurses had experience less than 5 years in Minia University Hospital and 43.8% of nurses had experience
less than 5 years in Minia General Hospital had very good knowledge regarding intravenous therapy with statistically significance
differences which p – value .003.
Table (6): Relation between Personal Data of The Studied Nurses with Their Total Practice Levels Regarding Intravenous
Therapy in Minia University Hospital (MUH) and Minia General Hospital (MGH) (n= 58).
Total practice levels
MUH (n= 29) MGH (n= 29)
X2/ Fisher
Personal data Not done Incomplete Complete Not done Incomplete Complete P – value
test
No. (%) No. No. No. (%) No. No.
(%) (%) (%) (%)
Marital status
Single 0(.0) 6(100.0) 0(.0) 2(25.0) 6(75.0) 0(.0) 11.784 .019*
Married 6(30.0) 11(55.0) 3(15.0) 11(61.1) 6(33.3) 1(5.6)
Divorced 0(.0) 3(100.0) 0(.0) 0(.0) 3(100.0) 0(.0)
Fisher (P - value) 5.873 (.209) 7.089(.131)
Age/ years
Less than 20 0(.0) 6(100.0) 0(.0) 1(14.3) 6(85.7) 0(.0)
20- < 30 3(18.8) 11(68.8) 2(12.5) 12(52.2) 11(47.8) 0(.0) 4.512 .341
30- 40 3(42.9) 3(42.9) 1(14.3) 0(.0) 4(80.0) 1(20.0)
Fisher (P - value) 5.261(.262) 9.355 (.05*)
Education
Secondary nursing school 1(9.1) 10(90.9) 0(.0) 3(50.0) 3(50.0) 0(.0)
Health institute 4(30.8) 6(46.2) 3(23.1) 5(45.5) 6(54.5) 0(.0)
B.Sc 1(20.0) 4(80.0) 0(.0) 4(50.0) 3(37.5) 1(12.5) 4.754 .576
Master 0(.0) 0(.0) 0(.0) 1(25.0) 3(75.0) 0(.0)
Fisher (P - value) 6.884(.142) 3.813(.702)
Years of experience
Less than 5 years 1(12.5) 7(87.5) 0(.0) 10(62.5) 6(37.5) 0(.0)
5-< 10 2(16.7) 10(83.3) 0(.0) 2(33.3) 4(66.7) 0(.0) 13.998 .007**
10- <15 3(33.3) 3(33.3) 3(33.3) 1(14.3) 5(71.4) 1(14.3)
Fisher (P - value) 10.130(.038*) 7.301 (.121)
Total practice levels
MUH (n= 29) MGH (n= 29)
X2/ Fisher
Personal data Not done Incomplete Complete Not done Incomplete Complete P – value
test
No. (%) No. No. No. (%) No. No.
(%) (%) (%) (%)
Yes 2(13.3) 10(66.7) 3(20.0) 12(60.0) 7(35.0) 1(5.0) 6.069 .048*
No 4(28.6) 10(71.4) 0(.0) 1(11.1) 8(88.9) 0(.0)
Fisher (P - value) 3.637 (.162) 1.244 027*) 1.245 1.246
Table (6): shows that 15.0% of married nurses in Minia University Hospital and 5.6% of married nurses in Minia General
Hospital had complete practice regarding intravenous therapy with statistically significance differences which p – value .019 and
33.3% of nurses had experience 10 - < 15 years in Minia University Hospital and 14.3% of nurses had experience 10 - < 15 years in
Minia General Hospital had complete practice regarding intravenous therapy with statistically significance differences which p – value
.007. Also, 20.0% of nurses in Minia University Hospital who attended previous training and 5.0% of nurses in Minia General
Hospital who attended previous training had complete practice regarding intravenous therapy with statistically significance differences
which p – value. 048.
Table (7) Relation between Personal Data of The Studied Nurses with Their Total Attitude Levels Regarding Intravenous Therapy
in Minia University Hospital (MUH) and Minia General Hospital (MGH) (n= 58).
Total attitude levels
MUH (n= 29) MGH (n= 29)
Personal data Negative Positive Positive X2/ Fisher test P – value
Negative (n=7)
(n= 12) (n= 17) (n= 22)
No. (%) No.(%) No. (%) No.(%)
Marital status
Single 4(33.3) 2(11.8) 2 (28.6) 6(27.3) 2.174 .337
Married 6(50.0) 14(82.3) 4(57.1) 14(63.6)
Divorced 2(16.7) 1(5.9) 1(14.3) 2(9.1)
Fisher (P - value) 3.440 (.179) .178 (.915)
Age/ years
Less than 20 6(50.0) 0(.0) 0(.0) 1(4.5) 10.690 .005**
20- < 30 6(50.0) 10(58.8) 5(71.4) 18(81.8)
30- 40 0(.0) 7(41.2) 2(28.6) 3(13.7)
Fisher (P - value) 13.540 (.001**) 1.077 (.583)
Educational level
Secondary nursing school 1(8.3) 4(23.5) 1 (14.2) 7 (31.8)
Health institute 4(33.3) 9(52.9) 3(42.9) 8 (36.4) 9.114 .028*
B.Sc 7(58.4) 4(23.6) 3(42.9) 3 (13.6)
Master 0(.0) 0(.0) 0(.0) 4 (18.2)
Fisher (P - value) 3.792 (.150) 4.115 (.249)
Years of experience
Less than 5 years 6(50.0) 2(11.8) 4 (57.1) 12 (54.6)
5-< 10 6(50.0) 6(35.3) 1 (14.3) 5 (22.7) 4.153 .125
10- <15 0(.0) 9(52.9) 2 (28.6) 5 (22.7)
Fisher (P - value) 10.449 (.005**) .265 (.876)
Yes 8 (66.7) 7 (41.2) 5 (71.4) 15 (68.2) .770 .380
No 4 (33.3) 10 (58.8) 2 (28.6) 7 (31.8)
Fisher (P - value) 1.830 (.176) .026 (.872)
Table (7): presents that, 58.8% of nurses aged 20 – 30 years in Minia University Hospital and 81.8 % of them in Minia
General Hospital had positive attitude regarding intravenous therapy with statistically significance differences which p – value .005
and 52.9% of health institute nurses in Minia University Hospital and 36.4% of them in Minia General Hospital had positive attitude
regarding intravenous therapy with statistically significance differences which p – value .028.
Table (8): Correlation between selected personal Data of the Studied Nurses with Their Total Knowledge, Practice, Attitude
Levels Regarding Intravenous Therapy in Minia University Hospital (MUH) and Minia General Hospital (MGH)
MUH MGH Total nurses
Knowledge Practice Attitude Knowledge Practice Attitude Knowledge Practice Attitude
score score score score score score score score score
Items P– P– P– P– P– P- P– P– P–
r r r r r r R r r
value value value value value value value value value
Age .327 .083 .077 .693 .218 .100 .049 .801 .460 .012* .089 .647 .206 .120 .130 .329 .256 .05*
Educational .591 .001** .025 .896 .034 .802 .155 .422 .003 .987 .151 .436 .281 .032* .010 .942 .003 .980
level
Years of .081 .675 .141 .465 .224 .092 .061 .754 .470 .01* .162 .400 .087 .517 .386 .003** .253 .05*
experience
Practice .067 .730 …. …. .148 .268 .247 .196 …. …. .002 .991 .298 .023* …. ….. .151 .259
level
P a g e | 10 Nagwa I., et al
Table (8): presents that, fair positive association between nurses knowledge score with their educational level and practice
level (r=.281; p – value 0.032 & r=.298; p – value 0.023 respectively), fair positive association between practice score with years of
nurses experience (r= .386;p – value 0.003) and fair positive association between nurses attitude with their age and years of
experience (r= .256;p – value 0.05, r= .253;p – value 0.05).
Discussion of nurses had good knowledge regarding care and peripheral

Most of the interventions and prevention strategies IV cannula safe usage.
such as insertion, monitoring and assessing peripheral venous Regarding Preparation for Cannulation, the present
catheter (PVC) sites are part of routine nursing care. The nurse study illustrated that less than half of MUH nurses and MGH
should have accurate knowledge of the preparation and nurses had good knowledge about preparation for
administration of the IV Infusion and IV device. In addition, cannulation. This result agree with (Osti et al., 2019) who
they should also know about the prevention, treatment, and mentioned that the majority of the studied sample had proper
management of local and systematic complications supported knowledge regarding intravenous cannulation that includes the
by dynamic evidence‐based practice guidelines. One of the cannula size, site, duration, proper steps during cannulation,
major risks for phlebitis incidence is due to the placement and and sign and symptom of infection and proper measure to
maintenance of PVC by insufficiently trained staff prevent infection. This result may be due to less than one-third
(Mohammed & Ahmed, 2017). of studied nurses had secondary nursing school and they don't
Regarding the age of the studied nurses, the current take sufficient clinical training
study revealed that more than two-thirds of the studied nurses Regarding the studied nurses' knowledge during
their age in between 20 - < 30 in MUH and MGH with mean ± cannulation, the current study showed that less than two-thirds
SD 25.7 ± 5.1 years. This result comes in the line with (Ouda, of the studied nurses in MUH had good knowledge about the
Mahmoud, Kafi, and Soliman, 2019) that studied ''Nurses' steps during cannulation and more than two-third of MUH
Knowledge and Practices Regarding Peripheral Intravenous nurses had good knowledge during cannulation. This result
Cannulation and Blood Sampling in Pediatric Health Care didn’t come in the line with (Osti et al., 2019) who stated that
Settings '' and reported that the most of the studied sample was the majority of the studied sample was doing correct practices
in between 18:30 years and with mean ± SD 24.44 ± 4.30 regarding intravenous cannulation. This result due to less than
years. This result comes in accordance with (Milutinović, half of the studied nurses had experienced less than 5 years.
Simin, & Zec, 2015) who studied " Risk factor for phlebitis: a Regarding the relation between studied nurses in
questionnaire study of nurses’ perception" and reported that Minia university hospital (MUH) and Minia general hospital
the mean age of the nurses was 33.2 (SD=7.2) years of age. (MGH) according to their knowledge after cannulation, the
The youngest nurse was 20 years and the oldest was 56 years current study showed that less than half of the studied nurses
old. This result due to the nurses' age after graduation ranged in MUH had good knowledge and more than half of MUH
from 20- 23 years. nurses had very good knowledge. This result comes in to
Regarding educational level, the current study agree with (Ouda et al., 2019) who studied '' Nurses'
illustrated that less than one-third of studied nurses had Knowledge and Practices Regarding Peripheral Intravenous
secondary nursing school. This result contradicted with Cannulation and Blood Sampling in Pediatric Health Care
(Milutinović et al., 2015) who founded that more than half of Settings'' and revealed that half of the studied nurses had
the nurses (61.8%) had completed secondary medical school, satisfactory knowledge regarding peripheral intravenous
while more than one-third of them graduated from college or cannulation and blood sampling. This result comes in to agree
university, and three (2.9%) had a master's degree in nursing. with (Lamsal & Shrestha, 2019) who studied ''nurses’
Regarding previous experience and training the knowledge and practice regarding intravenous therapy in a
current study showed that less than half of the studied nurses teaching hospital, Bhagalpur'' and reported that the level of
had experienced less than 5 years and slightly less than two- knowledge was found inadequate and level of practice was
thirds of the studied nurses attend previous training. This found unsatisfactory on IV therapy.
result differs from (Ouda, et al., 2019) who mentioned that Regarding the relation between studied nurses in
less than half of the studied nurses had experienced less than 3 Minia university hospital (MUH) and Minia general hospital
years and less than one quarter had experience less than 5 (MGH) according to their knowledge regarding prevention
years. In addition, Ouda, et al., (2019) mentioned that more and complications of intravenous therapy, the current study
than half of the studied nurses had previous training. This showed that more than two-thirds of MUH nurses had good
result may be due to the working in the emergency and knowledge and less than two-third of MGH had very good
pediatric department difficult work so many nurses transferred knowledge regarding prevention and complications of
to another department intravenous therapy with statistical significance differences P-
Regarding the relation between studied nurses in value .036 This result was supported by (Osti et al., 2019)
Minia university hospital (MUH) and Minia general hospital who mentioned that the respondents had knowledge that
(MGH) according to their general knowledge, the present thrombophlebitis and infection are the common complications
study showed that more than one-third of MUH nurses of IV cannulation and the most of them were aware of the
compared to less than two-third of MUH nurses had good influences of environmental cleanliness on IV site infection.
knowledge. this result was confirmed by (Qamar, But this result comes inconsistent with (Milutinović et al.,
Muhammad, Kousar, Waqas, & Gilani, 2017) who studied 2015) who studied ''Risk factor for phlebitis: a questionnaire
'' Nurses Knowledge and Practices towards Care and study of nurses' perception'' and reported that nurses
Maintenance of Peripheral Intravenous Cannulation in recognized some factors that may reduce the incidence of
Services Hospital Lahore, Pakistan'' and reported that the most phlebitis; however, more than half of the nurses were unaware
that the material and diameter of the cannula can affect the Pakistan'' and reported that the more than have of the studied
incidence rate of phlebitis. nurses had poor practices.
Regarding the relation between studied nurses in Regarding Correctly Administration of Blood
Minia University Hospital (MUH) and Minia General Products, the present study showed that more than half of
Hospital (MGH) according to their practice regarding perform studied nurses in MUH and less than half of nurses in MGH
correctly infection control precautions, the current study administered blood products correctly. This result comes in
showed that the most of the studied nurses in MUH and MGH the line with (Flood & Higbie, 2016) who studied ''A
didn’t apply infection control during I.V preparation. This comparative assessment of nursing students' cognitive
result comes inconsistent with (El-Greeb et al., 2018) who knowledge of blood transfusion using lecture and simulation''
studied the Nurses' Compliance with Infection Control and reported that less than half of the studied nurse
Standard Precautions at Outpatient Clinics of Urology and administered blood products correctly. Also, this result was
Nephrology Center - Mansura University'' and reported that confirmed by (Frazier, Higgins, Bugajski, Jones, & Brown,
there was a satisfactory score level in relation to handling 2017) who studied '' Adverse Reactions to Transfusion of
sharps instruments, wearing gloves and following infection Blood Products and Best Practices for Prevention'' and
control precaution. reported that less than two-thirds of the studied sample follow
Regarding the relation Between Studied Nurses in the guideline in the administration of blood product.
Minia University Hospital (MUH) and Minia General Regarding the Flushing of PIVC's, the present study
Hospital (MGH) According to Their Practice Regarding illustrated that less than half of studied nurses in MUH and
Perform Correctly Hand Washing Procedure, the current study MGH flushed of PIVC's. this result didn’t come in accordance
showed that the majority of the studied nurses didn’t apply with (Graveto, Costa, de Almeida Osório, Cosme, &
hand washing before I.V preparation. This result was Parreira, 2019) who studied ''Nurses’ peripheral intravenous
supported by (Jemal, 2018) who studied ''knowledge and catheter-related practices: a descriptive study'' and reported
practices of handwashing among health professionals in dubti that more than half of the studied sample make flushing of
referral hospital, dubti, afar, northeast Ethiopia'' and reported PIVC's.
that the majority of the studied sample was knowledgeable Regarding Correctly IV Fluid Considerations via
and more than one third were not knowledgeable. However, Peripheral IV line, the current study showed that less than
the majority of health professionals had poor practice and less one-third of studied nurses in MUH and less than one-quarter
than half of them had a good practice of handwashing. Also, of nurses in MGH done completely fluid considerations via
this result was lower than the result of a study done at Shonen Peripheral IV line. These result results come in accordance
Gibe Hospital, Southeast Ethiopia, in which the majority of with (Thabet Ahmed, Mohammad, Ez El-Deen, & Sayed,
the studied sample had good knowledge and less than fifth had 2013) who studied ''Effect of a designed nursing protocol on
poor knowledge (Alemu et al., 2015). This result may be due nurse's knowledge and practice regarding Intravenous
to nurses believes not important to wash their hands before the Therapy'' and reported that the most of the studied nurses had
procedure but it's important after doing the procedure poor practices regarding I.V fluids. This result was confirmed
Regarding the relation between studied nurses in by (Qamar et al., 2017) who reported that less than half of
Minia university hospital (MUH) and Minia general hospital the studied nurses had good practices regarding administration
(MGH) according to their practice regarding performing I.V fluids.
correctly personal protective equipment, The current study Regarding the change of PIVC dressing and
showed that the most of studied nurses in MUH and more than securement of the cannula, the current study showed that less
half of MGH nurses applied PPE. This result comes than two-thirds of studied nurses in MUH and less than half in
inconsistent with (Powers, Armellino, Dolansky, & MGH changed of PIVC dressing and securement of cannula
Fitzpatrick, 2016) who studied '' Factors influencing nurse correctly. This result comes inconsistent with (Ouda et al.,
compliance with Standard Precautions'' a reported that most of 2019) who studied ''nurses' knowledge and practices regarding
the studied sample had poor compliance with standard peripheral intravenous cannulation and blood sampling in the
precautions. pediatric health care setting and mentioned that the majority of
Regarding the relation Between Studied Nurses in the studied nurse had unsatisfactory practices.
Minia University Hospital (MUH) and Minia General Regarding correctly management of I.V therapy
Hospital (MGH) According to Their Practice Regarding complications the current study showed that, less than three
Perform Correctly Intravenous Cannulation, the current study quadrants of studied nurses in MUH and more than have of
showed that the majority of nurses in MUH and MGH didn’t nurses in MGH managed of I.V therapy complications. This
follow the correct steps of cannulation. this result was come result was confirmed by (Punjot, Mathew, Suseel, &
inconsistently with (Morgaonkar et al., 2017) who studied'' Thomas, 2018) who studied '' A study to assess the
Educational intervention to improve intravenous cannulation effectiveness of infusion experts on the nursing interventions
skills in pediatric nurses using low-fidelity simulation: Indian of peripheral intravascular devices among patients admitted to
experience'' and reported that most of the studied sample a tertiary care hospital of the city'' and reported that the nurses
perform correctly intravenous cannulation. become aware of measures that prevent I.V therapy
Regarding the Preparation of Intravenous Fluids, the complications.
current study showed that more than half of studied nurses in Regarding the total practice levels regarding
MUH and less than one-third MGH prepared and administered intravenous therapy, the present study showed that less than
I.V fluid correctly. This result comes in the line with (Qamar two-third had incomplete practices level This result didn’t
et al., 2017) who studied '' Assess Nurses Knowledge and come in the line with (Othman & Ahmed, 2019) who studied
Practices towards Care and Maintenance of Peripheral ''nurses Knowledge, Attitude and Practice Concerning Fluid
Intravenous Cannulation in Services Hospital Lahore, Therapy in Children Hospital in Erbil City, Kurdistan Region
Iraq'' and reported that less than two-thirds of the studied
sample had fair practices. This result comes inconsistent with knowledge for studied nurses p value (0.044) and There is
(Arbaee, 2016) who reported that the majority of the studied statistical significance difference between years of experience
nurses followed the correct practice of care and maintenance and level of knowledge p value (0.005). In contrast with (As,
of IV cannula. 2011) who studied ''Knowledge and performance of health
Regarding the relation between studied nurses in team about infection control in the neonatal intensive care
Minia university hospital (MUH) and Minia general hospital units at Assiut and El Minia university hospitals'' and stated
(MGH) according to their opinion regarding their roles during that the nurses who aged less than 20 years had excellent
and after intravenous therapy, the current study showed that score of knowledge.
less than one-quarter of the studied nurses in MGH and MUH Regarding the relation between personal data of the
had correct pinion regarding their roles during and after studied nurses with their total practice levels regarding
intravenous therapy. This result comes in the line with (El- intravenous therapy in Minia university hospital (MUH) and
Greeb et al., 2018) who stated that all studied nurses showed Minia General Hospital (MGH), The current study showed
a good level of knowledge related to the definition of infection that there were statistically significance differences between
control and standard precautions, the cycle of infection, aim the total level of practices and the socio-demographic
and components of standard precautions of infection control characteristics. This result come in agree with (Abd-Alfatah
standards and post-action of the needle stick. Generally, the et al., 2013) who reported that, there is statistical significance
total knowledge categories showed a good level of studied difference between age of studied nurses and level of practice
nurses. with P value (0.001) and there was statistical significance
Regarding nurses' attitude about intravenous therapy, difference between having training courses and level of
the current study showed that more than one third of nurses practice. This result may be due to slightly less than two third
worked in Minia University Hospital (MUH) had negative of the studied nurses attend previous training.
attitude about Intravenous Therapy. This result comes in the Regarding the relation between personal data of the
line with (Othman & Ahmed, 2019) who studied ''nurses studied nurses with their total attitude levels regarding
Knowledge, Attitude and Practice Concerning Fluid Therapy intravenous therapy in Minia University Hospital (MUH) and
in Children Hospital in Erbil City, Kurdistan Region Iraq' and Minia General Hospital (MGH), the current study stated that,
reported that more than half of the studied nurses had negative there were statistically significance differences between
attitude regarding intravenous therapy and recommended to nurse's attitude and their age and educational level.
pay attention to nurses' knowledge, attitude, and practices This result come in agree with (Carr et al., 2011)
through an educational program. who studied ''Interns' attitudes to IV cannulation'' and reported
Regarding the correlation between selected personal that there were statistically significance differences between
data of the studied nurses with their total knowledge, practice, nurse's attitude and the socio-demographic characteristics
attitude levels regarding intravenous therapy in Minia (Hossain, Hasan, & Haque, 2016) who studied ''Assessment of
University Hospital (MUH) and Minia General Hospital, the the level of knowledge and practice on intravenous
present study mentioned that there was a fair positive canalization among staff nurses of selected tertiary care
association between nurses knowledge score with their hospital in Dhaka city'' reported the same result.
educational level and practice level (r=.281; p-value 0.032 &
r=.298; p-value 0.023 respectively), fair positive association Conclusion
between practice score with years of nurses experience (r= Based on the result of the present study one third of
.386; p-value 0.003) and fair positive association between nurses worked in Minia General Hospital had complete
nurses attitude with their age and years of experience (r= .256; knowledge regarding intravenous therapy than a few of
p-value 0.05, r= .253; p-value 0.05). this result comes in the nurses worked in Minia University hospital, studied nurses in
line with (Abd-Alfatah et al., 2013) who reported that there is Minia University hospital had more practice and positive
no statistically significant difference between the nurses' attitude than nurses in Minia General Hospital regarding
knowledge and their practice regarding nursing care of intravenous therapy.
children undergoing hemodialysis. This result in the same line
with the evidence high nurses educational had more Recommendations
knowledge and practices in dealing with illness child. Based on the results of the present study are:
Regarding the relation between personal data of the The educational program should be applied and
studied nurses with their total knowledge levels regarding repeated every 3 months in the same study settings and
intravenous therapy in Minia university hospital (MUH) and adopted in other similar settings with necessary modifications,
Minia general hospital, the current study illustrated that there the provision of continuing education programs is suggested
were statistically significance differences between the total regularly to refresh and update the knowledge of nurses, as
level of nurses' knowledge and educational level and Years of well as to reinforce appropriate practices in pediatric units
experience. This result come in agree with (Mohammed, related to intravenous therapy with continuous supervision.
Sultan, & Abdulhassan, 2017) who reported that there were
statistical differences between socio-demographic References
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Assessment of Applying Clinical Audit for Pregnant Woman with Iron Deficiency Anemia.
1 Yasmeen Mohammed Badry 2 Nadia Abdallah Mohammed 3 Naglaa Mohammed Amein
1. B.Sc. Nursing south valley university.

2. Prof.of Obstetrics &Gynecology Nursing.
3. Lecturer of Community Health Nursing
Abstract
Background: clinical audit is a complementary part of the standards it includes a checklist and action plan. The
checklist can be used to test or audit standards. The action plan is a conclusive part of the audit. Iron deficiency
anemia during pregnancy is one of the most significant health problems in the world. Impact of iron deficiency
anemia on the pregnant women its outcomes that it has many serious consequences on increase the risk of fetal growth
retardation, premature delivery. Aim of the study: To assess clinical audit which used for the pregnant woman with
iron deficiency anemia. Research design: descriptive design was carried out in this study. Setting: All Maternal and
Child Health centers in Qena City and Minia City which were four centers in Minia and six centers in Qena. Sample:
convenient sample of 500 records of pregnant women. Tool of data collection: Tool 1: questionnaire sheet includes
the socio-demographic include personal and obstetrical history. Tool 2: Standard of care for the pregnant with iron
deficiency anemia adopted from (WHO) source. Results: we found that 76% in Qena city versus 82%in Minia city
had mild anemia, while 24% in Qena city versus17.6% had moderate anemia. Absence of woman with severe and
very severe anemia .distribution of Mild and Moderate anemia was higher in urban. More than 75% of standard points
were applicable in the two governorates. Conclusion: The present study concluded that the nurses of Maternal and
Child Health centers didn’t apply all points of WHO audit. Recommendations: Every healthcare facility should
develop and implement an Annual Clinical Audit Forward Plan as part of its annual planning and delivery cycle for
clinical audit activities and the facility's safety and quality governance framework. Health care providers need further
training to apply clinical audit completely .Health care records needed updated to conclude all point of WHO clinical
audit related to absence of some of care services to pregnant woman.
Introduction World Health Organization (WHO) motivates that

The clinical audit is an important integral part of hemoglobin ideally should be maintained at or above 11.0
standards it includes a checklist and action plan. The checklist g/dl, and should not be allowed to fall below 10.5 g/dl in the
can be used to test or audit the standards. The action plan is second trimester. As regarding WHO guidelines, anemia has
the critical part of the audit .Its importance is highlight on classified as: (A) Mild anemia (Hb 10 to 10.9 g/dl); (B)
areas which need strengthening or correcting and assist the Moderate anemia (Hb 7 to 9.9 g/dl); (C) Severe anemia (Hb
supervisor, mangers in their routine supervisory care. Without less than 7 g/dl); (D) Very severe (Hb less than 4 g/dl).
making changes after the audit, standards will be difficult to (Breymann, 2015)
maintain and impossible to improve. (Saragiotto et al, 2014) Both industrialized and developing countries have
Iron deficiency anemia during pregnancy is one of elevation rates of iron deficiency anemia during pregnancy.
the most serious health problems in the world. Its expansion is Rating from the World Health Organization gives an account
more in developing countries, of its results that it has many that from 35% to 75% (56% on average) of pregnant women
serious consequences on increase the risk of fetal growth in developing countries, and 18% of women from
retardation, low birth weight, premature delivery, increased industrialized countries are anemic. (Ponte Polo, 2018)
perinatal mortality, and reduced resistance to infection for
both mother and baby. Later on, it has a pernicious effect on Aim of the study
health for both mother and baby if dropped out without Aim of the present study was to assess clinical audit
treatment. (AlzahebAl-Amer, 2017) which used for the pregnant woman with iron deficiency
anemia.
Significance of the Study
Audit is a tool to improve the quality, effectiveness Research design
and efficiency of care provided to patients by measuring the Descriptive design was carried out in this study.
existed standards and changing behavior against them when
required. To improve the quality the findings of an Setting
implemented audit have to be sent to all the health care This study was conducted at all maternal and child
professionals who had taken part in it with recommendations health centers (MCH) are in Qena City which are six Centers
for improvements in their day to day work (Grol et al, 2013) and all MCH centers in Minia City which are four Centers.
World Health Organization (WHO) evaluates that Including Qena centers (Hai El-masaleh,sady abd el-
two billion people over 30% of the world's populations are reheem,sady omar,El-maana,Babdar Qena, madina El-
anemic, although prevalence rates are inconstant because of omal)and Minia centers( Reaya el- osra(1), Reaya el- osra(2),
variation in socioeconomic conditions, lifestyles, food habits, El -Sharky Medical Centre Health 1 , El-araby Medical Centre
and rates of communicable and non-communicable diseases. Heath 2).
(Chandra & Sun, 2015)
P a g e | 15 Yasmeen M., et al
Sample
A convenient sample of (500) pregnant women Data Collection Tools of the Study
records in six maternal and child health centers at Qena city Two tools was used in this study:
and four maternal and child health centers at Minia city.  Tool I A questionnaire sheet includes socio-
sampling technique was included in the study according to the demographic data as case history, obstetric history
following criteria : (gravity-parity-abortion-live children).
 Tool II: Standard of care for the pregnant with iron
Inclusion criteria deficiency anemia adopted from (WHO, 2010)
A pregnant woman which their hemoglobin level source, occur some modification by the investigator
was ˂11 g/dl. associated with the study.
Exclusion criteria
A pregnant woman which their hemoglobin level was
≤11 g/dl.
Results
Table (1): Distribution of studied sample per their demographic characteristics (n=500) at Qena and Minia city:-
Qena Minia
Demographic characteristics (n=250) (n=250) X2 P – value
No. % No. %
Age / years
18 - < 23 62 24.8 88 35.2
23- < 28 78 31.2 60 24.0 7.467 .113
28- < 33 69 27.6 67 26.8
33- < 38 34 13.6 30 12.0
38 – 42 7 2.8 5 2.0
Mean ± SD 26.8 ± 5.4 26.1 ±5.6 t=1.553 .121
Residence
Rural 142 56.8 1 .4
Urban 108 43.2 249 99.6 19.717 .000
Table (1) shows that distribution of the studied sample in step with their demographic characteristics and it had been found
that 35.2% of pregnant women in Minia versus 24.8% in Qena city aged (18 - < 23), also reveal that 24% of ladies in Minia versus
31.2% in Qena aged (23- < 28).As regard residence, quite half of women from rural areas in Qena while in minia 99.6 % were from
urban . P-value of them which is very statistically significant. In Minia and Qena city most of pregnant women were at their age group
(18-˂23) years. In Minia and Qena city were few pregnant women at (38- ˂42). Age of the studied pregnant women from (18-42) at
Minia city had a mean of 26.1 ±5.6, while in Qena city was 26.8 ± 5.4.
Part ӀӀ Table (2): Standard of care for the pregnant with iron deficiency anemia (n.500)
Qena Minia
Standards Fisher P – value
No. % No. %
1-Give all pregnant women a standard dose of 60 mg 250 100 250 100.0 0 1
iron+400μg folic acid daily for six months daily.
2-Where the prevalence of anemia in pregnancy is over 250 100 250 100 0 1
40%, advises the lady to continue the prophylaxis for 3
months in the postpartum period.
3-Give iron supplementation even if folic acid is not 250 100.0 250 100.0 0 1
available.
4-Examine or screen all women for anemia during 250 100.0 250 100.0 0 1
antenatal visits by drawing blood and determine
hemoglobin concentration.
5-Give anemic pregnant woman 120mg iron daily for 3 0 .0 0 0 0 1
months.
6-Follow-up in two weeks to check clinical progress, test 250 100.0 250 100.0 0 1
results and compliance.
7-follow-up again in four weeks later all women with 250 100.0 250 100.0 0 1
severe anemia that are treated with iron and folate therapy
8-Refer women with severe anemia to a higher level of 250 100.0 250 100.0 0 1
care, if they are in the last month of pregnancy.
9-Refer women with severe anemia to a better level of 250 100.0 250 100.0 0 1
care, if they have signs of respiratory distress or cardiac
abnormalities such as edema
10-Refer women with severe anemia to a better level of 250 100.0 250 100.0 0 1
care, When the conditions don’t improve or worsen after
one week of iron or folate therapy.
11-provide advice on the consumption of iron-rich food 250 100.0 250 100.0 0 1
and vitamin C.
12-Record test results and also the treatment provided 250 100.0 250 100.0 0 1
within the woman health's card.
Table (2) shows that following two items of standards (Where the prevalence of anemia in pregnancy is over 40%, advise
the woman to continue the prophylaxis for 3 months in the postpartum period) and (provide advice on the consumption of iron-rich
food and vitamin (C) wasn’t applicable, while the other points of standard were applied completely and the way of clinical practice
was similar within the Minia and Qena city.
90.00% 76.00% 82.40%

80.00%
70.00%
60.00%
50.00% 24.00%
40.00%
17.60%
30.00%
20.00%
10.00% 0.00% 0.00% 0.00% 0.00%
0.00%
Mild anemai Moderate anemia Severe Very severe
Qena Minia
Figure (1): percentage distribution of levels of anemia in Qena and Minia city
Figure (1): cleared that percentage distribution of levels of anemia in Qena and Minia city revealed that mild anemia was
over three quarter (76%) in Qena city and 82% in Minia city .moderate anemia was high in Qena city(24 %),Severe anemia ,and
Very severe anemia were zero within the two governorates
83.40%
90.0%
62.60%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
18.90%
18.50%
20.0% 8.30% 8.30%
10.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
0.0%
1- 12 (1st trimester) 13- 27 (2nd trimester) 28- 40 (3rd trimester)
Mild anemia (n= 190) Moderate anemia (n= 60) Severe Very severe
Figure (3): frequency distribution between hemoglobin level of pregnant women and their gestational age at Qena city
Figure (3):distribution of hemoglobin level of pregnant women to their age at Qena city showed that with in the 1 st
trimester moderate anemia was fewer than mild anemia ,in 2 nd mild anemia was fewer than moderate anemia, in third trimester
moderate anemia was fewer than mild anemia ,but high percentage of women in 2 nd trimester had mild and moderate anemia .
83.00% 86.40%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0% 7.80% 9.10%
9.20%
10.0% 4.50% 0.0%
0.0% 0.0% 0.0% 0.0% 0.0%
0.0%
1- 12 (1st trimester) 13- 27 (2nd trimester) 28- 40 (3rd trimester)
Mild anemia (n= 206) Moderate anemia (n= 44) Severe Very severe
Figure (4): frequency distribution between hemoglobin level of pregnant women and their gestational age at Minia city
Figure (4): distribution of hemoglobin level of pregnant women to their gestational age at Minia city showed that within
the 1 st trimester mild anemia was fewer than moderate anemia ,in 2 nd mild anemia was fewer than moderate anemia, in 3 rd
trimester moderate anemia was fewer than mild anemia ,but high percentage of women in 2 nd trimester had mild and moderate
anemia.
Discussion clinical record review, there was no specific follow up or

The present study comprises 500 anemic pregnant referral linked to Hb level. The pregnant women were only
woman records, who attended MCH centers during the year asked to attend for Antenatal Care supported national standard
2017, also regarding socio-demographic data .it was (once a month in Trimester I and II, twice a month until 36
considered that pregnant woman hemoglobin level should be weeks of gestation, and once per week after 36 weeks of
less than 11mg/dl. within the present study, elected to assess gestation). This might be understood since there was no
the appliance of clinical audit for pregnant women with iron routine screening of Hb levels, that the women weren’t asked
deficiency anemia due to great weight of this subject. standard when to return to check the following Hb level. also, this audit
of take care of anemic pregnant women was prepared by was conducted at a hospital, so there was no referral
WHO and systematically we evaluated against the current performed. Second point: provide advice on the consumption
practice and further monitoring are accustomed observe of iron-rich food and vitamin C because records containing
refinement in health care provision. delivered care to pregnant women not containing this point.
As regards clinical audit, no prior studies discussed From the interview, the midwives at the antenatal clinic gave
application of clinical audit, but demonstrated management of education on anemia which iron tablets, but there’s no
iron deficiency anemia in pregnancy as screening, diagnosis, recorded educational session. The midwives usually provide
treatment, complication, level of anemia with auditing after knowledge on the influence of anemia which iron tablets may
delivery anemic pregnant women demonstrated that over three minimize the danger of anemia. Furthermore, midwives and
quadrants were applicable except the subsequent points: first obstetricians frequently prescribed iron tablets and folic acid
point Where the prevalence of anemia within pregnancy is but this was not taken by an appropriate demonstration on
over 40%, advise the woman to continue the prophylaxis for 3 dietary structure. They told the women about the dosage and
months in the postpartum period because the relationship also the proper time to pull the iron tablets but didn’t provide
between pregnant women and MCH center discontinued after notice about what form of food can prevent or increase iron
delivery. In congruence with (Tolkien et al, 2015) there was absorption.
no directory of follow up or referral associated with Hb level, Levels of anemia in Qena and Minia city revealed
Follow-up is needful to organize referral or further medical that mild anemia was more than three quarter in Qena city
awareness. It’s important that primary health care providers and 82% in Minia city .moderate anemia was higher in Qena
are able to take mark and cure or transfer individuals with city nearly one quarter,Severe anemia and Very severe anemia
severe anemia. Indonesian Midwifery Standards don’t remind were zero in the two cities . In congruence with, (Zekarias
about the continuation as Iron Guidelines, but the sole etal, 2017) out of all anemic pregnant women about 59.7%
condition that any severe anemia case should be said to the were mildly anemic, 33.3%were moderately anemic and
hospital for further management. In Indonesia, midwives only therefore the rest 7% were severely anemic.
recommended treating mild to moderate anemia. From the
Regarding demographic characteristics ,it was found The age distribution of the pregnant women was
that the overwhelming majority of pregnant women was in found to be highest among the age (18-˂ 23) and lowest at
Qena city quite three quarter (78%) among the age (23- ˂ (38-42), in Qena city a high percentage of pregnant women
28)yrs and vast minority at(38-42)yrs, but in Minia city, The found (78%) among the age (23- ˂ 28) and lowest at (38-42).
numbers of the pregnant women were found to be highest Regarding residence over half the ladies from rural areas in
among the age group of (18-˂23) and lowest at(38-42)yrs. In Qena city, while in Minia nearly one hundred from urban and
both cities, the vast minority were at (38- ˂42)yrs. Meanwhile, its highly significant. A high percentage of women in
in the study of (Waldenström etal,2017) the age distribution 2ndtrimester had mild and moderate anemia.in the two city.in
of the pregnant women was found to be highest among the age Qena and Minia there weren’t any women reported with
between 25-30 years old 37%, followed by pregnant women severe or very severe anemia.
with the age 25 yrs old 35% and these findings on the same
line with Qena city results. Recommendations
Regarding residence quite half of the women were  Every health center should develop and implement an
from rural areas in Qena city, while in Minia nearly one 100% Annual Clinical Audit Forward Plan as a component
from urban and its highly significant. in rural areas Mild and of its annual planning and delivery cycle for clinical
Moderate anemia was higher in Qena city, while in urban audit activities and also the facility's safety and
areas Mild and Moderate anemia was higher at Minia city, quality governance framework.
within the two city, severe and really Very severe anemia was  Health education activities are allotted to expand
zero. awareness among women and within the community
On the contrary, at the study of (Adam etal,2018) of the importance of iron and folate supplementation
Pregnant women living in urban areas nearly one quarter less in pregnancy.
likely to be anemic during pregnancy than women in the rural  Health care providers need further training to use
area, the previous result didn’t match with this study. The clinical audit completely.
difference within the socioeconomic status, educational, and  Health care records needed updating to concluded all
occupational status of pregnant women, the difference within clinical audit points.
the health service access between rural and urban areas may  Follow-up relations between mother and MCH
be the justification for the difference. centers should be continued especially within the
Regarding Hemoglobin distribution, mild anemia primary 3 months after delivery.
was more prevalent in Minia city, but moderate anemia was  A nationalistic policy and locally adapted guidelines
more prevalent in Qena city. for iron and folate supplementation are in place and
In Qena city, in the1st trimester moderate anemia are performed in correct way.
was fewer than mild anemia, in 2nd trimester mild anemia  Egyptian ministry of health should develop new
was fewer than moderate anemia, in 3rd trimester moderate strategies and plans to spice up the standard of care
anemia was fewer than mild anemia, but the overwhelming level regarding a clinical audit.
majority of women in2nd trimester had mild and moderate
 Improve Clinical Practice: Audits aim to boost the
anemia.
standard of care through the systematic assessment of
In Minia city, that within the 1st trimester mild
clinical practice.
anemia was fewer than moderate anemia, in 2nd mild anemia
 Health care providers of maternal and neonatal care
was fewer than moderate anemia, in 3th trimester moderate
are competent in: the importance of iron
anemia was fewer than mild anemia, but the vast majority of
supplementation during pregnancy and also the
women in 2nd trimester had mild and moderate anemia.in the
postpartum period; the correct dosage and period of
two cities.
supplementation for the protection and remedy of
On the contrary, (El Bilbeisi,2020) the age group of
anemia; anemia discovery in pregnant women; and
the anemic pregnant women under our study showed different
when to refer women for supplementary diagnosis
gestation periods;20.9%, 28.6%, 50.5% were within the first,
and treatment.
second, and third trimester of pregnancy. Previous results
didn’t match with this study that showed that a high
Reference
percentage found within the second trimester.
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Effect of educational nursing guideline about paracentesis procedure care on nurses' performance
Eman Samir Fahmy 1, Hayah Abou Elazayiem Bayomi 2, Rokaia Fathi Mohamed 3
1. Clinical instructor of Medical Surgical Nursing-Faculty of Nursing - South Valley University

2. Assistant Professor of Medical Surgical Nursing - Faculty of Nursing - South Valley University
3. Lecturer of Medical Surgical Nursing - Faculty of Nursing- Minia University
Email of the corresponding author: e.sf31@yahoo.com
Abstract
Background: paracentesis is a common invasive method for managing patients with ascites; but it is
associated with many potential complications. Nurses play a crucial role in preventing theses complications by
providing special care before, during and after the procedures. Aim of the study: To evaluate the effect of educational
nursing guideline about paracentesis procedure care on nurses' performance. Methodology: Research design: A pre/
posttest quasi-experimental research design was utilized in the present study. Sample: A convenient sample of (40)
nurses was included in this study. Setting: The study was carried out at the tropical medicine departments of Qena
University Hospital and Qena General Hospital, Qena governorate, Egypt. Tools of data collection: Two tools were
utilized to collect data, First Tool: Structured interviewing questionnaire covered 2 parts: First part: Demographic
data of the nurses. Second part included knowledge assessment sheet about paracentesis procedure. Second Tool:
Observational checklist about paracentesis procedure. 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. Results: The study results
revealed that there was a highly statistical improvement in total level of nurses' performance regarding paracentesis
procedures at post and follow up phases after implementation of educational guidelines than before, with (p<0.001).
Conclusion: The application of educational nursing guidelines about paracentesis procedure enriched nurses'
knowledge and practice than before. Recommendations: Continuous nursing education about paracentesis procedure
is recommended to upgrade the knowledge and skills of nurses, replication of the current study on a larger probability
sample from different geographical areas to achieve generalizable results. Also it is important to investigate the effect
of applying this educational nursing guideline on ascetic patients' outcome.
Key Words: Educational Nursing Guidelines- Paracentesis - Nurses Performance
Introduction care is beginning with (assessment for patient condition, vital

Paracentesis is a procedure in which a needle or sings, taking consent, providing explanation about procedure,
catheter is inserted into the peritoneal cavity under sterile gathering needed supplies, preparing patient as emptying
conditions in order to; drainage fluid from abdominal cavity in bladder, and positioning), while during procedure actions
ascites condition, relieve pressure on the abdominal and chest include (maintaining aseptic technique and closely monitoring
organs, and to study chemical, bacteriological and cellular for the patient throughout the procedure for any abnormalities)
composition of the peritoneal fluid for the diagnosis of (Watkins et al., 2015). Post procedure interventions include;
diseases.( Saberifiroozi, 2017). applying a sterile dressing and a pressure bandage at the
However Paracentesis has been shown to be a safe puncture site to prevent leakage of fluid, continuing to
and efficient method for treating patients with severe ascites monitor vital signs, assessing for hypovolemia, electrolyte
that is resistant to nutritional and diuretic therapy, it can cause shifts, and changes in mental status, giving prescribed albumin
severe problems to the patient, and associated with some risks intravenously after large volume paracentesis and
or complications. These complications can be divided into; documenting the procedure (National clinical Paracentesis
systemic, local and intra-peritoneal complications. Systematic guidelines, 2015)
complications as (severe hypotension and infection), local as
(abdominal wall hematoma and localized infection at the Significance of the study
puncture site), and intra-peritoneal as (perforation of vessels The flow rate of ascetic patients (from 2016 to the
and viscera, peritonitis) (Biecker, 2011). Several national and end of 2017) was nearly about 250 patients in Qena university
international studies showed that nursing adherence rate to hospital (Statistical unit of Qena university hospital, 2017).
paracentesis guideline is correlated with positive patient's Researcher viewed from working experience that there was a
outcomes, patient's safety, and reducing the risks for either gap between the actual practice and expected paracentesis care
local or systemic complications. (Saberifiroozi, 2017). according to the adopted guideline of care for ascetic patients
Hence the successful Paracentesis procedure mainly undergoing Paracentesis.
depends on skillful practitioner, highly strict aseptic Several conducted studies revealed that a high
technique, good preparation and carefully monitoring for the percent of ascetic patients undergoing paracentesis suffering
patients throughout the procedure, nurses have a major from either local or systemic complication as a result of
responsibilities toward patients undergoing Paracentesis malpractice (Saberifiroozi, 2017). One of these studies is that
because in order to minimize of intraperitoneal fluid without conducted in Mansura university hospital by (El-Sayed et al.,
intravascular volume depletion, preventing injury, and inhibit 2018) and found that 32% of patients had signs and symptoms
infection of peritoneal cavity (Gines et al., 2014). of hypovolemia after paracentesis because of lack of
Nursing role toward patient undergoing paracentesis monitoring, rapid and increased drainage of ascetic fluid, as
classified into pre, during and post procedure. Pre-procedure
P a g e | 21 Eman S., et al
well as 11% suffering from peritonitis due to breaking down paracentesis, its indications, contraindications, possible
of aseptic technique. complications and how to prevent them, needed supplies,
Furthermore in our geographical area at Qena nurses role before, during and after paracentesis procedure). It
hospitals nurses considered that the physician is the only consists of 20 multiple choices questions and used for nurses
responsible one for performing paracentesis procedure, and before and after the implementation of educational nursing
there is a lack of awareness that they have a major role in guidelines through three follow up phases.
assessing, preparing and monitoring patient from the
beginning until finishing, as well as after the procedure. There Scoring system: If nurses have score 60 % and more
for this study was conducted to investigate the effect of this was considered ''satisfactory" level of knowledge and if
educational nursing guideline regarding paracentesis care on they had less than 60% it will be considered ''unsatisfactory"
nurses' performance. level of knowledge.
Aim of the study 2. Second Tool: Observational checklist adopted from

The aim of this study was to evaluate the effect of (National Clinical Paracentesis Guideline, 2015) was used
educational nursing guideline about Paracentesis procedure as a pre and posttest for assessing the nurses' practices pre,
care on nurses' performance during and post paracentesis procedure. The steps of care
categorized into (not done, incompletely done, and completely
Research Hypotheses done).
Application of standardized nursing guideline of care
about paracentesis procedure will improve nurses' Scoring system
performance If the nurses was done more than 70% from practices
it will be considered ''high performance'', if they had less than
Research Design 70% it will be considered ''low performance''.
A pre/post quasi-experimental research design was
utilized to meet the aim of this study. Educational booklet was given to each nurse included in the
study in order to provide educational nursing guidelines about
Subjects paracentesis procedure. It is divided into two parts:
A convenient sample of 40 nurses (25 nurses from Theoretical part included (definition and causes of ascites,
Qena University hospital and 15 nurses from general definition of paracentesis, its indications, contraindications,
hospital). possible complications and how to prevent them, needed
equipment, right sites of needle insertion) and practical part
included (how to prepare patients undergoing paracentesis,
Inclusion criteria aseptic and right technique of needle insertion, patient's
All available nurses at tropical medicine department positioning, care during paracentesis and monitoring, nursing
of Qena University Hospital and in the tropical department of actions after finishing the procedure).
Qena general hospital who accept to participate in the current
research. Tools Validity:
The tools were tested for content validity by a jury of
Setting of the study five experts in the field of the study and necessary
The study was conducted at the tropical modifications were done. The tools were tested for internal
medicine departments in Qena University Hospital and Qena consistency.
General Hospital, Qena governorate, Egypt.
Tools Reliability
Study Duration Internal consistency was evaluated using Cronbach's
Data collection for this study was carried out through Alpha coefficient test which revealed that tools of the study
six months, from the beginning of January 2019 till the end of were reliable as indicated by the value of (0.87 and 0.91) for
June 2019. knowledge and practice respectively
Tools of data collection Pilot study

Two tools were utilized in order to fulfill this study: A pilot study was conducted on 4 nurses (10% of the
total sample) to test clarity, completeness and to determine the
1. First Tool: time involvement. They included in our actual sample because
A structured questionnaire was designed by the no modifications needed to be performed.
researcher after reviewing of the recent related literature
(James and solove, 2016, El-Sayed et al., 2018) consists of Ethical Considerations
two parts:- A written initial approval was obtained from
Part (1): Demographic data: as (name, age, marital status, the research ethical committee of the faculty of nursing, Minia
place of residence, qualification, years of experience, previous University. The purpose of the present research was explained
training programs). for every nurse and each nurse has had the right to agree or
refuse participation in the study and written consent was
Part (2): Knowledge assessment sheet obtained from nurses who participated in this study. They also
Self-administered knowledge sheet was filled by informed that the information obtained would be confidential
participants nurses about abdominal paracentesis procedure and would be used only for the purpose of the study. Each
include; (definition and causes of ascites, definition of
assessment sheet was coded and nurses' name didn't appear on then by nurses until the researcher became sure that nurses
the sheets in the purpose of anonymity and confidentiality. were applying these steps perfectly. The education of the
standardized nursing guidelines carried out at morning, and
Data Collection Procedure after noon shifts from 1/2/2019 to 28/2/2019.
Phase I: Preparatory and administrative phase:
Administrative approval was obtained from the dean of Phase III: Evaluation phase: One month after providing of
Faculty of Nursing, Minia University to the managers of the educational intervention, the 1st post test was conducted
selected hospitals before implementation of the study, and for evaluating the nurses' knowledge and practice; the
then an official permission to conduct the proposed study was knowledge was evaluated by allowing each nurse to refill tool
obtained by the researcher from the manager of Qena (I) individually, while the practice was evaluated by the
University Hospital and Qena General Hospital. Also the researcher through observing each nurse while performing
official approval for data collection was obtained from the paracentesis procedure care individually and rechecking each
medical consultant of the study setting after explanation of the step if done completely, incompletely or not done through
purpose of the study. Moreover written consent was obtained using guidelines check list tool (II). The 1st posttest was
from each nurse participated in this study. conducted at morning, and after noon shifts from 1/4/2019 to
30/24/2019.
Phase II: Implementation phase: Once the permission was One month later (from 1/5/2019 to 31/5/2019), the
obtained to conduct the study, the researcher initiated data 2nd posttest was done using the same technique and the last
collection. Collection of data was started from the beginning third posttest was performed by the same way after another
of January 2019 to the end of June 2019, through 4 days month (from 1/6/2019 to 30/6/2019). Post-tests were
weekly during 2 shifts, the first shift is from (8 am: 2 pm), and conducted by interviewing and observing each participant
the second shift is from (2 pm: 8 pm). alone.
At initial interview the researcher introduced herself
to initiate communication, explained the nature and purpose of Limitations/difficulties of the study
the study and the nurses were persuaded by the importance of 1. Work load of nurses was an obstacle as the
their role in providing a safe paracentesis procedure and researcher was waiting for a long time to start the
preventing its complication. Then each nurse was involved in session with participants, also this make some
a pre-test, she/ he was assessed for his or her baseline participants to be tired to listen and has low
knowledge using (tool I), this tool was filled individually by concentration and need continuous repetition, which
the nurses within about 15 min, then each nurse was assessed required a lot of time and effort.
individually by the researcher during her/his routine care in 2. Interruptions during conducting sessions by other
paracentesis procedure to determine their baseline of practice staff members.
using (tool II).
Nurses were divided into groups according to shifts Statistical Analysis of Data
and time available, each group contain 2 to 7 nurses and each Data entry was done using compatible personal
group of nurses selected the suitable time for receiving the computer. The statistical analysis was done using SPSS–20
teaching sessions whenever they have minimal workload. Two statistical software package. Data were collected, revised,
teaching sessions were conducted at the prepared training coded, analyzed, and tabulated using number and percentage
places for each group using the prepared teaching aids and distribution. Data were presented using descriptive statistics in
media (booklets, power point and videos ), in order to cover the form of frequency and percentages for quantitative
the following items (definition and causes of ascites, continuous data which were compared by using student T–test
definition of paracentesis, it's indications, contra-indications, in case of comparisons between the mean scores of the two
complications, equipment, the sites of needle insertion, patient studied groups. For multiple groups F–test or (ANOVA) was
positioning, nursing role before, during, and after paracentesis used. Person correlation analysis was used for assessment of
procedure. Each session took around 40 minutes. Each nurse the interrelationships between knowledge and practices
obtained a booklet that included all the training contents. The pre\post\follow up program. Statistical significance was used
application of nursing guidelines was performed by researcher at p. value < 0.05.
Results
Table (1): Frequency distribution of the participants according to their demographic data (n=40).
Item (N=40) %
Gender:
Male 6 15
Female 34 85
Age
18-24 21 52.5
≥ 25 19 47.5
Mean+ SD 23.22±3.91
Years of experience
1-6yrs 29 72.5
≥ 7yrs 11 27.5
Qualification:
Diploma 5 12.5
Technical Institute 32 80
Bachelor 3 7.5
Previous courses in paracentesis
Yes 0 0
No 40 100
Place of residence
Rural 25 62.5
Urban 15 37.5
Marital status
Single 12 30
Married 28 70
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.
77.50%
92.50%
85%
100.00% 72.50% Satisfactory
27.50%
15% Unsatisfactory
50.00% 7.50%
22.50%
Unsatisfactory
Satisfactory
0.00%
Pre Post1 Post2 Post3
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.
100.00% 92.50%
82.50% 85%
90.00%
80.00% 82%
70.00%
60.00%
High performance
50.00%
Low performance
40.00% 18%
30.00%
17.50% 15%
20.00%
7.50%
10.00%
0.00%
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)
Nurses level of knowledge about paracentesis (n=40)
Pre Post1 Post2 Post3 P1 P2 P3 P4 P5 P6
Mean +SD Mean +SD Mean +SD Mean +SD
8.60+0.92 15.35+2.04 14.60+2.72 13.67+3.45 0.000** 0.000** 0.000** 0.029* 0.002* 0.024*
Nurses level of practice regarding paracentesis procedure (n=40)

Pre Post1 Post2 Post3 P1 P2 P3 P4 P5 P6
Mean +SD Mean +SD Mean +SD Mean +SD
Pre paracentesis procedure care
0.000** 0.000** 0.000** 0.017* 0.000** 0.022*
15.25+1.97 13.37+1.84
5.60+4.43 14.25+273
During paracentesis procedure care
4.62+4.95 0.000** 0.000** 0.000** 0.772 0.019* 0.005**
16.47+3.43 15.07+3.01
16.32+3.02
After paracentesis procedure
22.02+5.08 18.42+1.70
4.53+5.96 20.85+4.59 0.000** 0.000** 0.000** 0.259 0.000** 0.000**
Mean score for total level of practice
53.80+7.85 48.87+5.60
14.75+13.9 51.42+9.91 0.000** 0.000** 0.000** 0.121 0.000** 0.000**
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 after implementation 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
Knowledge Practice
Items t test P value
Mean +SD Mean +SD
Pre 8.60±0.92 14.75±13.9 2.93 .006**
Post1 15.35±2.04 53.80±7.85 36.3 .000**
Post2 14.60±2.72 51.42±9.91 31.8 .000**
Post3 13.67±3.45 45.87±5.60 72.65 .000**
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)
Total scores of nurses’ knowledge about paracentesis procedure
Pre X2 Post1 X2 Post2 X2 Post3 X2
Characteristics P value P value P value P value
Unsatisfy Satisfy Unsatisfy Satisfy Unsatisfy Satisfy Unsatisfy Satisfy
N % N % N % N % N % N % N % N %
Age
18-24yrs 18 45 3 7.5 1.71 2 5 19 47.5 .261 4 10 17 42.5 .568 9 22.5 12 30 5.23
25-32yrs 13 32.5 6 15 .191NS 1 2.5 18 45 .609NS 2 5 17 42.5 .451NS 2 5 17 42.5 .022*
Gender
Male 5 12.5 1 2.5 .138 2 5 4 10 6.79 2 5 4 10 1.86 2 5 4 10 .120
Female 26 65 8 20 .711NS 1 2.5 33 82.5 .009** 4 10 30 75 .173NS 9 22.5 25 62.5 .729NS
Qualification
Diploma 4 10 1 2.5 0 0 5 12.5 0 0 5 12.5 0 0 5 12.5
11.2 .811 1.76 3.79
Technical 27 67.5 5 12.5 3 7.5 29 72.5 6 15 26 65 11 27.5 21 52.5
.004** .667NS .414NS .150NS
Bachelor 0 0 3 7.5 0 0 3 7.5 0 0 3 7.5 0 0 3 7.5
Years of experience
1-7yrs 22 55 7 17.5 .162 2 5 27 67.5 .055 4 10 25 62.5 .120 9 22.5 20 50 .661

8-14yrs 9 22.5 2 5 .687NS 1 2.5 10 25 .814NS 2 5 9 22.5 .729NS 2 5 9 22.5 .416NS
Place of residence
Rural 18 45 7 17.5 1.15 1 2.5 24 60 1.17 3 7.5 22 55 .471 7 17.5 18 45 .008

Urban 13 32.5 2 5 .282NS 2 5 13 32.5 .278NS 3 7.5 12 30 .493NS 4 10 11 27.5 .927NS
Total scores of nurses’ knowledge about paracentesis procedure
Pre X2 Post1 X2 Post2 X2 Post3 X2
Characteristics P value P value P value P value
Unsatisfy Satisfy Unsatisfy Satisfy Unsatisfy Satisfy Unsatisfy Satisfy
N % N % N % N % N % N % N % N %
Marital statues
Single 9 22.5 3 7.5 .061 1 2.5 11 27.5 .017 2 5 10 25 .037 3 7.5 9 22.5 .054
Married 22 55 6 15 .804NS 2 5 26 65 .896NS 4 10 24 60 .847NS 8 20 20 50 .817NS
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)
Total score of nurses’ practice regarding paracentesis procedure
Characteristics X2 X2 X2 X2
Low High Low High Low High Low High
P value P value P value P value
N % N % N % N % N % N % N % N %
Age
18-24yrs 19 47.5 2 5 1.94 1 2.5 20 50 .478 4 10 17 42.5 .568 9 22.5 12 30 .3.48
25-32yrs 14 35 5 12.5 .163NS 2 5 17 42.5 .489NS 2 5 17 42.5 .451NS 3 7.5 16 40 .062NS
Gender
Male 4 10 2 5 2 5 4 10 2 5 4 10 2 5 4 10
1.22 6.79 1.86
Female 29 72.5 5 12.5 1 2.5 33 82.5 4 10 30 75 10 1.25 24 60 .037
.268NS .009** .173NS
.847NS
Qualification
Diploma 5 12.5 0 0 0 0 5 12.5 0 0 5 12.5 0 0 5 12.5
6.16 .811 1.76 4.28
Technical 27 67.5 5 12.5 3 7.5 29 72.5 6 15 26 65 12 30 20 50
.046* .667NS .414NS .117NS
Bachelor 1 2.5 2 5 0 0 3 7.5 0 0 3 7.5 0 0 3 7.5
Years of experience
1-7yrs 24 60 5 12.5 2 5 27 67.5 4 10 25 62.5 10 25 19 47.5
.005 .055 .120 1.01
8-14yrs 9 22.5 2 5 1 2.5 10 25 2 5 9 22.5 2 5 9 22.5
.944NS .814NS .729NS .315NS
Place of residence
Rural 19 47.5 6 15 1.95 2 5 23 57.5 .024 3 7.5 22 55 .471 8 20 17 42.5 .127

Urban 14 35 1 2.5 .162NS 1 2.5 14 35 .877NS 3 7.5 12 30 .493NS 4 10 11 27.5 .722NS
Marital statues
Single 9 22.5 3 7.5 .668 2 5 10 25 2.07 2 5 10 25 .037 4 10 8 20 .091
Married 24 60 4 10 .414NS 1 2.5 27 67.5 .150NS 4 10 24 60 .847NS 8 20 20 50 .763NS
Table (5) Showed that there 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.
Discussion Discussion of the demographic characteristics of the

Today, there are many challenges facing nursing staff Studied Sample
as; an expansion in technology, consumer demand for high The current study findings revealed that the majority
quality of care, pressure for cost containment, decreased a of nurses were females; this might be due to the fact that the
length of stay in hospitals, an aging population, and increase profession of nursing in Egypt is more specialized and private
incidence of comorbidities. These challenges are strongly to females; because the study of nursing field was exclusive to
associated with a need to prepare high qualified nurses with females till only few years ago. In addition, male nurses in
most focus on their knowledge and practice (Duchscher, contrast to females prefer to travel to work abroad due to the
2019). higher salaries and better opportunities. This finding was in
Ascites is one of the most common pathological the same line with (Elsayed, et al., 2018) who conducted a
conditions in developing countries especially Egypt known as study entitled "Applying nursing safety measure to prevent
excessive accumulation of extracellular fluid within the complications for liver cirrhotic patient undergoing
peritoneal cavity, which usually develops as a result of paracentesis" at Mansoura University and found that the
cirrhosis of the liver. Paracentesis is the main procedure for majority of studied nurses were females. While In contrast of
removing ascetic fluid from the peritoneal cavity via a (Ghonemy et al., 2016) who reported that the most of the
temporary ascetic drain. Prevention and reducing the studied sample were males and viewed that this result may
incidence of potential paracentesis complications is a major reflect a social background, keeping women away from this
role of nurses (Robinson, 2019). So this research was job and due to the fact that most of female nurses are
conducted to support nurses in providing safe and effective appointed to care for maternal and child health care. Also, this
care for patients undergoing paracentesis through may be due to the fact that males cover night duties while a
implementing standardized nursing guideline of care about female does not.
paracentesis procedure. As regards nurses' ages, more than half of the studied
nurses were younger than 25 years, this would be due to that
the young nurses constituted the main work power in the
hospitals and were confined to provide the direct nursing care
to patients, while the older nurses assumed the administrative
roles. This finding was similar to that was revealed by implementation of nursing safety measure to prevent
(Mobed, et al., 2018) who conducted a study entitled "Effect complications for liver cirrhotic patient undergoing
of Designed Nursing Guidelines on Nursing Intervention to paracentesis.
Reduce Complications for Cirrhotic Patients Undergoing After implementation of the educational guidelines,
Paracentesis" in Assuit, Egypt and found that the majority of there was a significant improvement in the total scores of
the studied nurses were in the age group of young adults. nurses' knowledge regarding paracentesis procedure. This fact
However, this finding disagreed with (Yboa et al., 2016) who achieved the current study hypothesis in which the application
revealed that studied nurses' age ranged between 24 and 45 of standardized nursing guideline of care about paracentesis
years. procedure significantly improved nurses' knowledge. This
Considering the years of experience, the majority of finding was in harmony with (Mobed, et al., 2018) who found
studied nurses had less than 7 years of experience which a statistically significant difference in the nurses' knowledge
might be related to their young age and new graduation. This about paracentesis items at pre and posttests. Similarly; this
fact was consistent with (Mohamed, et al., 2018) who finding was consistent with (Venkatramana et al., 2014) who
revealed that the majority of studied nurses had experience revealed that the majority of studied nurses had adequate
less than 7 years. However, against to results of (Khalil, knowledge at the post test phases. Also in consistent with the
2013) who found that the studied nurses' experience was more results of a study conducted by (Yboa et al., 2016), who
than 10 years. found that the educational interventions were effective in
Regarding qualification level of the studied nurses, improving the knowledge level of nursing staff and suggested
the present study revealed that, more than two thirds of the that group base intervention can improve knowledge of health
studied nurses had technical nursing education. This result care workers about nursing procedures.
might be due to that the technical institute of nursing provided
the community with large number of nurses; due to the great 3- Discussion of educational nursing guidelines effect on
turnout of students to study in nursing technical institutes; to nurses' practice
speed up their employment and to improve their income. This The present study demonstrated a major deficiency in
finding agreed with (Elsayed, et al., 2018) whose study nurses' practice before, during and after paracentesis
revealed that the majority of nurses were having technical procedure prior to implementation of the educational
education, while On the opposite side of (Ahmad, 2011) guideline; it was a striking finding that (82.5%) of them had a
revealed that nursing diploma took the highest percentage in low performance level before guidelines education, this was
their study. Also our results revealed that no one of studied mainly due to that nurses were believing that they had not any
nurses had any in-service training courses related to the role in paracentesis procedure considering it a medical
paracentesis procedure care; this may be attributed to their procedure not as a nursing. In addition there was a lack in
hospital focusing on courses related to infection control rather training programs regarding paracentesis care for new staff
than courses related to improving the quality of nursing care. nurses, teaching aids and standards for care inside the units.
This finding was consistent with (Mobed, et al., 2018) who These findings were in agreement with (Yboa et al., 2016)
found that less than one third of studied nurses had in-service and (Elsayed, et al., 2018) who found low level of nurses'
training courses related to paracentesis procedure, and stated practice regarding care of patients undergoing paracentesis.
that there no focus on educating and training the new staff The implementation of the guidelines led to a
members on techniques and protocols of nursing procedures. significant improvement in nurses' practice in all tested areas
Concerning marital status and place of residence, which was observed throughout the follow up tests compared
more than two thirds of studied nurses were married and to pretest; reflected the positive impact of the guidelines
resident in rural areas; this may be due to the habits of early education on nurses' practice and achieved the research
marriage in Upper Egypt especially in the rural areas. These hypothesis. This is in agreement with (Bayoumi and
findings agreed with (shehab, et al., 2018) who revealed that mahmoud, 2019) and (Elmagraby and Mohammed, 2019)
the majority of studied nurses were married. In contrast, who found that there was a highly statistically significant
(Gomarverdi., et al., 2019) conducted a study in which more improvement in nurses' practice immediately and 6 months
than half of studied nurses were single. after implementation of the educational guideline compared
with before.
2- Discussion of educational nursing guidelines effect on According to figure (1), figure (2) and table (2), the
nurses' knowledge highest levels of knowledge, practice and mean scores of both
The results of current study highlighted the overall were reported after implementation of the educational
unsatisfactory nurses' knowledge about paracentesis procedure guideline during the follow-up (1 and 2) respectively. While,
at the pre-implementation phase reflecting the lack in their there is some decline in the level of nurses' knowledge and
scientific preparation. It was found that about two thirds of the practice at the follow-up (3) test compared to follow-up (1 and
nurses had inaccurate knowledge about patient's preparation, 2). These results are in agreement to study done by (Jan et al.,
indications and contraindications of paracentesis, also the 2015) who found that the improvement in knowledge and
majority of them had incomplete knowledge about (needed practices was partially declined after two months of
equipments, sites of needle insertion, patient positioning, signs implementation of teaching protocol. These findings might be
and symptoms of hypovolemia and peritonitis). This may be explained by the fact that the health authorities, hospital
attributed in to insufficient courses related to paracentesis managers and head nurse of departments did not follow nurses
included in their undergraduate curriculum of nursing performance and ensuring that they applying standardized
education, and on the other hand to lack of continuous guidelines of care for patients, in addition to lack of
education and in service training programs. These findings are opportunity for providing continuous education in hospital to
consistent with a study conducted by (Elsayed, et al., 2018), improve the nurses' performance knowledge.
in which nurses' knowledge was generally low before
4-Discussion of relation between demographic data and monitoring for patient' vital signs compared with nurses with a
nurses' (knowledge/ practice) diploma. While this finding was opposite to (Seliman, et al.,
Knowledge 2014) who highlighted that there was no statistical significant
The relationship between personal characteristics of difference in total practice scores of nurses through all
nurses and their knowledge and practices was investigated in assessment periods regarding their sex and educational level.
this study. It was found that there was a significant relation However, the study revealed that nurses' age, years of
between nurses' knowledge scores and their ages at the third experience, place of residence, marital status and training
follow-up test; in which nurses older than 25 years were had courses had no effect on their level of practice. These findings
more satisfactory knowledge level than the younger categories are against to the results of (Thomsen et al., 2018) and (Jan
with (P. value 0.022). This result was in harmony with that of et al., 2015) who found a significant relation between nurses'
(Sabaq, et al., 2019) who found that there was a significant practice and their age, and years of experience.
relation between nurses' knowledge scores and their age at the
pre-program phases. On the other hand this finding is opposite Conclusion
to (Koshy, 2016) who found that there was no significant Based on the findings of the present study, it can be
relation between nurses' knowledge scores and their age. concluded that nurses who received nursing educational
Concerning gender of nurses, the study revealed that guidlines about paracentesis procedure showed a statistically
there was a significant correlation between the gender of significant improvement in their total level of knowledge and
studied nurses and their knowledge regarding paracentesis practice than before, and this is supported the research
procedure at the posttest (1), in which females had the highest hypothesis. The improvent in nurses' performane was
percentage of knowledge than males with a p value of (0.009). significantly higher after one and two months of guideline
This finding was in the same line with (Mobed, et al., 2018) application with some decline at the third follow up phase
who demonstrated a significant relation between nurses' (after three months) which indicate the need for performing
knowledge scores and their sex during the pre-test, but against training sessions for nurses at regular intervals.
the results of (Koshy et al., 2016) whose study revealed no
statistical difference between knowledge score and nurses Recommendations
gender. Based on results of the present study it can be
Concerning qualifications, the present study revealed recommended that:
that there was a highly significant correlation between the 1. More attention must be paid to paracentesis
educational qualifications of studied nurses and their procedure and its care in the curriculum for all
knowledge regarding paracentesis procedure in the pretest (p educational categories of nursing students.
0.004); presented as higher knowledge scores achieved by 2. It is necessary to develop a continued nursing
bachelor degree nurses. This finding agreed with (Elmagraby education and in-service training programs in internal
and Mohammed, 2019) who illustrated that there was a medicine units at both Qena General and University
significant correlation between educational qualifications and Hospitals especially for newly jointed nurses about
total nurses' knowledge score. This can be explained as standardized guidelines of care ascetic patients
nurses with more education response better than diploma undergoing paracentesis in order to improve the
nurses to educational training programs. However this finding quality of care using a scientific booklet, brochures
is in contrast with the study of (Nimbalkar, et al., 2014) who and Panners.
found that the variable of educational qualifications does not 3. Periodic monitoring for nurses' adherence to
play a role in nurses' knowledge. paracentesis guidelines and to evaluate the level of
However, no statistically significant relations were nurses performance..
found between staff nurses' knowledge and their years of 4. Replication of the current study on larger probability
experience, place of residence, marital status and training sample and on other health care settings.
courses. These results were against of (Thomsen et al., 2018)
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Assessment of Knowledge, Beliefs and Level of Internet Addiction among Nursing Students at Minia
University
Shimaa Abd El-Razek Younis1, Eman Mohamed Mahfouz 2, Yosria El-Sayed Hossien3
1. Assistant lecturer of Community Health Nursing, Faculty of Nursing, Minia University, Egypt.
2. Professor of Public Health medicine, Faculty of Medicine, Minia University, Egypt.
3. Professor of Community Health Nursing, Faculty of Nursing, Minia University, Egypt.
Abstract
Background: Worldwide, Internet addiction is a major and serious challenge. With uncontrolled use of the internet,
university students may suffer from academic problems, distractions, and social isolation. Aim: This study aimed to
assess knowledge, beliefs, and level of Internet addiction among nursing students at Minia University. The Health
Belief Model was used as a theoretical framework in the study. Design: Descriptive research design. Setting: The
study was conducted at the faculty of nursing at Minia University. Sample: Three hundred and seventy (370) students
were included using a stratified random sample. Tools: Data collected using two tools, the 1st tool was a self-
administered questionnaire based on The Health Belief Model to assess the students' knowledge and beliefs about
Internet addiction, and the 2nd tool was the Arabic version of the Internet Addiction Test to assess the students' level
of Internet addiction. Results: 91.1% of the participants had poor knowledge about Internet addiction. Regarding
health beliefs toward IA, 66.5% had low perceived susceptibility, 64.1% had low perceived severity, 53.5% had high
perceived barriers, 56.8% had high perceived benefits, 64.3% had low perceived cues to action, and 73% had low
perceived self-efficacy. Concerning the level of Internet addiction, 44.6% had a mild level followed by 38.9% had a
moderate level and 3.5% had a severe level of Internet addiction. Conclusion: The majority of participants had poor
knowledge and low Health Belief Model constructs toward Internet addiction except for perceived barriers. The
majority had mild and moderate levels of Internet addiction and the minority had a severe Internet addiction.
Recommendation: strategies should be developed to increase awareness and decrease the level of Internet addiction
among university students.
Key words: Internet addiction, Beliefs, Knowledge, Level
Introduction al., 2018).The role of the nurse is to contribute to the

The Internet has become one of the most important preventive and therapeutic intervention to face this
tools for knowledge, work opportunities, education and phenomenon. The nurse should help students to understand
amusement involving social media platforms and networking the effects of excessive internet usage on themselves
and is increasingly developed to be a structural element of our physically and mentally and how to overcome these impacts
daily life (Thakur al., 2018). Over the past fifteen (15) years, of internet addiction(Hamzaa, 2017). Considering the
Internet use has grown very fast: in current society about 40% globalization and the complexity of IA community health
of the global population is online ( Kuss et al., 2014). The nurses must establish an effective program for the
growing popularity and frequency of internet use has resulted management of the addiction as well as the daily problems
in the appearance of clinical conditions manifesting abuse that such condition raises. Within the clinical context of
symptoms identified as Internet addiction (IA) (Spada, 2014). mental health, nurses can have an effective role not only in the
Internet addiction is classically defined as a condition where assessment, diagnosis, and treatment of IA but in the
an individual has impaired control of their internet use and prevention of that phenomenon as well
proceed to use the internet too much to the point where he/she (Fradelos et al., 2016).
suffers problematic effects which ultimately have negative
consequences on his/her life(Smyth et al., 2019). Internet Significance of The study
addiction primarily put forward by Ivan Goldberg in 1995 and Internet addiction (IA) is a worldwide phenomenon
since then, it has become a social-psychological problem and with different levels and it ranges from five to twenty-five
a lot of researchers have been studying this topic (Dongyun et percent among students in the united states (US), China, South
al., 2018; Wiederhold, 2018& Griffiths, 2018). Even though Korea, England, Australia, Taiwan, Japan, and other countries
IA was not formally added into the fifth edition of the in Eastern and Western Europe (Maheri et al., 2017).
Diagnostic and Statistical Manual of Mental Disorders (DSM- Internet World Stats revealed that Egypt has the second-
V) in 2013, Internet Gaming Disorder (IGD) has been highest number of internet users in Africa after Nigeria. On
involved in sector III, highlighting the significance of this area average, Egyptians stay 26 hours a week on the internet
for further study (Petry & O’brien, 2013; Cho et al., 2014; according to the MidEast Media Survey ‘Media Use in the
Hahn et al., 2017& Spada, 2014). Middle East’ in 2017 (Eltigani, 2019). University students are
Assessment of knowledge and beliefs regarding safe particularly at risk for encountering dependence on the
usage of the internet is necessary. Ong and Tan (2014) in a Internet, greater than other segments of the community. This
study aimed to assess IA in young people showed that can be attributed to numerous factors as the availability of
knowledge of IA among the public is a pertinent factor in the time, easiness of use, limitless access to the Internet and
prevention efforts regarding IA. Maheri et al., (2017) limited or no familial supervision (MMIN, 2017). Assessment
showed that improving college students' knowledge and of IA among university students is a pertinent factor for its
attitude about the addictive nature of the internet and side prevention effort.
effects of IA are crucial for the prevention of IA(Maheri et
P a g e | 30 Shimaa A., et al
Aim of the Study
Part III: A five-point Likert scale based on HBM assessed
The current study aimed to assess knowledge, beliefs the students' beliefs toward IA. The scale consisted of six
and level of internet addiction among nursing students at subscales as following: Perceived susceptibility (one question)
Minia University and perceived severity (5 questions), perceived barriers (9
questions), perceived benefits (6 question), cues to action (2
Theoretical Framework questions) and perceived self-efficacy (5questions).
One of the most commonly applied models in
explaining and adopting healthy behaviors such as the Scoring system
protective behavior of addiction is the Health Belief Model The statements of this part were scored on a five-
(HBM) (Zadeh et al., 2014). The HBM was created in the point likert-type scale as following: strongly disagree (1),
US in 1950 by the Department of Public Health Service to disagree (2), neutral (3), agree (4), and strongly agree (5). The
understand the reasons for the ineffectiveness of public health entire score for each subscale was calculated by summing up
services directed toward the prevention of health problems. of all of its statements. With summed scores > 60% indicates a
The application of the model after that extended for higher level of the HBM subscale/construct while a summed
comprehending the adherence with clinical remedy (Orji et score ≤ 60% indicates a lower level of the subscale for each
al., 2012). Health Belief Model explains that health-related one.
behaviors of people are based on their perceived
susceptibility, perceived severity, perceived benefits, Tool 2: The Arabic version of Internet Addiction test
perceived barriers, cues to action, and perceived self-efficacy (IAT): It is a self-rated scale developed by Young (1998) to
(Zadeh et al., 2014). assess the existence and severity of IA. This tool consists of
twenty (20) items; These 20 items involve distraction,
Subjects and Methods compulsivity, and dependency. The items also assess conflicts
Research Design in personal, social, or occupational life that may arise from the
Descriptive research design was utilized in the addictive use of the internet. The Arabic version of IAT has
current study. been validated in a study conducted in Lebanon by
Hawi (2013).
Setting:
The study was conducted at faculty of nursing at Scoring system
Minia University. The statements of the IA test were scored on a five-
point Likert-type scale, rarely (1), occasionally (2), frequently
Sample size (3), often (4), always (5). Sum of the scores that ranged from
Sample size was calculated based on Cochran 0 to 30 points indicated a normal level of internet usage;
formula, (1963) while n= t2×p (1-p)/ m2 considering 41.5% scores of 31 to 49 reflected a mild level of IA; scores of 50 to
prevalence rate of internet addiction according to Abdelghani, 79 indicated a moderate level, and scores of 80 to 100
M et al., (2018). indicated severe internet dependence (Young, 1998).
Inclusion criteria for the study sample Content Validity of the Tools
(1) Undergraduate students at faculty of nursing at The content validity of the study tools was tested by
Minia University five experts in community health nursing. The tools were
(2) Currently using the internet for at least 3 hours/day examined for content coverage, sequence of items, clarity,
and in the past 6 months relevance, applicability, words length, format, and overall
appearance. Based on experts` comments, recommendations
Study Tools and modifications were made.
Tool 1: A self-administered questionnaire developed by the
researcher based on HBM and consisted of 4 parts as Reliability of the Tools
following: Reliability of the study questionnaire was calculated
Part I: sociodemographic data of the students such as: Age, using Cronbach’s alpha. Based on data analysis, coefficient
sex, faculty grade, residence, parents' education, family alpha for the knowledge part was 0.78, perceived severity
income, quality of relation with parents and friends, residence was 0.81, perceived barriers was 0.82, perceived benefits was
during studying, smoking status and academic average. 0.76, cues to action was 0.68, self efficacy was 0.92 , for all
the subscales of the HBM was 0.080, and for the entire
Part II: the student's knowledge about IA such as: definition, questionnaire was 0.70. As regard to the reliability of the
signs, causes, types of IA, its physical, psychological and IAT, it was 0.93.
social effects, and management of IA.
Procedure
Scoring system Before conducting the study an official permission
The scores for knowledge part of the questionnaire was taken from the dean of the faculty of nursing to conduct
were calculated based on one point (1) for the correct answer the study. The interview with the students of each grade was
and zero (0) for the wrong answer or don’t know respectively. held at their specialized faculty class. The researcher first
Therefore the participants were considered to have a very introduced herself to the students, explained to them the
good level of knowledge if the total score >75 %, good if the purposes of the study briefly and an oral consent for
total score ranged from 60-75% and poor if the total score < participation was obtained. The tools of the study were filled
60% MMIN, M. (2017).
by the students and aided by the researcher. The time required descriptive statistics in the form of frequencies and
to fill the questionnaire was about 15 minutes. percentages for qualitative variables, and means and standard
deviations for quantitative variables. The Chi square used in
Pilot study tests of relationship. Probability (P-value) less than 0.05 was
It was applied on 10% of the calculated sample to considered significant. (p < 0.05).
assess the validity of the questionnaire and to assess
acceptability of the students to the topic of the research. The Ethical considerations
results of pilot study were included in the final results of the A written approval obtained from the ethics and
research as there were no major modifications were done in research committee of the faculty of nursing at Minia
the tools of the study University. Oral consent obtained from students after
explaining the nature and objectives of the study to gain their
Statistical Analysis cooperation. Each assessment sheet was coded for the purpose
Data entry and statistical analysis were done using of privacy and confidentiality. Participants were free to
SPSS 24.0 statistical software package. Data presented using withdraw from the study at any time.
Results
Table (1) Distribution of the studied Minia university nursing students according to their socioemographic characteristics in
the academic year of 2018/2019 (n=370)
Socio-demographic characteristics No Percent%
Age
18-21 244 65.9
22-24 126 34.1
Mean ± SD 20.78 ± 1.30
Gender
Male 150 40.5
Female 220 59.5
Faculty grade
1st year 89 24.0
2nd year 85 23.0
3rd year 111 30.0
4th year 85 23.0
Residence
Rural 278 75.1
Urban 92 24.9
Quality of relation with parents
Good 358 96.8
Poor 12 3.2
Residence during study
with family 231 62.4
away from family 139 37.6
Smoking
Smoker 20 5.4
Non smoker 350 94.6
Academic performance
Excellent 75 20.2
Very good 156 42.2
Good 105 28.4
Pass or weak 34 9.2
Father education
Does not read or write 52 14.1
Primary 47 12.7
Preparatory 35 9.5
Secondary 128 34.6
University 83 22.4
Post university studies 25 6.8
Mother education
Does not read or write 116 31.4
Primary 44 11.9
Preparatory 41 11.1
Secondary 109 29.5
University 48 13.0
Post university studies 12 3.2
Family income/month
less than 2000 L.E 166 44.9
2000-3000 L.E 158 42.7
More than 3000 L.E 46 12.4
Table (1) shows that 65.9% of the participants are in the age group 18 – 21 yrs with a mean score± SD 20.78 ± 1.30, 59.5%
of the participants are females, 75.1% live in rural areas, 96.8% have a good relationship with their parents, 62.4% are residents with
their parents during the study, 5.4% are smokers, and 42.2% their academic performance is very good. The table also shows that
34.6% of the participants their fathers' education is a secondary education, 31.4% their mothers don't read or write, 44.9% of the
participants their monthly family income is less than 2000 L.E
Table (2) Distribution of the studied Minia University nursing students according to their knowledge about definition and
signs of IA (N=370)
Item No %
Definition
 Complete answer 96 25.9
 Incomplete answer 258 69.7
 I don't know 16 4.3
Signs of IA#
 Irritability during withdrawal 163 44.1
 Jeopardizing a significant relationship, or responsibilities 214 57.8
 Loss of sense of time during use
 Check electronic notifications 206 55.7
 Preoccupation with the internet 114 30.8
 Failure to reduce time of use 105 28.4
 I don't know 185 50.0
27 7.3
#
Mutual exclusive more than one answer
Table (2) shows that 69.7% of the participants' definition of IA is incomplete while 4.3% don't know the definition of IA.
Regarding knowledge about signs of IA 57.8% mention jeopardizing a significant relationship or responsibilities as a sign of IA while
7.3% doesn't know any signs of IA.
Table (3) Distribution of the studied Minia University nursing according to their knowledge about causes and social effects of
IA (n=370)
Item No %
Causes#
 Personal privacy 78 21.2
 Emotional relief 164 44.6
 Escape from reality 189 51.4
 Free time and boredom 202 54.9
 Feeling lonely 141 38.3
 Easy access 90 24.5
21 5.7
 I don't know
Social Effects#
 Low academic performance 235 63.7
 Family disconnection 87 23.6
 low productivity of work 169 45.8
 I don't know 68 18.4
#
Mutual exclusive more than one answer
Table (3) shows that 54.9% of the participants mention free time and boredom as a cause of IA while 5.7% don't know
causes of IA. In relation to knowledge about social effects of IA, 63.7% mention low academic performance while 18.4% don't know
its social effect
100 91.1%
90
80
70
60 Very Good
50
Good
40
Poor
30
20
10 3% 5.9%
0
Very Good Good Poor
Fig. (1) Distribution of the studied Minia university nursing students according to their total level of knowledge about IA
Table (4a) Distribution of the studied Minia University nursing students according to their health beliefs toward IA (n=370)
Strongly Strongly
Agree Neutral Disagree
Item Agree disagree
No % No % No % No % No %
Perceived susceptibility
Likelihood o be internet addict 42 11.4 82 22.2 103 27.8 107 28.9 36 9.7
Perceived severity
IA is a serious disorder 35 9.5 60 16.2 74 20 160 43.2 41 11.1
Thinking of IA is a restless issue? 16 4.3 70 18.9 76 20.5 168 45.4 40 10.8
Strongly Strongly
Agree Neutral Disagree
Item Agree disagree
IA negatively affect my health 27 7.3 70 18.9 74 20 161 43.5 38 10.3
IA negatively affect me academically 68 18.4 154 41.6 72 19.5 55 14.9 21 5.7
IA may socially isolate me 55 14.9 102 27.6 92 24.9 82 22.2 39 10.5
Perceived barriers
limited social connection 78 21.1 98 26.5 76 20.5 92 24.9 26 7.0
Life seems boring without internet 54 14.6 116 31.4 68 18.4 84 22.7 48 13.0
Feeling lost without internet 60 16.2 68 18.4 80 21.6 107 28.9 55 14.9
Being an old fashioned person 61 16.5 95 25.7 55 14.9 103 27.8 56 15.1
No encouragement to  online time 58 15.7 92 24.9 61 16.5 126 34.1 33 8.9
Feeling lonely without internet 76 20.5 88 23.8 82 22.2 87 23.5 37 10
Negative effect on self-esteem 47 12.7 37 10 69 18.6 119 32.2 98 26.5
No other way to relieve stress 102 27.6 79 21.4 50 13.5 86 23.2 53 14.3
No help in decision making without internet 66 17.8 82 22.2 70 18.9 104 28.1 48 13
Table (4a) shows that 28.9% of the participants disagree they are susceptible to IA. As regards to their Perceived severity of
IA, 43.2% disagree that IA is a serious disease of the era. In the same domain of perceived severity, 45.4% disagree that thinking
about the negative effects of IA on health is a restless issue, 43.5% disagree that IA may negatively affect their health, 41.6 agree that
IA may negatively affect their academic performance, and 27.6% of the participants agree that IA may socially isolate them from their
family.
Regarding the participants' perceived barriers toward reducing internet use, the same table shows that 26.5% agree that
reducing internet time limit their social contact with friends and relatives, 31.4 agree that life seems boring without internet, 28.9%
disagree they will feel lost if they reduce their internet time, 27.8% disagree that they will be an old fashioned if they reduced their
internet time, 34.1% disagree that nobody encourages them to reduce their internet time, 23.8% agree they will feel lonely if reduce
their internet time, 32.2% disagree that reducing internet time may negatively affect their self-esteem, 27.6% strongly agree that there
is no other way to relieve stress if they reduced their internet use, and 28.1% agree that nobody will help them in their decision
making if they reduce internet use.
Table (4b) Distribution of the studied Minia University nursing students according their health beliefs toward IA (n=370)
Strongly Agree Agree Neutral Disagree Strongly disagree
Item
Perceived benefits
49 13.2 104 28.1 112 30.3 54 14.6 51 13.8
1-Focusing on important issues
2- Positive effect academically 71 19.2 156 42.2 68 18.4 50 13.5 25 6.8
3- Good relation with family/friends 45 12.2 93 25.1 108 29.2 96 25.9 28 7.6
4- Self satisfied with reduced use 36 9.7 141 38.1 122 33 48 13 23 6.2
5- Enjoying personal privacy 49 13.2 103 27.8 121 32.7 72 19.5 25 6.8
6- Positive effects on health 27 7.3 68 18.4 75 20.3 162 43.8 38 10.3
Cues to action
43 11.6 142 38.4 27 7.3 97 26.2 61 16.5
1- Cues to action from parents
2- Cues to action from teachers 26 7.0 93 25.1 37 10 117 31.6 97 26.2
Perceived self-Efficacy
25 6.8 78 21.1 91 24.6 85 23.0 91 24.6
1- Ability to reduce internet time?
2- Easiness to reduce internet time 23 6.2 58 15.7 40 10.8 98 26.5 151 40.8
3- Having a plenty of ideas to reduce internet time 19 5.1 51 13.8 83 22.4 103 27.8 114 30.8
4- If I worked hard on reducing time of internet
24 6.5 60 16.2 82 22.2 99 26.8 105 28.4
use, I would do it.
5-I intention to reduce daily hours of
33 8.9 90 24.3 114 30.8 62 16.8 71 19.2
internet time
Table (4b) shows that 30.2% of the participants are neutral about giving priority to important life issues as perceived benefits
of reducing internet, 42.2% agree that reducing the time of using the internet has a positive effect on their academic achievements,
29.2% are neutral about the benefit of improving their family and friends relation quality if they reduce internet time, 38.1% agree
that reducing their internet time will make them self satisfied, 32.7% are neutral about enjoying more personal privacy as a benefit of
reducing internet time, and 43.8% disagree that reducing internet time has positive effects on their health.
As regards to cues to action toward IA, the same table shows that 38.4% of the participants agree that their parents asking for
reducing internet time, 31.6% disagree that their teachers ask them to reduce their internet time. Concerning perceived self-efficacy
toward reducing internet time, 24.6% are neutral that they have the ability finding suitable ways to reduce internet usage, 40.8%
strongly disagree that it is easy to reduce internet time, 30.8% disagree that they have a plenty of ideas how to reduce internet time,
and 30.8% are neutral about their intention to reduce daily hours of internet use.
73 High
80 66.5 64.1 64.3
70 53.5 56.8 Low
60 46.5 43.2
50 33.5 35.9 35.7
40 27
30
20
10
0
Fig. (2) Distribution of the studied Minia University nursing students' level of health beliefs toward IA
3.5% 13%
Normal
38.9% Mild
Moderate
44.6%
Severe
Fig. (3) Level of IA among the studied Minia university nursing students, according to Young’s IAT (1998)
Fig. (3) Illustrates that, 44.6% of the participants had a mild level of IA followed by 38.9% had a moderate level, and 3.5%
had a severe level of IA.
Table (5): Relation between the studied Minia University nursing students' total level of IA and their socio-demographic data
(n=370)
Level of IA (n=370)
Normal Mild Moderate Severe
Variables X2 P
(n=48) (n=165) (n=144) (n=13)
No % No % No % No %
Age(year)
18-21 35 72.9 104 63.0 98 68.1 7 53.8 0.4
22-24 13 27.1 61 37.0 46 31.9 6 46.2 2.7
Gender
Male 7 14.6 64 38.8 69 47.9 10 76.9 0.001*
Female 41 85.4 101 61.2 75 52.1 3 23.1 24.1
Faculty Grade
1st year 9 18.8 28 17.0 47 32.6 5 38.5
2nd year 13 27.1 49 29.7 22 15.3 1 7.7 26.2 0.002*
3rd year 17 35.4 41 24.8 50 34.7 3 23.1
4th year 9 18.8 47 28.5 25 17.4 4 30.8
Residence
Rural 34 70.8 128 77.6 110 76.4 6 46.2 0.07
Urban 14 29.2 37 22.4 34 23.6 7 53.8 6.9
Father Education
Do not read or write 9 18.8 18 10.9 24 16.7 1
7.7
Primary 5 10.4 24 14.5 16 11.1 2
15.4
7.7
Preparatory 7 14.6 11 6.7 16 11.1 1
30.8
18.1 0.2
Secondary 16 33.3 67 40.6 41 28.5 4
23.1
University 8 16.7 31 18.8 41 28.5 3
15.4
3 6.3 14 8.5 6 4.2 2
Post university
Mother Education
Do not read or write 14 29.2 48 29.1 49 34.0 5 38.5
Primary 10 20.8 22 13.3 12 8.3 0 0.0 14.9 0.4
5 10.4 20 12.1 15 10.4 1 7.7
Preparatory 12 25.0 55 33.3 39 27.1 3 23.1
Level of IA (n=370)
Normal Mild Moderate Severe
Variables X2 P
(n=48) (n=165) (n=144) (n=13)
No % No % No % No %
Secondary 6 12.5 15 9.1 24 16.7 3 23.1
University 1 2.1 5 3.0 5 3.5 1 7.7
Post university
Family income/month
less than 2000 L.E 21 43.8 75 45.5 69 47.9 1 7.7
17.5 0.008*
2000-3000 L.E 25 52.1 71 43.0 51 35.4 11 84.6
7.7
more than 3000 L.E 2 4.2 19 11.5 24 16.7 1
Residence during study
with family 29 60.4 109 66.1 85 59.0 8 61.5 1.7 0.6
away from family 19 39.6 56 33.9 59 59.0 5 38.5
Smoking
Smoker 0 0.0 8 4.8 9 6.3 3 23.1 10.9 0.01*
Non smoker 48 100.0 157 95.2 135 93.8 10 76.9
Academic performance
Excellent 16 33.3 32 19.4 27 18.8 0 0.0
Very good 20 41.7 81 49.1 52 36.1 3 23.1 39.6 0.001*
4 30.8
Good 9 18.8 45 27.3 47 32.6
6 46.2
Pass or weak 3 6.3 7 4.2 18 12.5
* Statistical significant difference, Chi-squared test.

Table (6) shows that there are significant statistical differences between the level of IA and gender of the participants while
males have a significant sever level of IA compared to females where the p-value is 0.001. The same table shows that there are
significant statistical differences between the level of IA and faculty grade of the participants where the p-value is 0.002. An
additional statistically significant difference is found between the level of IA and monthly family income of the participants while
participants with a monthly family income ranges from 2000-3000 LE have a significant severe level of IA compared to others where
the p-value is 0.008. Another statistically significant dereference is found between the level of IA and smoking status of the
participants while non-smokers have a significant severe level of IA compared to smokers where the p-value is 0.01. The same table
shows that there are significant statistical differences between the level of IA and academic level of the participants while participants
whose academic performance is pass/weak have a significant severe level of IA compared to those with higher academic performance
where the p-value is 0.001.
Discussion susceptibility to IA. Concerning the beliefs regarding the

One of the significant attributes of the current severity of IA, the current study showed that more than half
societies is the increased media utilization particularly the (54.3%) of the participants disagreed with the severity of IA.
internet. Important benefits of the internet shall not delude us This result contradicted Lau et al. (2018) who found that
from the rising inclination of IA (Maheri et al., 2018). The about half (48%) of the participants agreed with the severity
current study aimed to assess knowledge, beliefs, and level of of IA. This contradiction might be attributed to the poor level
IA among nursing students at Minia University. of knowledge about IA among participants of the current
As regards to the level of knowledge about IA among study.
the participants, the current study revealed that the majority Concerning the participants' beliefs regarding the
(91.1%) of the participants had a poor level of knowledge barriers to reduce internet time, the current study revealed that
about IA followed by 5.9% had good knowledge, and the about near to half (46%) of the participants agreed that feeling
minority (3%) had very good knowledge. This result agreed bored without the internet is a barrier for reducing internet
with Chander (2019) who revealed that the majority time. This finding was congruent with Lau et al. (2018) who
(78.33%) of the participants had a poor level of knowledge detected that about half (47%) of the participants had the same
and less than one quarter (21.67 %) had a good level of belief. Another important barrier for reducing internet time
knowledge about the negative effects of IA. Similar to the perceived by the participant of the current study is that the
current study MMIN (2017) found that the majority (58%) internet is the main way for relieving stress in their life, while
had an average knowledge, followed by about one-third (34%) that barrier is agreed on by about half (49%) of the
had good knowledge regarding using of the internet. A participants. Based on a study explored the multidimensional
Previous study by Zadeh et al. (2014) reported that needs of students for the prevention of IA by Shahrbabaki et
knowledge is essential for admitting healthy behavior such as al. (2017) adequate societal support such as designing
addiction protective behaviors. Also knowledge about the entertainment programs for students or organizing sports
negative effects of addictive behaviors can save students events can help overcome these barriers.
against it. Thus, raising knowledge of university students Regarding the participants' perceived benefits of
about the addictive nature of the internet and side effects of IA decreasing the internet time, the current study revealed that
is necessary for changing their IA behavior. about two thirds (61.7%) of the participants agreed that an
As regard to health beliefs toward IA among the important benefit of reducing internet time is the positive
participants, the current study showed that less than half effect on their academic study. Similarly, Lau et al. (2018)
(38.6%) of the participants disagreed with their susceptibility revealed that about half (47%) of the participants agreed that
to IA. similarly, Wang et al. (2016) revealed that more than improving academic performance is a benefit of reducing
half (53.2%) of the participants disagreed with their internet use. Concerning the perceived self-efficacy toward
reducing internet time, the current study revealed that more significant relationship between IA and academic
than two-thirds (67.3%) of the participants disagreed with the achievement among participants.
easiness of reducing internet time. Contrary to the current
study, Wang et al. (2016) revealed that more than half Conclusion
(55.8%) of the participants disagreed with the difficulty of The majority of participants had poor IA knowledge
reducing the internet use. and low HBM constructs (perceived susceptibility, perceived
According to Young (1998) IAT, the current study severity, perceived benefits, and perceived self-efficacy)
showed that 13% of the participants were normal internet toward IA except for perceived barriers. The majority had
users, less than half (44.6%) had a mild level of IA followed mild and moderate levels of IA and the minority had a severe
by more than one third (39.9%) had a moderate IA, while the IA. The study also revealed a relationship between the level of
minority (3.5%) had a severe level of IA. These findings were IA and gender, faculty grade, monthly family income, and
in harmony with Khalil et al. (2016) who detected that more academic performance of the participants.
than one third (38.4%), and 2.1% of participants were
categorized as moderate to severe internet addict respectively Recommendations
while almost two-thirds (59.6%) of the participant students (1) 1-Strategies and different treatment modalities should
were average (normal and mild) internet user. Similar results be developed to increase awareness and decrease the
to the current study were found in a study conducted by level of IA among university students. For instance,
Rajeswari et al. (2017) who found that less than one quarter Cognitive–behavioral therapy (CBT) and
(22%) were normal internet user, about half (49%) of the motivational interviewing are suggested by several
participants were mildly addicted to the internet followed by studies as an effective treatment for IA.
less than one third (28.5%) moderately addicted, and the (2) 2-Establishing more recreational services by the
minority ( 0.5%) severely addicted to the internet. university such as sports centers to participate in
Regarding the relation between the level of IA and hobbies can be helpful to defeat feelings of isolation,
sociodemographic data of the participants, the present study boredom, and symptoms of IA withdrawal.
showed that there was a significant statistical difference (3) Nurse teachers need to include the different types of
between the level of IA and gender of the participants, while addictions, such as IA, to nursing study courses, and
males had a significant sever level of IA compared to females. updated education on the issue is required.
This result were in the same line with Chi et al. (2020); (4) 4-Further studies include the participants' families in
Rajeswari et al. (2017); Krishnamurthy and Chetlapalli the intervention of IA is recommended especially, for
(2015); Anand et al. (2018) & Ragheb et al. (2018). students with severe level of IA to emphasize novel
The current study revealed that there was a methods of socialization and pleasure for the whole
significant statistical difference between the level of IA and family to increase their activities while offline.
the faculty grade of the participants. This result was in
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Assessment of Knowledge and Attitude among Faculty of Nursing Students Regarding Blood Donation
1,Asmaa Yehia Youssef Ezeldain 2, Yosria El-Sayed Hossein3, Eman Sameh Mohammed, 4 Naglaa Mohammed Amein 4
1. B. Sc in Nursing, Minia University, Egypt.

2. Professor of Community Health Nursing, Faculty of Nursing, Minia University, Egypt.
3. Assist Professor of Public Health and preventive Medicine, Faculty of medicine, Minia University, Egypt.
4. Lecturer of Community Health Nursing, Faculty of Nursing, Minia University, Egypt.
Abstract
Blood is the vital fluid which carries oxygen, nutrients, hormones, vitamins and antibodies to the tissues in the body
and sends away the carbon dioxide and waste matters formed in the tissues from the body. Aim of the study: to
assess knowledge and attitude among nursing students regarding blood donation. Research design: A descriptive
research design was used for this study. Sample: A Stratified random sample, from first, second, third & fourth
academic year students in Faculty of Nursing Minia University. Data collection Tool: three tools were used in the
study: Tool I: Demographic characteristics of nursing students and their previous history, Tool II: Knowledge
Assessment Tool, and Tool III: Blood donation Attitude Scale. Results The current study found that more than half
of nursing students aged between 20- 21 years with mean ± SD 20.05 ± 1.3 years, about three quarter of them was
female, more than one quarter of them were in 3rd year academic years and more than two third of them comes from
rural area. About more than half of nursing students had unsatisfactory knowledge about blood donation and most of
them had positive attitude about blood donation. Conclusion: About more than one third of nursing students had
satisfactory knowledge about blood donation and most of them had positive attitude about blood donation. Also, there
was statistically significant difference between nursing students' knowledge and their age, academic years and attitude
toward blood donation. Recommendation: Increase knowledge of nursing students about blood donation through
making a seminar and workshop about it.
Keywords: Attitude, Blood donation, Knowledge, Nursing Students
Introduction A positive attitude among nursing students will bring

Blood is vital fluid that acts as nutrients transport change in the attitude of blood donation among patients
throughout the body to perform its functions (Nataba, 2019). during care and can be a core group to educate many friends
Blood donation occurs when a person has blood drawn and and relative about the need for blood donation. There is also
used for transfusions and/or made into biopharmaceutical need to encourage, inspire, and motivate students to donate
medications by a process called fractionation (separation of blood voluntarily and become a professional donor
whole-blood components). Donation may be of whole blood (Singh et al., 2015).
(WB) or of specific components directly (the latter called Community Health Nurses are clinically responsible
aphaeresis) (Frasiska et al., 2016) Blood donors can be for the donation session, with the care of the donors and the
differentiated into voluntary, family replacement, and paid safety of the blood being their main priority. It also has the
donors. About 108 million blood donations are collected role of the nurses to supervise the donor careers that carry out
worldwide. More than half of these are collected in high- a function similar to that of healthcare assistants in hospitals,
income countries, home to 18% of the world’s population and to ensure they deliver a first-class service. As well as
(Al-Mutairi et al., 2015). providing clinical leadership for the teams nurses are also
Blood donation can be started safely from 17 years of required to provide medical assessment expertise and have a
age, so it is important that the young generation can be critical role to play in the care before, during, and after donate
motivated to do this harmless task. In order to motivate blood and selection of donors as their suitability to certain
students, first we should be aware of the knowledge, attitude level (Goda, 2017).
and practices towards blood donation. Such studies are
important to understand various factors that affect recruitment Significance of the study
and retention of blood donors, to know the potential reasons “Blood connects us all” - was the theme for the
that restrict them from doing this simple but lifesaving task, World Blood Donor Day 14 June 2016. Blood transfusion is
and to know the reasons that motivate the donors to donate an important concern for the society, as it is lifesaving for
blood. This can further help in planning proper and creative patients with bleeding disorders, accidents, surgeries,
ways to recruit regular voluntary donors (Ugwu et al., 2019). inherited/acquired hematological diseases, and malignancies
In a developing country like ours, lack of knowledge, (Razdan et al., 2018).
blood donor recruitment and retention strategy and various In spite of, extensive efforts and a number of blood
misconceptions have resulted in a limited number of voluntary donation programs being organized worldwide, availability of
donors. This challenge can be tackled by adopting such adequate and safe blood still remains short to meet the
recruitment methods that can overcome the misconceptions increased demand in developing countries. The major
and also motivate the public to donate at an early age, so that challenge was recruitment of voluntary, non-remunerated
they become lifelong voluntary donors (Ugwu et al., 2019). blood donors. Literatures identified that many factors are
Some people believe that it is a national and religious duty responsible such as, lack of knowledge, negative attitudes, and
while others stated that they would only donate if a family inconvenience for facilities. Increase level of knowledge and
member or a friend is in need. (Al-Haqqan et al., 2016).
P a g e | 39 Asmaa Y., et al
positive attitude towards voluntary blood donation in young Part 2: Student's previous history regarding blood donation,
people is highest priority (Tadesse et al., 2018). included (4) questions to assess previous history regarding
The World Health Organization (WHO) recommends blood donation : If the student ever donated blood, been asked
that, for any country to meet the minimum demand for blood, questions before donating blood, how many times, when was
collection should be at least from 1% of the population, on the last time he/she donated blood and where was the last time
average, high income countries have 9 times higher donation he/she donated blood .
rate compared to low-income countries (Elias et al., 2016).
Tool II: Knowledge Assessment Tools: consisted of (31)
Aim of the Study closed ended questions to assess of student knowledge about
This study aims to assess knowledge and attitude blood donation such as: have attended seminars on blood
among nursing students regarding blood donation. donation, have information on blood donation, what is the
amount of blood contained in the human body, what are the
Research Questions: components of blood, what is the right age for blood donate,
1. What is the level of knowledge of nursing students what is the appropriate weight for the person who donate
regarding blood donation? blood, amount of blood a person can donate in a single time,
2. What is the attitude of nursing students regarding blood blood group and types, different types of blood donors…etc.
donation?
Tool III: Blood donation Attitude Scale. This scale
developed by Manikandan, et al., (2013). The scale included
Subjects and Methods statements to assess students’ attitude regarding blood
Research Design: donation. It consisted of 20 statements. All statements have
A descriptive research design was used for this study. response format (agree/ disagree or neutral) as: blood donation
is charitable or voluntary, I think blood donation is a positive
Setting: behavior, parents should be informed before donation of
This study conducted in the Faculty of Nursing at blood, I think blood donation can lead to anemia.
Minia University for all grades. Total number of students in
data collection year (2017- 2018) were one thousand four Scoring system:
hundred seventy-five (1475). Scoring system for tool II student’s knowledge about
blood donation, each correct response took two scores, wrong
Subjects: answer took one score and the not known response took
A stratified random sample was collected, from first, (zero). The total score < 37.2 scores (less than 60%) was
second, third & fourth academic year students of Faculty of considered as unsatisfactory while score of 37.2 scores (60%
Nursing. and more) was considered as satisfactory level
While scoring system for tool III Blood donation
Sample size: Attitude Scale, was carried out by using 3-point Likert scale.
The sample size was calculated according to this agree = 2, neutral = 1 disagree = 0. Positive attitude statement
formula: was scored from two (for participants who agreed) to zero (for
participants who disagreed). The opposite of this scoring was
Formula: 𝑛 = 𝑡2× (1 − 𝑝)/𝑚2. used for the negative attitude statements. Accordingly, the
total score ranged between zero to 40 points. The total score <
Description 24 scores (less than 60%) was considered as negative attitude
 𝑛 = required sample size. while score 24 scores (60% and more) was considered as
 𝑡 = confidence level at 95% (standard value of 1.96). positive attitude about blood donation.
 𝑝 = expected prevalence of students' blood donor
(50%). Validity and Reliability
 𝑚 = margin of error at 5% (standard value of 0.05). The tool tested for content validity by a jury of five
 𝑛 = (1.96) × 0.8(1 − 0.8)/ (0.05) . 𝑛 = ∼384
2 2 experts in the field of the study to test the content validity of
tools and necessary modifications was done. Reliability of the
Accordingly, the minimum sample size needed was tools was performed to confirm its consistency by using
384 students, then we added additional number of students, 10 Cornbrash's alpha test to tools II and III were 0.847 & 0.901
% of the calculated sample to guard against non-response so respectively
the sample was 422, and it was distributed equally between
1st, 2nd, 3rd & 4th academic year students of Faculty of Pilot Study
Nursing. Pilot study was carried out on (10%) of sample 42
students from nursing students selected randomly from
Tools for Data Collection: different academic years to check and ensure the clarity of
Tools for data collection consisted of three tools: Arabic questionnaires, identify the obstacle and problems that
may encountered during data collection and to estimate the
Tool I: A structured interview questionnaire designed by the time needed to complete the questionnaires items and included
investigator to collect data includes two parts: in the study.
Part 1: Demographic Characteristics of the student, it

consisted of (4) items age, gender, class year, residence.
Data collection procedure University, official permission was obtained to collect
An official permission was obtained from the Dean necessary data from the Dean of Faculty of Nursing and Vice-
of Faculty of Nursing and Vice-dean for education and dean for education and Student Affairs and from Academic
Student Affairs and from Academic Departmental Heads of Departmental Heads of Faculty of Nursing.
Faculty of Nursing. An oral agreement was taken from the The Students were informed that their participation
students who participate in the study after explaining the aim in this study is completely voluntary and there is no harm if
of the study. Confidentiality of obtained data was maintained they choose not to participate and no individual information is
and ensure for every student before starting data collection. shared outside of the research. Oral informed consent was
Arabic translation of the study tool was done. Data was obtained from each participating nursing student after
collected from the student at the beginning of academic year explaining the nature and benefits of the study. Each
after permission of the nursing educators two days for each assessment sheet was coded, and student names not appeared
year's students during their clinical area. on the sheets for the purpose of privacy and confidentiality.
The time consumed to fill the questionnaires was
between 20 to 30 minutes. The investigator stayed with the Statistical analysis
students until the questionnaires were completed to ensure The collected data were analyzed using Statistical
objectivity of the responses and to ensure that all item was Package for Social Sciences (SPSS) IBM 25 for windows.
answered. Data collection started at the beginning of October Data were collected, tabulated. Quantitative data were
2018 to the end of February 2019. presented by mean (standard deviation) , while qualitative data
presented by frequency distribution. The Chi-square test was
Ethical and Legal Considerations used to compare between proportions. Test of significance
A written initial approval was obtained from the were considered as: insignificant (NS) P.value ≥ 0.05, *
Research Ethical Committee of the Faculty of Nursing, Minia significant P.value < 0.05, and ** highly significant P<0.01.
Results
Table (1): Socio Demographic characteristics of the studied nursing students (n = 422).
Demographic Characteristics No. %
Age / years
18- 19 131 31.0
20- 21 230 54.5
22- 23 61 14.5
Mean ± SD 20.05 ± 1.3 years
Sex
Male 109 25.8
Female 313 74.2
Academic years
1st year 107 25.4
2nd year 115 27.3
3rd year 116 27.5
4th year 84 19.9
Residence
Urban 132 31.3
Rural 290 68.7
Table 1 shows that 54.5% of the studied nursing students aged between 20- 21 years with mean ± SD (20.05 ± 1.3) years,
74.2% of them was female, 27.5% of them was in 3rd year academic year and 68.7% of them comes from rural area.
Table (2): Frequency distribution of the studied nursing students regarding previous history of blood donation (n = 422).
Previous blood donation No. %
Yes 66 15.6
No 356 84.4
If no, the causes are (n= 356)
Anemia 144 40.4
Not have a chance 105 29.5
Fear from infection 38 10.7
Hypotension 6 1.7
Fear from needle 42 11.8
Thinness 21 5.9
If yes, number of donations
One time 49 74.2
More than one 17 25.8
Were asked a question before donation
Yes 44 66.7
No 22 33.3
If yes it was (n=44)
Previous donate, when, Hb level 18 40.9
Have chronic illness, take antibiotics, take fluids before donation 13 29.5
Last time of donation, have blood disease 5 11.4
Have any virus disease 4 9.1
Suffer from anemia 4 9.1
Causes of blood donation (n= 66)
Help people 43 65.2
Volunteer 2 3.0
Previous blood donation No. %
Help patients and reassure my self 10 15.2
Surgery for my relative 11 16.6
Last time of donation (n=66)
Less than one year 38 57.6
More than one year 28 42.4
Place of donation (n=66)
In the hospital 15 22.7
In blood bank 6 9.1
In blood donation car 45 68.2
Table 2 presents that 84.4% of the studied nursing students don't previous blood donation, 40.4% of them the main causes of
its was anemia. Concerning number of donations 74.2% of nursing student donated one time, 66.7% of them reported they asked
before donation, and 40.9% the main question was about level of hemoglobin. Regarding causes of blood donation 65.2% of them
was to help the people, 57.6% of them last time of donation was less than one year and 68.2% of them donated in blood donation car.
Yes;
20.4%
No;
79.6%
Figure (1): Distribution of the studied nursing students regarding attended previous workshop (n = 422).
Figure (1): demonstrates that 20.4% of the studied nursing students attended previous workshop, and 79.6% of them don't
attended any previous workshop.
Table (3.a): Frequency distribution of the studied nursing students regarding their general knowledge about blood donation
(n = 422).
General knowledge no. %
Amount of blood in the body 345 81.8
Components of blood 414 98.2
Knowledge about ABO blood type 388 98.2
Know their blood groups 153 36.3
Methods of measuring Hb level 7 1.7
How much blood is removed during a donation cession? 285 67.5
Time consuming during blood donation (min) 97 23.0
Are there diseases transmitted through blood? 94 22.3
Advantages of blood donation 319 75.6
Precautions before blood transfusion 372 88.2
Precautions after blood transfusion 399 94.5
Table 3.a shows that 98.2% of the studied nursing students answered correctly components of blood, 94.5% and 88.2% of
them answered correctly precautions after and before blood transfusion respectively, but 36.3% of them know their blood group.
Table (3.b): Frequency distribution of nursing students regarding their knowledge about donor eligibility (n = 422).
Knowledge about donor eligibility no. %
What are the age limits of the donor? 42 10.0
What is the suitable weight of the donor? 115 27.3
What is the minimal interval between two male donations by a person? 184 43.6
What is the minimal interval between two female donations by a person? 163 38.6
Level of Hb for male donation 186 44.1
Level of Hb for female donation 207 49.1
Can a pregnant woman donate? 412 97.6
Can a female during menstruation donate? 26 6.2
Can donate with whole blood 195 46.2
Knowledge about donor eligibility no. %
Can donate with platelets only 88 20.9
Normal blood pressure for donated person (mmHg) 399 94.5
Laboratory investigations before donation 362 85.8
Laboratory investigations after donation 91 21.6
Can a person on medications for chronic diseases donate? 392 92.9
Psychiatric patients can donate 257 60.9
Person with previous surgery can donate 215 50.9
Contraindications of donation 331 78.4
Table 3.b presents that 97.6% of nursing students answered correctly pregnant women can donated or not, 94.5% of them
know normal blood pressure for donated person and 929% of them answered correctly if a person on medications for chronic disease
donate or not.
Table (3.c): Frequency distribution of nursing students regarding their knowledge about consequences of donation (n = 422).
Knowledge about consequences of donation no. %
There are complications after donation 94 22.3
Compensated the donated blood (plasma) 137 32.5
Compensated the donated blood (RBCs) 141 33.4
Compensated the amount of iron lost during donation 139 32.9
Table 3.c shows that 33.4% of nursing students answered correctly time of compensated red blood cells, 32.9% and 32.5% of
them answered correctly time of compensated the amount of iron lost during donation and plasma
Figure (2): Frequency distribution of the studied nursing students regarding their total knowledge level about blood donation
(n = 422).
Figure (2): illustrates that more than one third (37.7%) of the studied nursing students had satisfactory knowledge about
blood donation and 62.3% of them had unsatisfactory knowledge.
Table (4): Frequency distribution of the studied nursing students regarding their attitude about blood donation (n = 422).
Blood donation attitude Agree Neutral Disagree
no. % no. % no. %
Volunteer work 412 97.6 6 1.4 4 .9
Positive behaviors 399 94.5 14 3.3 9 2.1
Unnecessary 66 15.6 334 79.1 22 5.2
Inform parents before donation 326 77.2 67 15.9 29 6.9
Lead to anemia 178 42.2 171 40.5 73 17.3
Ready to continuous donation 163 38.6 193 45.8 66 15.6
Feel empathy with the patient need blood donation 367 87.0 32 7.6 23 5.5
Physically strong people only can donate 137 32.5 253 60.0 32 7.6
Ready to continuous donation in emergency situation 341 80.8 44 10.5 37 8.7
Improve the health 396 70.1 48 11.4 78 18.5
Check blood before donation limit increasing the infectious diseases 380 90.0 29 6.9 13 3.1
Fear from it 221 52.4 174 41.2 27 6.4
Increase chance for infectious disease with it 266 63.0 99 23.5 57 13.5
Encourage the volunteer 322 76.3 78 18.5 22 5.2
Deficiency knowledge is the main causes of limit blood donation 328 77.7 64 15.2 30 7.1
May occur complications during and after donation 311 73.7 55 13.0 56 13.3
Take it from volunteer only 221 52.4 136 32.2 65 15.4
Take long time 75 17.8 279 66.1 68 16.1
Discover correct information about the health 349 82.7 39 9.2 34 8.1
Lead to psychological changes 65 15.4 253 60.0 104 24.6
Table 4 shows that 97.6% of the studied nursing students agreed with blood donation is a volunteer work, 94.5% of them
agreed with it’s a positive behavior, 90.0% of them agreed with they checked blood before donation limit increasing the infectious
disease and 87.0% of them agreed with they felled empathy with the patient need blood donation.
Negative
Negative
attitude;
9.7%
Positive
attitude;
90.3%
Figure (3): Frequency distribution of the studied nursing students regarding their attitude about blood donation (n = 422).
Figure (3): illustrates that the majority (90.3%) of the studied nursing students had positive attitude towards blood donation
and 9.7% of them had negative attitude.
Table (5): Relations between the studied nursing student's total knowledge levels and their demographic data (n = 422).
Demographic Characteristics Unsatisfactory Satisfactory X2 P – value
(n= 263) (n=159)
No. % No. %
Age / years
18- 19 114 43.3 17 10.7 50.944 0.0001*
20- 21 122 46.4 108 67.9
22- 23 27 10.3 34 21.4
Sex
Male 71 27.0 38 23.9 .496 0.481
Female 192 73.0 121 76.1
Academic years
1st year 99 37.6 8 5.0 57.054 0.0001*
2nd year 59 22.4 56 35.2
3rd year 57 21.7 59 37.1
4th year 48 18.3 36 22.6
Residence
Urban 89 33.8 43 27.0 2.129 0.145
Rural 174 66.2 116 73.0
**Highly significant P<0.01
Table (5): shows that there was highly statistically significant difference between the studied nursing students' knowledge
and their age (p value > 0.0001) as 21.4 % of those who had a satisfactory knowledge level were in age group (22-23 years) versus
10.3% who had an unsatisfactory knowledge level.
Also, there was a statistical significant difference between different academic years and their knowledge level as by
increasing the academic year, the knowledge level increase (p = 0.0001).
Table (6): Relations between the studied nursing students’ attitude and their demographic data (n = 422).
Demographic Characteristics Negative Positive X2 P – value
(n=41) (n = 381)
No. % No. %
Age / years
18- 19 16 39.0 115 30.2 1.488 .475
20- 21 19 46.3 211 55.4
22- 23 6 14.6 55 14.4
Sex
Male 15 36.6 94 24.7 2.742 .098
Female 26 63.4 287 75.3
Academic years
1st year 14 34.1 93 24.4 5.898 .117
2nd year 5 12.2 110 28.9
3rd year 14 34.1 102 26.8
4th year 8 19.5 76 19.9
Residence
Urban 11 26.8 121 31.8 .418 .518
Rural 30 73.2 260 68.2
Table (6): presents that there was no statistically significant difference between the studied nursing students' attitude and
their demographic data.
Table (7): Relations between the studied nursing students total knowledge levels and their attitude (n = 422).
Knowledge
Attitude Unsatisfactory Satisfactory X2 P – value
(n= 263) (n=159)
No. % No. %
Negative (n = 41) 34 12.9 7 4.4 8.211 .004**
Positive (n=381) 229 87.1 152 95.6
**Highly significant P<0.01
Table (7): cleared that there was highly statistically significant difference between the studied nursing students' knowledge
and their attitude toward blood donation as 95.6% of those who had a satisfactory knowledge level had positive attitude versus 12.9%
of those who had unsatisfactory knowledge level had negative attitude.
Discussion practice regarding blood donation among medical students of

Blood donation is life saving and useful in surgery, government Thiruvannamalai Medical College in Tamil Nadu,
accidents, delivery cases, bleeding peptic ulcer, liver diseases, India, found that 36.0% of them don't donated blood because
lung diseases, cancer, burn cases and blood diseases such as they suffered from anemia also, Andsoy et al. (2016)
hemophilia, anemia, thalassemia but some of the patients determined the relationship between the knowledge, attitude
needing transfusion do not receive timely access to safe blood. and behaviors of the Turkish nursing students towards blood
Safe blood donor is a blood donor who donates blood donation and their emphatic tendencies at School of Health in
voluntarily, without knowing the beneficiary, without any Karabuk University stated that 31.1% of the Turkish nursing
expectation and without being under pressure of a direct or students are reluctant to donate blood due to the pain caused
indirect nature (Kurian & Sarkar, 2016). by injection and the fear from faint. but this result
Regarding mean age of the studied nursing students, contradicted with a recent study done by Verma et al. (2018)
it is 20.05 ± 1.3 years. This result was in the same line with a showed that most common reason of non-donation of blood
recent study done by Chauhan, Kumar and Thakur (2018) among medical students was lack of awareness regarding
determined the knowledge, attitude and practices (KAP) of Dr when and where to donate blood, which constitute about 50.5
rpamc Tanda in Himachal Pradesh about voluntary blood %. Second most common reason was fear of pain and
donation conducted among undergraduate medical students in discomfort which constitute about 19.1 % while 13.9 % of the
India showed that the mean age being 20.42 ± 1.38 years. students said they never got an opportunity to donate blood.
Concerning gender of the studied nursing students, Reasons like family discouragement, busy life, concern about
three quarters of them was female students. This result was in sterility of equipment's were also noted.
the same line with a recent study done by Cicolini et al., Regarding number of donation, about three quarters
(2019) investigated factors involved in the blood donation of the studied nursing students donated once and nearly two
(BD) in a population of Italian nursing students mentioned third of them mentioned that the main cause of blood donation
that three quarters of participants was female nursing students. was to help the people. This result in the same line with Al-
Regarding previous history of blood donation among Asadi and Al-Yassen (2018) who evaluated the knowledge
the studied nursing students the current study found that the and attitude of two colleges in Basrah University students in
majority of them don't donate blood previously and about Iraq about blood donation. It was found that 64.7% of
three quarters of nursing students who donates donated one Medicine and College of Administration and Economy
time only. This result was agreement line with a recent study students donated only once and among 74.5% of them the
done by Kanani et al. (2018) compared the reasons for blood main cause of donation was moral satisfaction.
donation and knowledge about blood donation among medical Regarding the studied nursing students' knowledge
science undergraduate students in Jamnagar and it showed that level more than one third (37.7%) of them had satisfactory
80.0% of them never donated blood previously. Also, study knowledge about blood donation. This result was lower than
done by Verma, et al. (2018) assessed knowledge, attitude, what found by Mulatu et al. (2017) who assessed the
and practice towards blood donation and its associated factors knowledge, attitude and practice of blood donation among
among undergraduate medical students at Netaji Subash residents of Aman Sub-City, South West Ethiopia they
Chandra Bose medical college Jabalpur presented that 83.5% mentioned that 76.0% of total respondents had good
of students never donated blood, but this result contradicted to knowledge while 14.0% only had poor knowledge. but a
a recent study done by Cicolini et al. (2019) mentioned that recent study done by Melku. et al. (2018) found that 51.6%
near to two third of Italian nursing students ever donated of undergraduate health science students had inadequate
blood previously and more than one third of donated Italian knowledge. This difference may be due to when the authors
nursing students donated five times and more. scored students' knowledge calculated 70.0% and above had
Concerning causes of non- blood donation among the adequate knowledge while in these results calculated 60.0%
studied nursing students nursing students more than one third and above had adequate knowledge
of them said due to anemia, followed by thy didn’t have a Also, this result contradicted with Bharatwaj,
chance to donate and then near to one quarter of them fear Vijaya, and Rajaram (2012) find out the knowledge, attitude
from needle and infection. This result was in accordance with and the practice with regards to voluntary blood donations of
a recent study done by Govindasamy, Sivasankaran, and the 280 students of second and third MBBS at the Sri
Purushothaman (2019) determined knowledge, attitude and Lakshminarayana Institute of Medical Sciences which is
located in Pondicherry, India concluded that all the donation (p<0.001) when compared with the students belongs
participants had an incomplete knowledge regarding the to the 17–20 years of age group.
various aspects of voluntary blood donation. This difference Regarding relations between the studied nursing
related to medical collages did not study any topics related to students' attitude with their gender and residence; there were
blood donation so they hadn't knowledge about it. not statistically significant differences. This result was in the
Concerning the studied nursing students' attitude same line with a recent study done by Melku. et al. (2018)
more than one third of them had positive attitude about who showed that gender and residences not associated with
readiness to donate continuously in the future. This result was undergraduate health science students' attitude, but this result
in the same line with Andsoy et al. (2016) who found that was inconsistence with Govindasamy, Sivasankaran, and
40.0% of Turkish nursing students stated that they were Purushothaman (2019) who revealed that sex had a
willing to donate blood. significant association with attitude towards blood donation.
The present study more than three quarters of the The female sex had a more negative attitude and outlook
studied nursing students had positive attitude about towards donation of blood.
encouraging the volunteer to donate blood. This result was in Concerning the relation between the studied nursing
the same line with a recent study Melku. etal. (2018) students's total knowledge levels and their attitude there was
mentioned that 89% of undergraduate health science students statistically significant difference between the studied nursing
were encouraged others to donate blood. students' knowledge and their attitude toward blood donation.
Regarding the studied nursing students' attitude, the This result was in the same line with Verma et al. (2018) who
majority of them had positive attitude towards blood donation. presented that medical student there was statistical
This result was in the same line with a recent study done by significance difference between medical students' knowledge
Alsalmi et al. (2019) reported that the majority of the health and their attitude about blood donation.
professions students in Saudi Arabia delivered a positive
attitude regarding blood donation and Melku. et al. (2018) Conclusion
mentioned that 79.2% of undergraduate health science Based on the results of the present study, can be concluded
students had positive attitude regarding blood donation. that:
Regarding the relation between the studied nursing About one third of the studied nursing students had
students' total knowledge levels with their age in which satisfactory knowledge level about blood donation and the
students aged between 20- 21 years were more knowledgeable majority of them had positive attitude about blood donation.
than who aged between 18 – 19 year with statistically Also, there was statistically significant difference between the
significance differences. This result was in the same line with studied nursing students' knowledge with their age, academic
Verma et al. (2018) who showed that medical students years and their attitude towards blood donation.
belongs to >20 years of age group has significantly more
knowledge regarding blood donation (P <0.001) when Recommendations
compared with the students belongs to the 17–20 years of age Based on results of the present study the following can be
group. recommended that:
Regarding relations between the studied nursing  Increase knowledge of nursing students about blood
students' total knowledge levels with their gender and donation through making seminars and workshop
residence; there was not statistically significance differences. about it.
This result in the same line with a recent study done by  Introduce a lecture in the curricula taught for first
Melku., et al., (2018) who showed that gender and residence year students about donating blood.
were not associated with undergraduate health science  Encourage the implementation of future educational
student's knowledge. also, Govindasamy, Sivasankaran, and program for students in all faculties to increase their
Purushothaman (2019) mentioned that sex failed to prove a knowledge and positive attitudes toward blood
significant association with blood donation, but this result was donation.
inconsistence with a recent study done by Verma et al.,  Future studies should focus on the other students in
(2018) showed that medical female students when compared other faculties.
with male have more knowledge and good attitude regarding
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Effect of Educational Program on Women's Awareness and their health status regarding antenatal
Exercises
Hend Shabaan Refaey1; Ekbal Abd El Rehem Emam 2; Essa Mahmoud Mohamed 3 Amany Hassan Abd Elrahim
1. B.Sc. Nursing Faculty of Nursing-Minia University;

2. Professor of Woman Health and Obstetric Nursing, Faculty of nursing – Minia University
3. Assistant Professor of Obstetrics and Gynecology Medicine, Faculty of Medicine -Minia University
4. Lecturer of Woman Health and Obstetric Nursing, Faculty of Medicine -Minia University
Abstract
Background: Exercise during pregnancy is generally beneficial and can strengthen muscles, reduce backache and
stress, and provide a feeling of well-being Aim of the study: This study aim was to evaluate the effect of educational
program on woman's awareness and their health status regarding antenatal exercises. Research design: Quasi
experimental research design (one group pre- test, post-test)was utilized to fulfill the aim of this study Setting:
This study was conducted at antenatal out-patient clinic at Minia University Hospital for Obstetric &Pediatric
(MUHOP) hospital Sampling: convenient sample includes 75 pregnant women in their second trimester. Tools of data
collection included: tools 1: Interviewing sheet, 2: Awareness assessment tool (pre/post educational program, 3: An
observational checklist, 4: Brief Short Form Health Survey (SF-19) 1.0 Questionnaire items. Results: regarding
pregnant women awareness , near to half of them their opinion about their health was fair pre educational program
compared with minority of them post-test program, and improve physical function of them post educational program
than pretest program regarding more three vigorous and moderate activities, lifting or carrying home purchases,
bending, kneeling, standing, and walking long distances with highly statistically significance differences P – value ≤
0.0001 respectively Conclusion: None of the pregnant woman had pre-educational program awareness compared to
post-education program, as it was increased and total Short form health mean scores of the pregnant woman regarding
antenatal exercise was increased post educational program than pre educational program (68.1 ± 13.4) and (54.5 ±
12.7) respectively), Recommendation: identify the most effective specific types of guidance and motivation in the (or
maintaining) exercise in pregnant women.
Keywords: Antenatal Exercises, Educational Program, Women's Awareness
Introduction As pregnancy progresses, the exercise program may

Exercise during pregnancy is generally beneficial and need modification because the change in the woman’s center
can strengthen muscles, reduce backache and stress, and of gravity makes her more prone to falls. Therefore, an
provide a feeling of well-being. The amount and type of activity may be safe in the first trimester but not in the third
exercise recommended depend on the physical condition of trimester. Exercise should be tailored to the way the woman
the woman and the stage of pregnancy and relaxation feels to avoid becoming overly fatigued. Generally, if a
exercises use during the day and before bed woman cannot carry on a conversation while exercising, she is
(Murray, et al., 2019). doing too much. The woman should stop exercising and seek
Teach women who have no medical or obstetric medical advice if she has chest pain, dizziness, headache,
complications to exercise in moderation for at least 20 to 30 vaginal bleeding, decreased fetal movement, or signs of labor
minutes or more on most if not all days of the week (ACOG, while exercising (Linnard-Palmer, et al., 2016).
2015; Beckmann et al., 2014). Recreational sports can be Nurses need to encourage pregnant women to
continued if no risk of falling or abdominal trauma is present. perform moderate exercise. Women who exercise more or are
Joint and ligament laxity and lumbar lordosis increase the risk athletes may need to change their diet to fulfil increased
of injury, especially in the third trimester. Contact sports and nutritional needs. Extra calories could be required to recover
exercise with a high risk for falling such as rock climbing or energy in exercise. Serving fruit, yoghurt, or pasta before and
skiing should be avoided. Exercise in the supine position after exercise may suffice. Additional water should be taken
should be discontinued after the first trimester to avoid supine before and after exercise. (Leifer, 2018).
hypotensive syndrome. Nurses play an important role in encouraging the
Walking is an ideal exercise because it stimulates effects of physical activity and fitness, educating women
muscular activity, gently increases respiratory and during breastfeeding on a healthy and safe diet, and directing
cardiovascular effort, and does not result in fatigue or strain. them to prenatal exercise (Van Poppel, et al., 2018). With the
Swimming and water exercises are excellent during pregnancy growing amount of scientific data on the beneficial benefits of
because the buoyancy of the water helps prevent injuries. maternal physical exercise, in pregnant women, writers from
Riding a stationary bike and yoga are also helpful. Exercise various countries note their inadequate degree. There are a
classes especially for pregnant women are often available and few research on the extent of knowledge of pregnant women
offer companionship with other women having similar and their practice of prenatal physical activity
experiences. Instruct the woman not to begin strenuous (Szumilewicz, et al., 2019).
exercise programs or intensify training during pregnancy.
Those who have been exercising strenuously before pregnancy
should consult the health care provider but may be able to
continue (Frontera et al., 2018).
P a g e | 48 Hend S., et al
Significance of the study: included questions related to different types of exercise in
Antenatal exercises have a great benefit for pregnant pregnancy (9), benefits of exercise in pregnancy (12), and
women as it help to improve nausea, better ability to cope contraindication of exercise in pregnancy (10)
with labor and childbirth, enhanced psychological well-being,
self-image and confidence. Decrease incidence of post-partum Scoring System:
blues, improved sleep patterns, body awareness and help in The woman's answers related to awareness were
quick post-natal recovery (Stephenson, 2014). scored and the total score calculated. According to the
Moderate, mild exercise is helpful during regular answers of the woman's responses, it was evaluated using the
pregnancy, but intensive exercise can be avoided. The nurse model key answer sheet which prepared previously by the
can direct the patient on exercise during pregnancy based on researcher. Women's scoring of awareness regarding antenatal
the assumption that the maternal circulatory system is the exercises was classified as follows: Each correct answer was
fetus's lifeline, and any change will affect the fetus' given a score of ‘one’ and wrong answer a score of ‘zero’
development and survival. Maternal cardiac status and respectively. For each area of awareness, the scores of the
fetoplacental reserve should be the basis for assessing exercise items were summed-up and the total divided by the number of
levels during all pregnancy trimesters. Present diet and the items, giving a mean score for each area. Poor awareness
wellbeing lifestyles mandate the provision of workout scored (< 50%); average awareness (50%-75%); good
knowledge during breastfeeding in maternal education awareness was considered if the percent score was 75% or
services. Activities to avoid include skydiving, horseback more.
riding, skiing, and scuba diving (ACOG, 2016).
The third tool:
Aim of the Study An observational checklist was used to assess the
This study aims to: application of exercise by pregnant women. It was included
Evaluate the effect of educational program on five types of exercised 17 practical steps as pelvic floor
woman's awareness and their health status regarding antenatal exercise (3 steps) (Sit on a chair with your back against the
exercises. seatback), back and abdominal exercise (3 steps) (Breath
naturally), abdominal breathing exercise (3 steps) (Breath in
Research Hypothesis: Utilization of educational program will through the nose and feel the abdomen expand), lower costal
be effective in increasing women's awareness regarding breathing (3 steps) (Breathe through the nose and feel your
antenatal exercises also improves their health status. chest.), and apical breathing (5 steps) (feel the upper lungs
moving slightly up and down). It was filed by the researcher
Method Research Design and was administered during and post-test after three months
Quasi experimental research design was utilized to of the program.
fulfill the aim of the study
Scoring System:
Sample A convenient sample includes 75 pregnant women in Application of exercise by pregnant women was
2nd trimester, Read and write and healthy women classified as follows: Each correct practice was given a score
of ‘one’ and wrong practice a score of ‘zero’ respectively for
Setting every step of exercises. Poor practice scored (< 50%); average
This study was conducted at the antenatal outpatient practice (50%-75%); the good practice was considered if the
clinic at Minia University Hospital for Obstetric &Pediatric percent score was 75% or more. the observational checklist
(MUHOP) hospital was graded as done and not done for every step of the
exercise.
Tools of Data Collection:
Tools of data collection were developed by the The fourth tool:
researcher after an extensive review of the literature and Short Form Health Survey (SF-36) 1.0 Questionnaire
similar studies conducted elsewhere. After that the developed Items. is one of the most popular instruments for assessing the
questionnaire are revised by 5 panels of obstetrical and HRQoL that, as a standard instrument, assesses the health
gynecological experts in nursing staffs, a structured interview outcomes. This questionnaire assessed two distinct
questionnaire was developed. The data collection tool dimensions of health, physical and psychological, and each
consisted of four tools: dimension is composed of four domains. The physical
dimension of HRQoL assessed the domains of physical
The first tool: Interviewing sheet: functioning (5 items) (Lifting or carrying home purchases),
A Self-administrative questionnaire was designed to role limitation-physical (3 items) (limited in the kind of work
collect data related to socio-demographic characteristics of the or other activities), and general health (1 item) (what would
woman such as (age, marital status, residences, educational you say about your health), social functioning (2 items) (How
level, and income). Also, it contains Past obstetric history as much of the time has your pregnancy-related emotional
No. of gravidity, No. of parity and source of women problems interfered with your social activities), pain (2) (How
knowledge in addition to mother telephone no. much bodily pain have you had during the past 4 weeks), and
energy/ fatigue/ emotional (6 items) (Have you been a very
The second tool: nervous person).
Awareness assessment tool (pre/post educational
program): It is a Self-Administered questionnaire that was
developed by the researcher after revising relevant literature.
Total number of the question were 31 questions which
Scoring system woman in the study sample received the knowledge regarding
The SF-19 consists of eight scaled scores, which antenatal exercises as benefits, types, indication, and
were the weighted sums of the questions in their section. Each contraindication of antenatal exercises) were given to the
scale was directly transformed into a 0-100 scale on the women through used face to face method to achieved the
assumption that each question carries equal weight, the lower desired goal and allow women to ask, discussion and reach a
the score the more disability and the higher the score the less high level of understanding. During these sessions, the
disability i.e., a score of zero is equivalent to maximum researcher used illustrations, examples of objects, booklets,
disability and a score of 100 is equivalent to no disability. and brochures the discussion was emphasized on improving
women’s knowledge. An additional 15 minutes were assigned
Validity and Reliability at the end of the discussion for questions and obtain the
To establish validity, the questionnaire was piloted feedback to ensure that the women got maximum benefits.
on a panel of 5 experts of Obstetrics and Gynecological staff, The entire study sample received booklet includes knowledge
and Nursing professors who reviewed the instruments for related to exercise.
clarity, relevance, comprehensiveness, understanding,
applicability, and easiness, to establish reliability, alpha 3. Evaluation phase (post-test)
Cronbach’s way to check the stability of the internal Three times of evaluation was done for each woman:
consistency of instrument were .079, .847, and .915 The first evaluation (pretest) was done before
respectively. implementation of the guideline as a baseline data using the
tool to assess awareness of the pregnant women. The second
Procedure The current study was achieved through three evaluation was conducted immediately after the educational
phases: Assessment phase that was included (pre-test to program to detect the level of women's awareness after health
assess women awareness regarding benefits, types, indication, education regarding antenatal exercises. The third evaluation
and contraindication of antenatal exercises). Implementation (posttest) an observational checklist was used after three
phase that included 1.conducting education program, and 2. months (posttest) for final evaluation.
Application of some types of antenatal exercises (pelvic floor The effect of health education program was done
exercises, back & abdominal exercises, and breathing through comparing between pretest and posttest that were
exercises). Evaluation phase that was included (post-test and conducted immediately and after three months
using an observational checklist).
Pilot Study: A pilot study was conducted on (8 women) 10%
1. Assessment phase(pre-test) of antenatal mothers at the previously mentioned setting to
During the assessment phase the researcher held the assess the current study tools for its clarity, validity, and time
first meeting with women to introduce self and explained the required to be applied. According to the results of the pilot, all
nature and purpose, duration, and activities of the study. They required and necessary modifications were done and the
were informed that participation in this study was voluntary women who were tested in the pilot study not included in the
and they had the right to withdraw at any time, oral approval study sample
of women to share in the study was achieved.
After obtaining the acceptance from women to Ethical Consideration: Official permission to carry out the
participate in the current research, the researcher provided an study obtained from women that are willing to participate in
overview and clarification about the assessment tool question the study, after explaining the importance, aim, nature and
then the self-administered questionnaire was distributed to purpose of the study, oral consent obtained from all women,
each woman to assess data related to socio-demographic data all participants have the right to refuse to participate and or
and obstetric history, the questionnaire took about 15 minutes withdraw from the study without Any rational any time,
to be completed. privacy was considered during the collection of data, no health
Then the researcher distributed the pretest hazards were present. Participants were assured that all their
questionnaire to assess women's awareness regarding data are highly confidential, anonymity was also assured
antenatal exercises benefits, types, indication, and through assigning a number for each woman instead of names
contraindication of antenatal exercises). to protect their privacy.
2. Implementation phase (conducting education program) Statistical Design the collected data were organized,
After assessing women's awareness regarding categorized, and analyzed using the statistical package of
antenatal exercises benefits, types, indication, and social science (SPSS) version 20 and Excel for figures. Data
contraindication of antenatal exercises) by awareness were presented using descriptive statistics in the form of
assessment questionnaire, the researcher collected the sample frequencies and percentages for qualitative variables, and
through two days per week from the beginning of the study. means and standard deviations for quantitative variables.
The study was carried out in the period from 15 July 2019 to Statistical significance was considered when P value ≤0.05,
the 15 February 2020. The researcher attended to antenatal high Statistical significance was considered when P value
care Department at 9:00 a.m., to 1:00 p.m.; Face to face ≤0.001, no Statistical significance was considered when P
interview. value ≥0.05 fisher exact test was used to detect the relation
The total sample (75) was divided into a small group. between women knowledge based on their selected socio-
The session's numbers were around two sessions/ day for each demographic characteristics and the relation between women
small group. Each session lasted for around 35 to 45 minutes. awareness and their clinical outcome.
During implementation of health education program, the
Results:
Table (1): Frequency distribution of the studied pregnant woman according to their socio-demographic characteristics (n= 75).
Personal characteristics No. (n = 75) %
Age / years
15- < 20 4 5.3
20- < 25 39 52.0
25- < 30 18 24.0
30- < 35 10 13.4
35 - < 40 4 5.3
Occupation
House wives 56 74.7
Office work 19 25.3
Educational level
Read and write 10 13.3
Basic education 41 54.7
University educated 20 26.7
Post university-educated 4 5.3
Residence
Rural 52 69.3
Urban 23 30.7
Table (1): shows that, 52.0% of pregnant women aged between 20- < 25 years with mean 25.1 ± 4.9 years. Regarding
pregnant women occupations, 74.7% of them were housewives, 56.7% of them had basic education and 69.3% of them lived in a rural
area.
Table (2): Frequency distribution of obstetric history of the pregnant woman (n= 75).
Obstetric history No. (n = 75 %
Parity
Nulliparous 14 18.7
Primiparous 61 81.3
Last parity (n= 61)
One year 3 4.9
More years 58 95.1
Mode of delivery (n= 61)
Vaginal 20 32.8
Cesarean section 41 67.2
Place of delivery (n= 61)
MCH 29 47.5
Private hospital 20 32.8
Others 12 19.7
Previous complication (n= 61)
Yes 7 11.5
No 54 88.5
# Sources of information
Television 21 28.0
Parents 21 28.0
Friends 10 13.3
Doctor 11 14.7
Nurse 6 8.0
Relative 6 8.0
# Responses not normally exclusive
Table (2): presents that, 81.3% of pregnant women had primipara, and 95.1% of them last parity was from more than one
year. Regarding mode of delivery, 67.2% of women delivered by caesarian section, 47.5% of them delivered in maternal and child
health center, and 88.5% of them didn't have any previous complications. Concerning pregnant women sources of information,
28.0%, 28.0% of them their source was a television and their parents respectively.
Table (3) Relation between total pregnant women awareness levels regarding antenatal exercise on pre and post educational
programs (n= 75).
Awareness level Pre Post Fisher P-value
No. % No. % test
Poor awareness 69 92.0 0 .0
Average awareness 6 8.0 7 9.3 180.672 .0001**
Good awareness 0 .0 68 90.7
* *Highly statistical significant difference at ≤ 0.01
Table (3): shows that 92.0% of the pregnant woman had poor awareness regarding antenatal exercise pre educational
program compared with 0.0% of them post-education program, 8.0% of them had average awareness pre-educational program
compared with 9.3% of them post-education program, and 0.0% of the pregnant woman had good awareness pre educational
program compared with 90.7% of them post education program with highly statistically significance differences P – value ≤ 0.0001.
68.1
80
54.5
60
40
20
0
Total mean scores of SF health
Pre Post
Figure (1 ) Frequency distribution of total Short form health mean scores of the pregnant woman regarding antenatal exercise (n= 75).
Figure (1): illustrates that total Short form health mean scores of the pregnant woman regarding antenatal exercise was
higher in post educational program than pre educational program (68.1 ± 13.4) and (54.5 ± 12.7) respectively)
100.00%
100.00%
90.00%
80.00%
70.00%
62.60%
60.00%
50.00%
40.00%
30.00%
22.70%
14.70%
20.00%
10.00% 0.00% 0.00%
0.00%
Poor practice Average practice Good practice
Immediate educational post education
Figure 2 Frequency distribution of the pregnant woman practice levels regarding antenatal exercise (n= 75).
Figure (2): illustrates that none (0.0%) of the pregnant woman had poor practice regarding antenatal exercise immediately
after educational program compared with 14.7% post-education program, none (0.0%) of the pregnant woman had average practice
regarding antenatal exercise immediately educational program compared with 22.7% post-education program, and all (100.0%) of the
pregnant woman had good practice regarding antenatal exercise immediately after educational program compared with 62.6% post-
education program.
Table (4): Relation between socio-demographic characteristics of the woman and their awareness levels regarding antenatal
exercise pre educational program (n=75).
Pre Test of
significance
Personal characteristics Poor awareness Average Fisher P-
(n= 69) awareness test value
(n=6)
No. % No. %
Age / years
15- < 20 4 5.8 0 .0
20- < 25 38 55.1 1 16.7 5.677 .225
25- < 30 16 23.2 2 33.3
30- < 35 8 11.6 2 33.3
35 - < 40 3 4.3 1 16.7
Occupation
House wives 54 78.3 2 33.3 5.890 .015*
Office work 15 21.7 4 66.7
Educational level
Read and write 10 14.5 0 .0
Basic education 37 53.6 4 66.7 2.857 .414
University educated 19 27.5 1 16.7
Post university-educated 3 4.4 1 16.7
Residence
Rural 49 71.0 3 50.0 1.146 .284
Urban 20 29.0 3 50.0
* Statistical significant difference at ≤ 0.05
Table (4): find that, there were no statistically significant differences between socio-demographic characteristics of the
woman and their awareness levels regarding antenatal exercise pre educational program EXCEPT their occupation, 78.3% of women
had poor awareness were houses wives pre educational program with statistically significance differences P-value .015.
Table (5): Correlation matrix between total awareness, total health status, and total practice scores of the woman regarding
antenatal exercise pre educational program (n=75).
Total awareness Total SF Total practice

scores scores scores
Total awareness scores r
P-value
Total SF scores r -.098-
P – value .403
Total practice scores r .288* -.146-
P – value .012 .213
Table (5): presents that, there were no statistically significant differences between total awareness, total health status, and
total practices scores of the woman regarding antenatal exercise pre educational program
Discussion age of the studied sample were 26.30 (3.35). this result differ
This study aim to evaluate the effect of educational with (Otaiby et al., 2013) "An Assessment of Pregnant
program on women's awareness and their health status Women Knowledge and Preferences in Saudi Arabia". Who
regarding antenatal exercises. Antenatal care is a part of the studied and mentioned that the mean age for the sample was
public health promotion and prevention program in most 28.5 ± 6.7 years.
countries. Safe maternity with improved neonatal outcomes is Regarding pregnant women occupation, slightly less
predicated on proper antenatal health care services, regular than three quarter of them were housewives, more than half of
exercise is promoted for its overall health benefits. Antenatal them had basic education and more than two third of them
exercises provide many health benefits to pregnant mothers lived in the rural area. This result come inconsistent
and their fetuses (Hasan et al., 2019). with(Prabha et al., 2019) who stated that more than half of
Regarding the Socio-demographic characteristics of the studied sample were undergraduate education and more
the pregnant woman, the current study showed that, more than than half live-in rural area. This result come in accordance
half of pregnant women aged between 20- < 25 years with with (Otaiby et al., 2013) who stated that less than two third
mean 25.1 ± 4.9 years. This result come in the line with of the studied sample were housewives, but the current study
(Prabha et al., 2019) who studied effects of antenatal differ with the same author who stated that slightly less than
exercise program and education on health related quality of half of the studied sample had a college degree or more.
life: a randomized controlled trial and reported that the mean
The current study come in accordance with result came inconsistent with (Wijesiriwardana &
(Sujindra et al., 2015) who studied '' Knowledge, attitude, Gunawardena, 2016) who founded that doing a job during
and practice of exercise during pregnancy among antenatal pregnancy was significantly associated with possessing a
mothers'' and reported that the majority of the study had ‘Good/Excellent’ level of knowledge on antenatal exercises
undergone primary education and more two third were among pregnant mothers. Similarly, living in a district other
homemakers. This may be due to that the most of people in than Colombo was also associated significantly with
rural area not interested in women education and they have a ‘Good/Excellent’ level of knowledge regarding antenatal
concept that the woman is only suitable for being a housewife. exercises and being occupied was associated with a level of
Regarding obstetric history of the pregnant woman, the ‘Good/excellent’ knowledge regarding antenatal exercises. In
present study illustrated that, the most of the pregnant women addition to this Watson et al., (2015) supported this result
had primipara and the majority of them last parity was from who founded that ''although age and years of practice played
more than one year. This result come inconsistent with no role in this awareness, practitioners who focused on
(Mbada et al., 2014) who studied knowledge and attitude of obstetrics and gynecology were more likely to be aware of the
Nigerian pregnant women towards antenatal exercise: a cross- current guidelines, than those in general practice
sectional survey and reported that the most of the studied
sample were nulliparous and (Otaiby et al., 2013) who stated Conclusion Based on the findings of the current study the
that most of the sample had given birth to more than one following conclusions can be drawn: None of the pregnant
child. woman had pre-educational program awareness compared to
Regarding mode of delivery, more than two third of post-education program, as it was increased and total Short
women delivered by caesarean section, less than half of them form health mean scores of the pregnant woman regarding
delivered in maternal and child health center and the most of antenatal exercise was increased post educational program
them didn't had any previous complications. This result in the than pre educational program (68.1 ± 13.4) and (54.5 ± 12.7)
same line with Mobarak and Sultan, (2019) assessed " respectively).
identify prevalence, indications and determinants of CS in
Alexandria, Egypt" carried out in Alexandria, Egypt between Recommendations Physical exercise services are
July and December 2017 reported that prevalence of CS in recommended for pregnant women and are growing in
Alexandria (2017) was 70.4%. popularity gradually
Concerning pregnant women sources of information,  Obstetric nurses should provide educational classes
the current study showed that less than one third of them their for the mothers' nurses to teach exercise for pregnant
source was television and their parents respectively. This women and integrate this instruction into a holistic
result differ with (Otaiby et al., 2013) who studied antenatal strategy that acknowledges other health habits.
education: an assessment of pregnant women knowledge and  Providing posters, booklets, and leaflets for mothers
preferences in Saudi Arabia and reported that Physicians were about the importance of prenatal exercise.
the preferred source of information by two third of the  Further work is required to identify the most
participants. This result come in the line with effective specific types of guidance and motivation in
(Wijesiriwardana & Gunawardena, 2016)" who studied the (or maintaining) exercise in pregnant women.
Knowledge, attitudes and practices regarding antenatal
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(4)
Assessment of Pain Intensity among Preschool-age Children during Venipuncture

1Yahia Mohamed Sayed; 2 Soheir Abd-Rabou Mohamed; 3 Nagat Farouk Abolwafa
1. Master degree in Pediatric Nursing Faculty of Nursing, Minia University

2. Professor of Pediatric Nursing, Faculty of Nursing –Cairo University
3. Lecturer of Pediatric Nursing Faculty of Nursing – Minia University
Abstract
Background: Venipuncture is a devastating medical, emotional, and physical problem for pediatric patients and their
families. Blood drawing is one of the most frightening and distressing nursing procedures for hospitalized children.
Aim: To assess pain intensity among preschool children during venipuncture. Research design: A descriptive
research design was used in the current study. Sample included 60 preschool-age children undergoing venipuncture
procedures over six months. Setting of the study: - Pediatric medical unit at Minia University Hospital for Obstetrics
and Pediatrics. Tools: Tool (I): structured interview questionnaire which developed by the researcher Tool (II):
Wong-Baker Faces Pain Rating Scale Tool (III): Children's Hospital of Eastern Ontario Pain Scale (CHEOPS).
Results: The highest percentage of the studied preschool-age children experienced severe pain during venipuncture
procedure according Wong-Baker Faces Pain Rating Scale. The total mean scores of Wong-Baker Faces Pain Rating
Scale and Children's Hospital of Eastern Ontario Pain Scale were high markedly during venipuncture. There were
statistically significant negative correlations between children's age and the total mean scores of the CHEOPS and
Face Pain Rating Scale during venipuncture. Conclusion: it was concluded that preschool-age children complained
from severe pain intensity during venipuncture procedure. Recommendation: An educational training program is
mandatory for pediatric nurses about pain assessment and pain management strategy during venipuncture and other
painful procedures.
Keywords: venipuncture, preschool-age children, pain intensity
Introduction &Danford, 2016). Uncontrolled pain also has a direct impact

Children are not outlandish with pain; in fact, it is a on health outcomes and more than a few effects on all areas of
part of their lives. They experience it during vaccination and life (Kahsay, 2017).
venipuncture in the early days of their births and even Venipuncture is a recurrently performed needle-
common diseases in their childhood. Irrespective of this related procedure, is one of the most alarming experiences and
universality of pain, it is yet a complex and multidimensional a common source of moderate to severe pain among children.
experience that is hard to clearly define and even more Venipuncture is a devastating medical, emotional, and
troubling when trying to understand what pain is among physical problem for both pediatric patients and their families
children (Ebrahimpour, Pashaeypoor, Salisu, (Walther-Larsen et al., 2017). Painful, invasive procedures
Cheraghi&Hosseini, 2019). are disturbing - for many children, worse than the disease
According to Becker, Navratilova, Nees, and Van itself. The seemingly endless barrage of needle sticks
Damme (2018), and the International Association of the frightens children and tears at the heart of parents, who are
Study of Pain [IASP] (2020), pain is much more than the unable to guard their children against them. One can assume
conscious perception of a sensory event. It is aversive and that the prick of a needle will hurt anyone, it is quite clear that
inseparably linked to emotion as reflected in the generally there are significant differences between children in how they
accepted definition of pain as "an unpleasant sensory and respond to noxious stimuli (Karlsson, Rydstrom,
emotional experience associated with actual or potential tissue Enskar&Englund, 2014).
damage, or described in terms of such damage". Meentken, Beynum, Legerstee, Helbing and
Emerging evidence from a recent study by Levy and Utens, (2017) documented that hospitalized children undergo
Mills (2018) emphasized that pain is considered the fifth vital multiple, cyclic procedures such as venipuncture throughout
sign. In the same context, Pancekauskaitė and Jankauskaitė their treatment course, and many describe such procedures as
(2018) pointed out that pediatric pain and its assessment and the most distressing part of their hospitalization. Management
management are challenging for health care professionals. of pain is a basic need and precise of all children; effective
Pediatric procedural pain is often underestimated and pain management requires health professionals, including
neglected because of various myths, beliefs, and difficulties in pediatric nurses, is eager to try many interventions to achieve
its evaluation and treatment. It is known that neonates and optimal results.
children can feel pain and that it has long-term effects that last Bukola and Paula, (2017); El Geziry, Toble, Al
through childhood into adulthood. Kadhi, Pervaiz, and Al Nobani, (2018) emphasized that
Pain is a substantial source of distress for unrelieved continuing pain may have untoward effects on
hospitalized children, family caregivers, and healthcare children's health, functional abilities, and quality of life.
providers alike. Pain in children can be produced from Appropriately managing the pain from vein punctures is
physical damage, disease process, invasive procedures, and associated with shorter hospital stays and lower hospital costs.
other unknown factors (Amponsah et al., 2020). Several Freedom from pain is the right of children and must be
previous studies have shown that children's common source of considered in nursing practice. Pain-reducing methods are
pain comes from medical procedures and nursing, such as grouped into two categories pharmacological and non-
immunization and venipuncture (Thrane, Wanless, Cohen pharmacological interventions or both (as integrative
P a g e | 56 Yahia M., et al
medicine). Non-pharmacological measures categorized into
biophysical interventions like massage, acupuncture, and Sample: -
transcutaneous electrical nerve stimulation (TENS), and heat The study sample consisted of all available
and cold therapy, behavioral-cognitive strategies such as preschool-age children undergoing venipuncture procedures
distraction, relaxation, play, guided imagery, therapeutic over six months (the total number was 60 children) who
touch, biofeedback, thought stopping, positive self-talk. admitted to the pediatric medical unit at Minia University
Alotaibi, Higgins, Day and Chan, (2018) documented that Hospital for Obstetrics and Pediatrics (MUHOP).
the mitigation of suffering is one of the four fundamentals of
nursing care. The pain must be detected before it can be Inclusion criteria:
alleviated, and the assessment of pain is an essential part of  Children aged 3-6 years.
nurses' responsibilities.  Children exposing to peripheral venipuncture (blood
sampling) without interventions to decrease pain
Significance of the Study during puncture.
Despite the up warding evidence on pain
management and the accessibility of evidence-based clinical Setting: -
guidelines, pain in children is still inadequately treated. This The current study was conducted in the pediatric
can be attributed to a lack of knowledge among health medical unit on the fourth floor at Minia University Hospital
professionals, misconceptions among children and their for Obstetric and Pediatric (MUHOP).
families, or lack of guidelines (Thrane et al., 2016).
Through empirical observations and experiences as a Data Collection Tools:
clinical instructor in the pediatric care units, it was noticed The following three tools were used to collect the required
that many children who are scheduled for venipuncture for data: -
blood sampling are exposed to varying intensity of pain.
Based on the literature review, preschool-age children were Tool I: A structured interview questionnaire in the Arabic
selected to participate in the current study because they are language was designed by the researcher after reviewing the
among the most affected age groups in the hospital. They have related literature and consists of 19 questions. It divided into
worries about the anticipation of the painful procedures, fear two parts:
of bodily injury from mutilation, bodily intrusion, body image Part 1: - Personal and social characteristics of children as age,
changes, disability, or even death. As well they perceive gender, rank, place of residence, mothers' age, and occupation.
painful procedure as a punishment for misdeeds. Part 2: - It involved 13 questions, five questions related to the
Effective procedural pain management is essential to child's medical history, such as diagnosis, history of previous
ensure adherence to the increased number of painful hospitalization, causes, and the number of prior
procedures required for health maintenance in pediatric hospitalization admissions. Also, it comprised five questions
patients and to create a cooperative and trusting relationship about past painful experiences that the child exposed to it. The
between health care providers, children, and their families. mothers of children have answered these questions as previous
Finally, most pain can be either prevented, treated, or at least painful events, factors that increase the child's pain, factors
reduced using inexpensive techniques. Despite this, most that decrease the child's pain, and the sites of the past pain.
children in our hospitals do not receive adequate treatment. This part included three questions related to the venipuncture
Thus; the aim of the current study was to assess pain intensity site, such as the site of venipuncture, numbers of vein
among preschool children during venipuncture. Ultimately, penetration, and the place where the venipuncture took place.
the results of the current study might generate attention and
motivation and evidence-base for further researches in the Tool II: - Wong-Baker Faces Pain Rating Scale, developed
field of pediatric pain as well as providing guidance and by Wong and Baker (1983). It was a self-report pain scale to
recommendations that should be reflected in pediatric nursing assess pain intensity in children aged 3 to 7 years. Each child
education and practice. was asked to choose the face that best described the intensity
of the pain being experienced. Each face was rated by number
Aim of the Study to determine the intensity of pain, which (0-10) coding as the
The aim of the current study was to assess pain following: (Face 0 = No hurt, Face 2 = Hurts a little bit, Face
intensity among preschool children during venipuncture 4 = Hurts a little more, Face 6 = Hurts, even more, Face 8 =
Hurt whole lot and Face 10 = Hurts worst). These faces were
Research question: - assigned scores from 0 to 10, with a higher score indicating a
 What is the level of pain intensity among preschool- higher severity of pain. According to a study in the Kingdom
age children during venipuncture? of Saudi Arabia, conducted by Alalo, Ahmad, and El Sayed
 What are the factors affecting the level of pain (2016) to identify pain intensity after an ice pack application
intensity among preschool-age children during prior to venipuncture among 50 school-age children that
venipuncture? modify the scoring system of Wong-Baker Faces Pain Rating
Scale to become score 0 referred to no pain, score two referred
Research design: - to mild pain, score 4-6 referred to moderate pain and score 8-
A descriptive research design was utilized to achieve 10 referred to sever pain. Apart from being acceptable and
the aim of the current study. Descriptive research seeks to straightforward, this scale had a high test-retest reliability and
provide an accurate description of observations of phenomena content validity. The scale had high reliability with a
(Grove & Gray, 2018). This design helps describe a situation Cronbach's alpha coefficient of 0.70, as tested by Drendel,
or an event in knowing the level of pain intensity among Kelly, and Ali (2011). The scale is available online without
preschool-age children during venipuncture. copyright restrictions.
preschool children about their rights to withdraw from the
Tool III: - The Children's Hospital of Eastern Ontario study at any time without giving any cause and without any
Pain Scale (CHEOPS): Developed by McGrath et al. effect on the care of their children. Confidentiality was
(1985). The scale can be used to monitor the effectiveness of secured for each mother and her child, where they assured that
interventions for reducing pain and discomfort. A behavioral the study was harmless, and all the gathered data used for the
observation scale will be used to rate a child's intensity of pain research purpose only.
on six verbal and motor behaviors. Each behavior was
assigned a value according to the following criteria, 0 Procedure
(behavior that is the antithesis of pain), 1 (behavior that not Before the venipuncture procedure: -
indicative of pain, but not the antithesis of pain), two behavior The researcher gave the mothers and their children a
indicating mild to moderate pain), and 3 (behavior indicative clear and simple explanation of the aim and the content of the
of severe pain). The total score for the tool ranges from 4-13; sheet; reassuring them that the procedure is safe, and invited
a score higher than 4 indicates pain. Concerning the them to participate and written informed consent was obtained
reliability of the scale, Suraseranivongse et al. (2001) tested from mothers. The researcher interviewed the children and
the scale reliability and it was 0.80, which was considered their mothers individually to collect data related to the
acceptable. CHEOPS is available online without copyright characteristics of children who met the inclusion criteria using
restrictions. (tool 1) the interview took place in the beside area of the
medical unit where venipuncture for blood samples taken.
Validity: After explaining the purpose and during the interview the
The content validity of the data collection tool (1) researcher explained the first pain assessment scales (Wong-
was examined by three experts who were affiliated to the Baker Faces Pain Rating Scale) and the second pain scale
Faculty of Nursing, Minia, and Assuit University at the (CHEOPS) taught each child about how to use the scale. The
Pediatric Nursing Department. The tool was examined for time for the interview took about 30-35 minutes for each
content coverage, clarity, relevance, applicability, wording. child. The procedure was discussed with the responsible nurse
Based on experts` comments and recommendations, minor to gain her cooperation and to save time and effort
modifications had been made, such as rephrasing and
rearrangements of some sentences. During venipuncture: -
Only a usual venipuncture done by the assigned
Pilot Study: - nurse based on physician written order. During the
The pilot study was conducted on six children who venipuncture procedure, the researcher assessed and
met the inclusion criteria to investigate and ensure the documented the child's pain intensity using the behavioral
feasibility, objectivity, applicability, clarity, and adequacy, observation scale (CHEOPS). Immediately after the
and to determine possible problems in the methodological venipuncture, each child was asked to choose the face that
approach or tools. The results of the pilot study were used to describes his intensity of pain based on Wong-Baker Faces
test the proposed statistical and data analysis methods. The Pain Rating Scale. Data collection was conducted over 6
tools were completed without difficulty. Children who months extending from March 2019 till August 2019.
participated in the pilot study were included in the total
sample of the current study. Statistical Analysis
The collected data was coded, categorized, tabulated,
Ethical Considerations: and analyzed using the Statistical Package for Social Science
Written approval was obtained from the Research (SPSS 20.0). Descriptive statistics in the form of frequencies,
Ethics Committee at the Faculty of Nursing, Minia University. percentages for the qualitative variables, mean and standard
Written permission was granted from the director of MUHOP deviation for the quantitative variables was used. Chi square
and the chairpersons of the pediatric medical units after was used to test the association between two Qualitative
explaining the aim and nature of the study. The written variables. Spearman's rank correlation was used to assess the
informed consent was obtained from the mothers of children interrelationships among the quantitative variables. Graphs
after a complete description of the study's aim and nature to were done for data visualization using Microsoft Excel. The P
gain their acceptance and cooperation. Children and their - value of ≤ 0.05 indicates a significant result while, P value of
mothers were informed that contribution to the study was > 0.05 indicates a non-significant result.
voluntary. The researcher also informed the mothers and
Results:
Table (1): Percentage Distribution of the Studied Children According to Their Personal and Social Data (n=60).
Personal and social data No. %
Age / years:-
3-<4 10 16.7
4 -< 5 18 30.0
5-<6 22 36.6
6 10 16.7
Mean ± SD 4.6 ± .9 years
Gender:-
Male 36 60.0
Female 24 40.0
The child rank within the family:-
First 22 36.7
Second 26 43.3
Personal and social data No. %
Third 8 13.3
Fourth or more 4 6.7
Mother educational level:-
Not read and write 42 70.0
University 3 5.0
Mother job:-
Housewife 51 85.0
Working outside house 9 15.0
Place of Residence:-
Rural 40 66.7
Urban 20 33.3
Table (1) presented the personal data pertinent to children and their mothers who participated in the current study. More than
one-third (36.6%) of children's age ranged from 5<6 years, and their mean age was 4.6 ± .9 years. Besides, 43.3% of them ranked as
the second child, 60% were male, and 40% were female. The highest percentage (70%) of the mothers was not read and write, and
85.0% of them were housewives.
Table (2): Percentage Distribution of the Studied Children According to Their Medical History (N=60).
Child illness history No. %
Child's diagnosis:
Pneumonia 10 16.7
Diarrhea, vomiting and dehydration 22 36.7
Favism 3 5
Post streptococcal glomernepheritis 7 11.7
Nephrotic syndrome 6 10
Diabetes mellitus 12 20
Type of the disease:-
Acute 48 80
Chronic 12 20
Previous hospital admission:-
Yes 33 55
No 27 45
If yes how many times of admission to hospital (n = 33):
1 17 51.5
2 14 42.4
3 2 6.1
Mean ± SD 1.5 ± .6
Reason for admission (n = 33):-
Emergency 27 81.8
Follow up 1 3
Medical condition 5 15.2
Table (2) pointed out that 36.7% of the studied children diagnosed with diarrhea, vomiting, and dehydration, followed by
diabetes (20%). The majority (80%) of the studies children had acute health problems. More than half (55%) of children had previous
hospital admissions, and 51.5% were admitted to the hospital for the first time. The mean of prior hospital admission was 1.5 ± .6
times, and 81.8 % from children admitted at the hospital for an emergency health problem.
Table (3): Percentage Distribution of the Studied Children According to Their Previous Painful Experience (n=60).
Previous history of pain No. %
Previous painful experience:
Yes 60 100
No 0 0
If yes, most site of pain in the previous time:- #
Abdominal pain 48 80
Chest pain 4 6.7
Bone pain 8 13.3
Teeth pain 42 70
NET pain 42 70
Headache 25 41.7
If yes, in the home what is the most measures to decrease pain
sensation:-#
Go to Sleep and Rest 55 91.7
Taking Shower 5 8.3
Playing with friends 25 41.7
Using Analgesics 36 60
Best position feels comfortable:- #
Abdomen 14 23.3
Back 21 35
On side 1 1.7
Semi-sitting 25 41.7
Sitting 2 3.3
Things relief pain at hospital:-#
Previous history of pain No. %
Presence of mother 60 100
Toys 32 53.3
Transitional objects 20 33.3
Play with children 33 55
# More than one answer was responded
Table (3) revealed that all (100%) of the studied children had previous painful experiences, and 80% of them suffered from
abdominal pain. The majority of children (91.7%) went to sleep and rest as home measures to relieve their pain, and 41.7% of them
felt comfort in a semi-sitting position. The mother's presence and playing with other children were the main things that reduced pain
in the hospital, as replied by 100% and 55% respectively of the studied children.
66.70%
33.30%
Dorsal hand veins Forearm veins (cephalic or basilic vein )
Figure (1): Percentage Distribution of Venipuncture Site among the Studied Children (n=60)
Figure (1) demonstrated that 66.7% of children had venipuncture in the dorsal hand veins whereas 33.3% had venipuncture
in the forearm veins.
60%
60%
50%
40%
40%
30%
20%
10%
0%
Moderate Severe pain
pain intensity
intensity
Figure (2): Pain Intensity during Venipuncture among the Studied Children According to Wong-Baker Faces Pain Rating
Scale (n=60)
Figure (2) showed that the highest percentage (60%) of the children suffering from severe pain intensity during the
venipuncture while 40%. of them suffering from moderate pain intensity during the venipuncture according to Wong-Baker Faces
Pain Rating Scale.
Table (4): Children's Hospital of Eastern Ontario Pain Scale among the Studied Children during Venipuncture (n=60).
CHEOPS No. %
Cry:
- No cry 0 0
- Moaning 30 50.0
- Silent crying 3 5.0
- Scream 27 45.0
Facial:
- Smiling 0 0
- Composed 18 30.0
CHEOPS No. %
- Grimace 42 70.0
Verbal:
- The child talks about positive things 0 0

- No complains 0 0
- Complaints the Child about pain 25 41.7
- Child complains about pain, and other things 35 58.3
Torso:
- Neutral 0 0
- Shifting 5 8.3
- Tense 20 33.3
- Shivering 5 8.3
- Upright 4 6.7
- Restrained 26 43.3
Touch:
- Not touching 0 0
- Reach 6 10.0
- Touch 8 13.3
- Grab 18 30.0
- Restricted 26 43.3
- Reach and grab 2 3.3
Legs
- Neutral 0 0
- Squirming/ kicking 11 18.3
- Drawn 9 15.0
- Standing (kneeling) 24 40.0
- Restrained 16 26.7
Table (4) demonstrated that 50% of the studied children reacted by moaning during venipuncture. Seventy percent of them
showed face grimacing. Concerning the verbal items of CHEOPS, 58.3% of the studied children complained about pain, and about
other things. In relation to torso items of CHEOPS, 43.3% of children watched restrained. It was found that 43.3% of children their
touch was restricted during venipuncture. Relating to the legs element of CHEOPS 40% of the studied preschool-age children their
legs showed kneeling.
Table (5): Total Mean Score of Faces Pain Rating Scale and CHEOPS during Venipuncture among the Studied Children
(n=60).
Pain scales Total Mean Score ± SD
Wong-Baker Faces Pain Rating Scale. 7.2 ± 2.2
CHEOPS 12.2 ± .75
Table (5) evident that the total mean score ± SD of the faces pain rating scale among children during venipuncture was 7.2 ±
2.2 while The total mean score ± SD of CHEOPS among children was 12.2 ± .75.
Table (6): Correlational Matrix between Children's Age and the Total Mean Scores of CHEOPS, Wong-Baker Faces Pain
Rating Scale during Venipuncture (n=60).
Items Child age Total CHEOPS Total Face scale
Child age R
P- Value
Total CHEOPS R -.490-**
P- Value .000
Face scale R -.305-* .758**
P- Value .018 .000
*Statistically significant differences
Table (6) illustrated that there were statistically significant negative correlations between children's age and the total mean
score of the CHEOPS and Face Pain Rating Scale during venipuncture (r=-.490, P=<.0001 & r=-.30, P=<0.05 respectively), and the
other personal data of the studied children has no effect of their intensity of pain during the venipuncture procedure.
Discussion Sadek (2017) and Ebrahem et al. (2019) to examine the

The aim of the current study was to assess pain effect of cryotherapy on pain intensity at puncture sites among
intensity among preschool children during venipuncture. 40 children undergoing hemodialysis. The study results
Regarding the studied children's characteristics, the current confirmed that 42.5% of children ranked as the second child
study results proved that more than one-third of their ages within their families. On the contrary, in a recent Egyptian
ranged from 5-6 years, and their mean age was 4.6 ± .9 years. study conducted by Ebrahem et al. (2019) to examine the
These results were supported by an Indian study carried out by effect of cryotherapy and balloon inflation on reducing venous
Abishak (2017) who found that 40% of children's age ranged cannulation pain among 45 children undergoing hemodialysis.
from 5-6 years, and their mean age was 4.3 ± 1.09 years. It was found that the maximum percentage (46.7%) of the
The current study results revealed that 43.3% of the studied children was ranked as the first child.
studied children ranked as the second child, similarly, in an Regarding the gender of the studied children, the
Egyptian study held by El Said, Ouda, Mahmoud, and El- current study results showed that the highest percentage was
males. These results were supported by a similar Egyptian effect before venipuncture on pain-related responses among
study held by El Said et al. (2017), who found that 60 % of 50 children. The results of the study indicated that 76% of
the studied children were males. In the same respect, Abishak studied children had previous hospital admissions.
(2017) found that 73.3% of the children were males, while In relation to the previous pain experience of studied
26.7% were female. On the contrary, a study conducted by children, the current study results revealed that all studied
Alalo et al. (2016) carried out a study to identify pain children had previous painful experiences. This result was
intensity after an ice pack application prior to venipuncture similar to a study done by Roy (2019), who summarized that
among 50 school-age children. The study summarized that 74%of studied children had previous painful experiences. The
52% of children were females, while 48% were males. results of the current study documented that 80% of them
The current study results proved that more than half suffered from abdominal pain. This result could be
of the studied children came from rural areas. This result rationalized as acute abdominal pain is one of the most
could be related to almost hospital referral of acute cases to common complaints in children. The same explanation was
MUHOP for better facilities and equipment and care for mentioned by Brusaferro, Farinelli, Zenzeri, Cozzali, and
children with various types of diseases in the Minia Esposito (2018), who documented that abdominal pain, is one
governorate and surrounding rural and semi-urban areas. In of the utmost common symptoms in children. The pain is
the same context, the United Nations Educational, often acute onset and may be due to several gastrointestinal
Scientific, and Cultural Organization [UNESCO] (2017) (GI) or extra intestinal causes.
documented that the rural population was 57% of the total According to Santillanes and Claudius (2015), as in
population worldwide. In the same line, Egypt Demographics adults, the usual site for venipuncture in infants and children is
Profile (2020) reported that the rural community was 57 % of the antecubital fossa. However, any reasonably accessible or
the total residents, and the rate of urbanization was 1.68 % easily visible peripheral vein may be used, such as those on
annual rate of change. In the same context, the results of an the hands, feet, or scalp for a tiny infant. The current study
Egyptian study carried out by Elhalafawy, Bahgat, Abd- results were in accordance with the above-mentioned
Elhafez, A., and Farag (2020) found that 80% of children empirical evidence and demonstrated that about two-thirds of
came from rural areas. children had venipuncture from dorsal hand veins, whereas the
Concerning the personal data related to the mothers rest had venipuncture from forearm veins. These results are
of the studied children, the current study results proved that similar to the findings of the study conducted by Abishak
the mothers' highest percentage (70%) were not read and (2017), who found that 60% of children metacarpal vein in
write. This result reflected the lower literacy rates among dorsal hand was punctured while 40% of them basilic vein
mothers who participated in the current study. In the same was punctured.
line, the Egypt Demographics Profile (2017) assured that Concerning the pain intensity level during
females' literacy rate was 65.5% compared to 63.5% in 2016. venipuncture site among the studied children related to Wong-
Accordingly, governmental and non-governmental Baker Faces Pain Rating Scale. The current study results
organizations' efforts should continue to focus on female showed that the highest percentage (60%) of the children
education, particularly in Upper Egypt. Because low levels of suffering from severe pain during venipuncture while 40|% of
literacy can hinder economic development in the current them had moderate pain. This result may indicate the suffering
rapidly changing, technology-driven world, this will positively of these children during venipuncture procedure.
reflect the health care system as a whole and care provided for Consistent with the current study results of El Said et
the sick child. al. (2017) who found that more than two thirds (72.5%) of
The current study results documented that more than children had severe pain during venipuncture at pre
one-third of children diagnosed as having diarrhea, vomiting, cryotherapy. A study done by Gaikwad, et al. (2017) was
dehydration, and one-fifth of them have diabetes. The current congruent with this result. They found that, the vast majority
study findings were in accordance with the World Health of them (93%) experienced severe pain. The current study
Organization (WHO) (2020), which documented that results are similar to the study's findings held by Aswathi
diarrheal disease is a chief reason for child mortality and (2015) to measure the effectiveness of local cold application
morbidity worldwide. It typically results from contaminated on pain response during intravenous cannula insertion among
food and water sources and is responsible for killing around children. The study findings concluded that the majority
525000 children every year. Severe dehydration and fluid loss (83.33%) of children experienced severe pain during
were the leading causes of diarrhea deaths. venipuncture.
A recent systematic review held by Patterson et al. This study results evident that the total mean score of
(2019) documented that the incidence rates in diabetes in the Wong-Baker Faces Pain Rating scale among children
children were available for 45% of countries (ranging from during venipuncture site was 7.2 ± 2.2.Similarly, Elhalafawy
6% in the sub-Saharan Africa region to 77% in the European et al. (2020) who found that the mean score of Wong-Baker
region). Worldwide annual incidence estimates were 98,200 Faces Pain score during fistula puncture was 7.266 and 5.667,
(128,900) new cases under 15-year (under 20 years) age- respectively, in days 1 and 2. These results are consistent with
groups. Corresponding prevalence estimates were 600,900 the results of the study conducted by Kurian (2019), who
(1,110,100) existing cases. The prevalence estimates have found that the total mean score of the faces pain rating scale
decreased in sub-Saharan Africa because allowance has been among children during venipuncture was 8.26 ± 1.36. The
made for increased mortality in those with diabetes. results of the current study were supported with that obtained
Concerning the previous hospital admissions of the by Fathalla and Bayoumi (2018), who found that total mean
studied children, the current study results showed that more score of the faces pain rating scale among children during
than half of the children had prior hospital admissions. This venipuncture was 6.28 ± .61. In the same direction, El Said et
result was similar to a quasi-experimental study conducted in al. (2017) found that the mean score of Wong-baker Faces
India by Roy (2019) to determine the local cold application's Pain Rating Scale for studied children was 8.30±1.80.
Regarding total mean score of CHEOPS among References
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Knowledge and Performance of Mothers Having Children with Cancer Undergoing Chemotherapy
1
El Shaima Gamal Hasan; 2 Soheir Abd-Rabou Mohamed; 3 Sanaa Mahmoud Ahmed; 4 Khalid Fathy Riad 5Aml Sayed Ali
(1) Master degree in Pediatric Nursing Faculty of Nursing, Minia University

(2) Professor of Pediatric Nursing, Faculty of Nursing –Cairo University
(3) Assistant Professor of Pediatric Nursing Faculty of Nursing – Minia University
(4) Assistant Professor of Pediatric Oncology South Egypt Cancer Institute –Assiut University
(5) Assistant Professor of Pediatric Nursing Faculty of Nursing – Minia University
Abstract
Background: Cancer is a leading cause of death for children worldwide. More than 80% of children with cancer are
cured in high-income countries, but only 20% are cured in many low-income countries. Aim: To assess the
knowledge and performance of mothers having children with cancer undergoing chemotherapy. Research design:
Descriptive research design was used in the current study. Sample: A purposive sample of 35 mothers having children
with cancer and undergoing chemotherapy participated in the study. Setting: The current study was conducted at the
pediatric unit at Minia Oncology Center. Tools: Tool (I): Structured Interview Sheet: covered the personal data of the
mothers and the characteristics of the child; Tool (II): mothers Knowledge Assessment Sheet and Tool (III): mothers
Performance Assessment Sheet. Results: There was lacking knowledge and performance of mothers having children
with cancer undergoing chemotherapy. There were no statistically significant relationships between the total mean
scores of mothers' knowledge and total mothers' practice regarding childhood cancer and chemotherapy as well as
their personal data as age, level of education, their children's age, gender and the child's rank in the family (p=>0.05).
Conclusion: The study concluded that the overall level of mothers' knowledge and performance was unsatisfactory.
Personal variables have no impact on the knowledge and performance of the mothers. Recommendation: The study
recommended that developing periodic educational programs and instructions to mothers having children with cancer
undergoing chemotherapy would improve their knowledge and performance regarding childhood cancer and
chemotherapy.
Keywords: Childhood Cancer, Chemotherapy, Mothers, knowledge, performance
Introduction nervous system (CNS) tumors, and neuroblastoma. The

Childhood cancer is a significant public health survival rate was calculated for 14,553 children, representing
problem worldwide and is the second leading cause of death 92.2% of the full study population (Soliman, Elhaida, Oke,
after accidents in children ages one to fourteen. Eweida, & Sidhom, 2019).
Approximately 1,190 children under the age of fifteen are Recently, Attar, Zagade, and Shinde (2020)
predicted to die from cancer in 2020. Around 11,050 children documented that childhood cancer is treated with different
in the United States under fifteen will be detected with cancer treatment methods commonly involving chemotherapy,
in 2020. Childhood cancer rates have been rising to some radiotherapy, surgery, immune therapy, stem cell therapy,
extent for the past few decades. Because of significant targeted cell therapy, hormonal therapy, and precision
treatment advances in recent decades, 84% of children with medicine. As reported by Marcdante and kliegman (2019);
cancer now survive five years or more. Overall, this is a Singaraju, Palaian, Shankar, and Shrestha (2020),
considerable increase since the mid-1970s, when the 5-year chemotherapy is used in almost all cases of cancer in children.
survival rate was about 58% (American Cancer Society, Over 50% of the children with cancer undergoing
2020). chemotherapy develop adverse drug reactions (ADRs). Cancer
More than eighty percent of children with cancer are chemotherapeutic agents kill cancerous and the normal rapidly
preserved in high-income countries, but in many low-income dividing cells, including bone marrow cells, gastrointestinal
and middle-income countries (LMICs), only 20% are cured. epithelium, hair follicles, and other side effects. Their main
The reasons for lesser survival rates in LMICs include an ADRs are nausea and emesis, mucositis, constipation,
incapability to attain an accurate diagnosis, inaccessible diarrhea, hematological toxicities, cardiac toxicity, alopecia,
therapy, abandonment of treatment, death from toxicity (side gonadal toxicity, pulmonary toxicity, neurotoxicity, and
effects), and excess relapse, in part due to lack of access to nephrotoxicity. The severity of the adverse effects may vary
essential medicines and technologies addressing each of these from mild nausea to life-threatening neutropenia.
gaps expands survival and can be highly cost-effective According to Tomlinson, Yuan, Cheng, and Hinds
(World Health Organization [WHO], 2018; Howard et al., (2020), successful management of symptoms are imperatively
2018). attributable to the potential for harmful effects on the child's
In the study of childhood cancer survivors and health health and well-being. Children with cancer experience a
outcomes over the last ten years in Children's Cancer Hospital myriad of symptoms, often occurring as symptom clusters.
57357 Egypt (CCHE), to determine the variations in survival Symptoms for children with cancer and their families are
by demographic, cancer type. A total of 15,997 children with burdensome, distressing, and often challenging to control.
cancer were analyzed; 58% were males and 42% females. The These symptoms result from the condition, its treatment, and
highest percentage of the children (48%) were in the youngest associated procedures that can hinder the child's psychosocial
age group (0–4 years). Fifty-nine percent of the children had and physical development and have adverse effects on the
solid tumors, and 41% had hematologic malignancies. The child's and family's quality of life. Experiencing frequent and
most common cancers were leukemia, lymphoma, central
P a g e | 65 El Shaima G., et al
severe symptoms is accompanied by a lower quality of life Hence, the current study was undertaken to assess
and may hinder multiple aspects of a child's development. mothers' knowledge and performance regarding the care of
As documented by Ameringer, Macpherson, and children having cancer and undergoing chemotherapy. Results
Jibb (2020), Valizadeh et al. (2020), chemotherapy's side of the current study may help in evaluation of the mothers'
effects might keep a child from partaking in social knowledge and performance regarding care of children having
interactions, such as playing or being with peers, that are key cancer. As well as providing guidance and recommendations
to facilitating psychosocial development. Symptoms as loss of that should be reflected in pediatric nursing education and
appetite, nausea, and vomiting lead to inadequate nutritional practice.
intake, negatively affecting physical development. Detecting
patients' needs is one of the primary steps of the nursing Aim of the study
process to plan and implement nursing interventions and The current study aimed to assess the knowledge and
prevent late effects. performance of mothers having children with cancer
Leading health care organizations, including the undergoing chemotherapy.
WHO and the American Academy of Pediatrics (AAP), have
endorsed that pediatric palliative care (PPC) ought to begin Research Questions
once a severe or life-threatening condition is diagnosed and The current study results answered the following
continue no matter whether or not a child receives treatment research questions:
aimed toward comfort or cure. Nurse clinicians and scientists  What is the level of mothers' knowledge regarding
were amongst the front runners within the field of pediatric the care of children having cancer and undergoing
palliative care within oncology. Several of the early nurse-led chemotherapy?
studies focused on the perspectives of mothers caring for their  What is the level of mothers' performance regarding
children with incurable cancer. Symptom management is a the care of children having cancer and undergoing
foundation of PPC, thus supporting the need for the early chemotherapy?
integration of PPC (Newman, Crane, Spruit, Alharrasi &
Bell, 2020). Research design:
Family education is an integral and crucial A descriptive research design was utilized to achieve
component of nursing care in pediatric oncology; it has the aim of the current study. This design helps describe a
recently been identified as a clinical and research priority situation or an event in exploring and knowing the level of
within the pediatric oncology community. Expert consensus mothers' knowledge and performance regarding the care of
recommendations have been developed to usher the provision children having cancer and undergoing chemotherapy.
of education to families of newly diagnosed patients.
Abundant the existing evidence for the provision of patient Subjects:
and family education in pediatric oncology is targeted to the A purposive sample of 35 mothers having children
time of initial cancer diagnosis. This underscores the with cancer and undergoing chemotherapy participated in the
overwhelming quantity of new information that is often current study. According to the statistical equation in which
provided in parallel with families' need to understand the the sample size ranged between 10% to 30% from the total
diagnosis and treatment to provide safe care for the child population size, the entire pediatric population admitted to the
within the home setting. It also highlights the significant pediatric oncology unit at Minia Oncology Center was 126
emotional impact of the new cancer diagnosis upon the child children in 2017.
and family (Haugen, Zupanec &Landier, 2020).
Inclusion criteria:
Significance of the study  Mothers were having newly diagnosed children with
Cancer is a chief cause of death among children cancer and free from chronic illness as diabetes or
worldwide; it's a life-threatening condition and a significant renal failure or other types of malignancies.
public health problem for pediatric patients. Globally millions  Mothers were having children and undergoing
of children die yearly due to cancer. 1,735,350 newly chemotherapy for the first time.
diagnosed cases and 609,640 cancer deaths are projected to  Mothers who agree to participate in the study
occur in the United States (Siegel, Miller & Jemal, 2019). regardless of their age or educational level.
The global cancer burden has doubled within the  Mothers who have no other child with cancer or any
last thirty years of the twentieth century. It is estimated that cancer patient receiving chemotherapy.
this will double again between 2000 and 2020 and nearly
triple by 2030. The cancer incidence estimate was Setting:
113.1/100,000 of the total population in 2012, and The current study was conducted at the pediatric
114,98/100,000 of the total population in 2013. Projections to oncology unit at Minia Oncology Center that is located in
2050 estimate cancer incidence in Egypt to be Minia city. It serves Minia governorate and affiliated with the
341.169/100,000 of the total population (National Cancer Ministry of Health and Population.
Control Plan of Egypt 2016-2020). Kamel, Baraka, Khalid,
and Ibrahim (2009) reported that according to the results of Data collection tools:
Egypt National Cancer Registry, Minia profile, the total The following data collection tools were utilized. The
number of malignancies reported during 2009, amongst researcher developed the tools after reviewing the related
children under the age of 15 years, was 258 cases; these cases literature.
represented 5.6% of all incident cancers (total of 4584
patients).
Tool (I): Structured Interview Sheet: It involved was no risk for study subject during application of the current
16 questions and classified into two parts: study, oral consent was taken from all mothers to participate
Part I: It contained 11 items that cover the personal in the study. The researcher explained the study's purpose and
data of the mothers as age, educational level, material status, nature through direct personal communication before
place of residence, and the number of children in the family. It participating in the study. These data were confidential and
also comprised the characteristics of the children with cancer were used for the research only. The study followed the
and undergoing chemotherapy such as age, gender, and rank common ethical consideration to participate in clinical
within the family. research, and privacy was assured during data collection.
Part II: It is comprised of five questions covers the Anonymity and privacy were assured through coding the data,
current medical history of the children as diagnosis and type and a mother has the right to refuse to participate in the study
of cancer, as well as the duration of illness, medications, and without any rationale. Children and their mothers were
previous hospitalization. informed that participation in the study was voluntary; the
Tool (II): Mothers; Knowledge Assessment Sheet: researcher also informed the mothers about their rights to
It involved 21 questions classified into two parts: withdraw from the study without giving any reason and
Part I: It involved 5 Multiple Choice Questions without any effect on their children's care.
(MCQs) to assess the mothers' knowledge regarding cancer,
including definition, causes, predisposing factors, signs and Data Collection Procedure:
symptoms, and methods of management. Primary approval was obtained from the Research
Part II: It contained 16 MCQs questions to assess Ethics Committee, Faculty of Nursing, Minia University.
mothers' knowledge regarding chemotherapy, including Official permission was obtained from the administrator of
definition, types, uses, phases, side effects on bone marrow, Minia Oncology Center and permission from the head of the
skin, digestive and respiratory systems, precautions, and pediatric oncology unit after explaining the study's aim and
measures to reduce the side effects. nature. After that, data collection started; the researcher went
Tool (III): Mothers' Performance Assessment to Minia oncology center for two days per week.
Sheet: Mothers were interviewed on individual bases to
It involved 17 MCQs questions to evaluate the explain the nature and purpose of the study and obtain
mothers' performance regarding the care of their children with personal data about their children's characteristics and current
cancer, such as care of signs and symptoms, e.g., nausea, medical history with cancer and undergoing chemotherapy
vomiting, pallor, fatigue, bone or joint pain, infection, and (tool I). The interview took place in the inpatient rooms in the
anorexia. Mothers' performance was assessed regarding pediatric oncology unit at Minia Oncology Center. Mothers'
chemotherapy sessions, such as dealing with chemotherapy's knowledge and performance regarding their children's care
side effects, e.g., fever, bleeding tendencies, mucosal with cancer and undergoing chemotherapy were assessed
ulceration, pain, nausea, and vomiting. using (tools II, III). The duration of the interview was ranged
from 25-30 minutes. Data collection was conducted over
Scoring system: for mothers' knowledge and twelve months extending from January 2019 till December
performance, each correct/ complete response took two 2019.
scores; the incomplete one took one score, and zero score was
given for the wrong answer or the not known/ done. The total Pilot Study
score was converted to 100% and then categorized as The pilot study was conducted on 10% (four mothers
following: score (≥ 50%) was considered satisfactory level; having children with cancer and undergoing chemotherapy)
meanwhile, mothers' overall score (less than 50%) was who met the inclusion criteria was done to ensure the
regarded as an unsatisfactory level of knowledge/ feasibility, objectivity, applicability, clarity, adequacy, content
performance. The total mothers' knowledge score was 42, validity, and internal consistency of the study tools and to
while 34 scores for the mother's total response related to their determine possible problems in the methodological approach
performance. . or the tools. The tools were completed without difficulty,
adding support to the validity of the tools. Little modifications
Validity and Reliability were made, e.g., rephrasing and rearrangements of some
The content validity of the tools was performed by a sentences. Mothers involved in the pilot study were excluded
jury of 5 experts in pediatric nursing and pediatric oncology. from the main study sample.
Tools were examined for content coverage, clarity, relevance,
applicability, wording, length, format, and overall appearance. Statistical Analysis
Based on experts` comments and recommendations, The collected data were coded, tabulated, and
modifications were made. The internal consistency was analyzed using the Statistical Package for Social Science
measured to identify the extent to which the tools measure the (SPSS 20.0). Descriptive data were expressed as mean and
same concept and correlate. Cronbach's alpha coefficient was standard deviation. Qualitative data were expressed as
used to assess the tools' internal consistency were .0861 & frequency and percentage. Fisher test was used to detect the
.910, correspondingly. relation between mothers' knowledge based on their selected
personal variables. Comparisons of means were performed
Ethical Considerations: using a paired-sample t-test. Level of significance at p<0.05,
Written approval obtained from the Research Ethics 0.001 were used as the cut of value for statistical significance.
Committee of the Faculty of Nursing, Minia University; there
Results:
Table (1): Personal Data of Studied Mothers in Percentage Distribution (n=35).
Personal data No %
Age / years
35- < 40 16 45.7
40 - < 45 7 20.0
45 - < 50 8 22.9
50- < 55 4 11.4
The degree of closeness to the mother:
Mothers 35 100
Level of education
Not read and write 10 28.6
Secondary education 1 2.9
Place of residence
Urban area 2 5.7
Rural area 33 94.3
Regarding mothers' personal data, the current study results revealed that more than two fifth (45.7%) of the studied mothers
were 35- < 40 years old, and the mean of their age was 42.5 ± 5.4 years. All (100%) of mothers who participated in the current study
were mothers. More than half (51.4 %) of them have basic education, and 94.3% lived in rural areas (Table 1).
Table (2): Personal Characteristics of Studied Children Having Cancer and Undergoing Chemotherapy in Percentage
Distribution (n=35).
Personal data No %
Age of the child/ years:
1- <5 12 34.3
5 - < 10 14 40.0
10 – 15 9 25.7
Child' gender:
Male 14 40.0
Female 21 60.0
The rank of the child within the family:
First 11 31.4
Second 6 17.2
Third and more 18 51.4
Table (2) clarified that 40% of the studied children were 5 - < 10 years old, their mean age was 3.4 ± 4.0 years, and 60%
were female. More than half (51.4%) of the children were ranked as the third and more within their families.
Table (3): Current Medical History of the Studied Children in Percentage Distribution (n=35).
Current medical history No %
Type of cancer
Leukemia 14 40.0
Nervous system cancer 4 11.4
Lymphoma 7 20.0
Adrenal cancer 1 2.9
Kidney cancer 6 17.1
Bone cancer 3 8.6
How long has cancer been discovered?
Within the past week 15 42.9
Within the last two weeks 20 57.1
Cancer-related surgery performed
Yes 5 14.3
No 30 85.7
Symptoms
Fever 8 22.9
Enlarged lymph nodes 7 20.0
Headache or vomiting 2 5.7
Bone or joint pain 2 5.7
Abdominal pain 1 2.9
Fever and enlarged nodes 5 14.3
Fever and pallor 1 2.9
Fever, pallor, and pain 3 8.6
Enlarged nodes and bleeding 4 11.4
Chest pain 1 2.9
Legs edema 1 2.9
Table (3) showed that 40% % of children have Leukemia, followed by Lymphoma, and 57.1% were discovered within the
last two weeks. The majority (85.7%) of the children didn't have any cancer-related surgery performed on them. Fever and enlarged
lymph nodes were the main symptoms experienced by children in the current study (22.9% & 20% respectively).
14.30%
85.70%
No yes
Figure (1): Number and percentage distribution of Mothers who Received Information About Childhood Cancer and Chemotherapy (N=35).
Regarding mothers' knowledge, Figure (1): proved that the majority (85.7%) of the mothers hadn't been given any
knowledge about childhood cancer and chemotherapy.
60%
60%
50%
40%
30% 20%
20%
20%
10%
0%
Media Relatives Physician
Figure (2): Sources of Mothers Been Given Knowledge About Childhood Cancer and Chemotherapy in Percentage Distribution (N=35).
Regarding the sources of knowledge given to mothers about childhood cancer and chemotherapy, figure (2) proved that the
mothers' highest percentage (60%) received their knowledge about childhood cancer and chemotherapy from physicians.
Table (4): Mothers' Knowledge about Childhood Cancer and chemotherapy in Percentage Distribution (n= 35).
Mothers’ knowledge Complete Incomplete Don’t know
No % No % No %
Definition of cancer 0 0 0 0 35 100
The most common types of cancer in children 0 0 4 11.4 31 88.6
The common symptoms of childhood cancer 0 0 1 2.9 34 97.1
Predisposing factors of childhood cancer 0 0 0 0 35 100
The different treatment methods for childhood cancer: 0 0 0 0 35 100
Definition of chemotherapy 0 0 3 8.6 32 91.4
Uses of chemotherapy 0 0 0 0 35 100
The different ways to give chemotherapy 0 0 0 0 35 100
All cancers treated with one type of chemotherapy 0 0 0 0 35 100
Total mean score of mothers’ knowledge 10.4±4
Table (4) highlighted that all (100%) of the mothers don't know the definition of cancer, predisposing factors of childhood
cancer, treatment methods, and uses of chemotherapy. The majority (88.6%, 97.1% & 91.4%, respectively) of the mothers don't know
the most common types of cancer in children and its symptoms and cannot define chemotherapy. The total mean score of the mothers'
knowledge was 10.4±4.
Table (5): Mothers' Performance Regarding Chemotherapy in the Pre-test, Post-test, and Follow-up (n= 35).
Mothers’ Performance Complete Incomplete Don’t know
No % No % No %
Side effects on the bone marrow 0 0 4 11.4 31 88.6
Side effects on the digestive system 0 0 4 11.4 31 88.6
Side effects on skin and hair 0 0 4 11.4 31 88.6
Side effects on the respiratory system 0 0 0 0 35 100
Protect the child from infection 0 0 0 0 35 100
Conditions that need contact with the physician immediately 0 0 0 0 35 100
Mothers' performance when the child exposed to bleeding 0 0 0 0 35 100
Mothers' performance when the child exposed to anorexia 0 0 0 0 35 100
Mothers' performance when the child exposed to vomiting 0 0 0 0 35 100
Mothers' performance when the child suffering from pain 0 0 2 5.7 33 94.3
Management of hair loss 0 0 1 2.9 34 97.1
Mothers' performance when the child exposed to diarrhea 0 0 0 0 35 100
Mothers' performance when the child exposed to mouth and throat problems 0 0 0 0 35 100
Total mean score of mothers’ performance 4.8±0.7
In relation to the mothers’ performance regarding childhood cancer and chemotherapy, table (5) revealed that equal
percentages (88.6%) of the mothers don’t know the side effects of chemotherapy on bone marrow, digestive system, skin, and hair
and respiratory system. All (100%) of the mothers don’t know what to do in the case of their children exposed to infection, bleeding,
anorexia, vomiting, pain, hair loss, and mouth and throat problems. The total mean score of the mothers’ knowledge was 4.8±0.7.
Table (6): Mothers' Level of Knowledge and Performance Toward Childhood Cancer and Chemotherapy (n = 35).
Items Satisfactory Unsatisfactory
No % No %
Mothers’ knowldege 0 0 35 100
Mothers’ performance 0 0 35 100
Table (6) demonstrated that all (100) of the mothers had an unsatisfactory level of knowledge and performance regarding
childhood cancer and chemotherapy.
Table (7): Relations Between the Total Mean Score of Mothers' Knowledge Regarding Cancer and Chemotherapy and Their
Personal Data (n= 35).
Personal data No. Mean ± SD Test of significance
Age / years t/ F test P - value
35- < 40 16 6.3 ± .4
40 - < 45 7 6.1 ± .4 1.148 .345
45 - < 50 8 6.0 ± .0 NS
50- < 55 4 6.0 ± .0
Level of education
Not read and write 10 12.0± .0
Read and write 6 8.0 ± .0 1.930 .145
Basic education 18 6.3 ± .5 NS
Secondary education 1 6.0 ± .5
The social status of the mother
Married 34 12.1 ± .4 .163 .689
Divorced 1 6.0 ± .0 NS
Place of residence
Urban area 2 6.0 ± .0 .337 .566
Rural area 33 12.2 ± .4 NS
Occupation
Works outside the home 1 6.0 ±.0 .163 .689
House wife 34 12.2 ± .4 NS
NS= Not statistically significant differences ** Highly statistically significant differences
Regarding the relations between the total mean score of mothers' knowledge regarding childhood cancer and chemotherapy
and their personal data, table (7) illustrated that there were no statistically significant relations between the total mean scores of
mothers' knowledge regarding childhood cancer and chemotherapy and their age, level of education, social status, place of residence,
occupation, and family type (p=>0.05).
Table (8): Relations between the total mean score of the mothers' performance regarding cancer and chemotherapy and their
personal data (n= 35).
Age / years t/ F test
35- < 40 16 5± .9
40 - < 45 7 4.6 ± .8 .518 .673
45 - < 50 8 4.8 ± .5 NS
50- < 55 4 4.0 ± .0
Level of education
Not read and write 10 4.0 ± .0
Read and write 6 4.0 ± .0 3.462 .028*
Basic education 18 5.4 ± .9
Secondary education 1 4.0 ± .0
The social status of the mother
Married 34 4.8 ± .7 .260 .614
Divorced 1 4.0 ± .0 NS
Place of residence
Urban area 2 4.0 ± .0 .540 .468
Rural area 33 4.8 ± .8 NS
Occupation
Works outside the home 1 4.0 ±.0 .163 .689
Housewife 34 4.8 ± .8 NS
Family type
Extended 25 4.4 ± .5 5.440 .026*
Nuclear 10 5.6 ± 1.1
NS= Not statistically significant differences * = Statistical significant differences
** Highly statistically significant differences
Regarding the relations between the total mean scores of mothers' performance regarding childhood cancer and
chemotherapy and their personal data, table (8) illustrated that there were statistically significant relations between the total mean
score of mothers’ performance and their level of education and type of family (p=<0.05). There were no statistically significant
relations between the total mean scores of mothers' performance regarding childhood cancer and chemotherapy and their age, social
status, place of residence, and occupation (p=>0.05).
Discussion mothers having children with leukemia undergoing

The current study results assured that the highest chemotherapy. The study results summarized that the highest
percentage of studied mothers were 35- < 40 years old, and percentage of mothers' ages ranged from 30 to 35 years and
the mean of their age was 42.5 ± 5.4 years. All of the mothers had basic and secondary school education. The vast majority
who participated in the current study were mothers. These of mothers were married and housewives.
results supported a study done by Hamad and Shaker (2019) The current study results revealed that the majority of
to assess the coping strategies among 54 mothers of children mothers came from rural areas. This result could be related to
with acute leukemia in Iraq. The study results proved that the Minia Oncology Center serving children with various
mothers' mean age was 36.53± 7.53 years, and the majority of types of cancers in the Minia governorate and surrounding
chief mothers (87%) were mothers. rural and semi-urban areas. In the same context, the United
The current study results evident that more than half Nations Educational, Scientific, and Cultural Organization
of the mothers had basic education, and their minority did not [UNESCO] (2017) documented that the rural population was
read and write. The result reflected that higher literacy rates 57% of the total population worldwide. In the same line,
among Egyptian mothers, especially in upper Egypt. On the Egypt Demographics Profile (2020) reported that the rural
same line, the Egypt Demographics Profile (2017) assured community was 57 % of the total residents, and the rate of
that females' literacy rate was 65.5% compared to 63.5% in urbanization was 1.68 % annual rate of change.
2016. Accordingly, efforts of governmental and non- Concerning children's characteristics, the current
governmental organizations should continue to focus on study results clarified that the highest percentage of the
female education because low levels of literacy can hinder the studied children were 5 - < 10 years old, their mean age was
economic development of a country in the current rapidly 3.4 ± 4.0 years, and nearly two-thirds of them were females.
changing, technology-driven world, this; of course, will reflect More than half of the children were ranked as the third and
positively on the health care system as a whole as well as care more within their families. Forty percent of the studied
provided for the sick child. children were diagnosed with leukemia. These results were in
In a descriptive-correlational study carried out by accordance with a study done by Hamad and Shaker (2019),
Khademi et al. (2019) to assess the caring power of 196 who found that more than half (52%) of the children were
mothers who have a child with cancer and its predictors, the females, and the majority (88.9%) of them were diagnosed
study results concluded that the average age of the mothers with leukemia. On the same perspective, Motlagh, Mirzaei-
was 34.53 years. Similarly, in an Egyptian study conducted by Alavijeh, and Hosseini (2019) found that the mean age of
Hassan and Ibrahim (2018) to determine the effect of children with cancer was 5.57 years, 47.1% of the children
supportive nursing intervention on the burden and coping were female, and 52.9% were male.
strategies of 60 mothers of children with cancer. The results Expanding recent literature by the American Cancer
showed that more than ninety percent of primary caregivers Society (2020) also demonstrated that leukemia is the most
were mothers in both groups, and 65% of the total mothers' significant common in early childhood, peaking between 2
ages ranged from 30 to > 35 years. More than one third and 4 years of age. There are numerous leukemia types,
(38.3%) of studied mothers have had a technical education, including acute lymphocytic leukemia (ALL) and acute
and high education represented thirty-five percent. Ninety myeloid leukemia (AML), which start in the bone marrow or
percent of mothers of studied cancer children were blood. Leukemia could cause bone and joint pain, fatigue,
housewives. weakness, pale skin, bruising, fever, weight loss, and enlarged
In an Egyptian study held by Taha, Mohamed, lymph nodes.
Mahmoud, and Khaled (2019) to evaluate the effect of Recently, the American Cancer Society (2020)
nursing instructions on knowledge and reported-practice of 50 documented that numerous signs and symptoms of childhood
cancer. Common symptoms include fatigue, pale skin, cancer and receiving chemotherapy have a moderate
infections and fever, easy bleeding or bruising, shortness of knowledge level.
breath, bone or joint pain, loss of appetite, loss of weight, The newest recommendations indicate that it is
abdominal distention and sometimes headaches, seizures, crucial to ensure that mothers understand several fundamental
balance problems, and vomiting. The findings of the current concepts elaborate in caring for a child with cancer within the
study were in accordance with the above-mentioned empirical first days after diagnosis and after discharge following the
evidence and proved that the highest percentage of studied initial hospital admission, so parents know how and when to
children complained from fever, enlarged lymph nodes, and seek care at the hospital (Jackson, Liang, Frydenberg,
bleeding. Higgins, & Murphy, 2016). On the contrary, the current
The current study results proved that the majority of study results demonstrated that all mothers had an
the mothers did not give any knowledge about childhood unsatisfactory level of knowledge regarding childhood cancer
cancer and chemotherapy. These results could be rationalized and chemotherapy.
as the mothers were not informed about childhood cancer and On the same line, Saeed, hamzah, and Nitavid
chemotherapy. These results also showed the urgent need to (2019) studied the effectiveness of a structured teaching
implement teaching sessions for mothers about that issue for program on enhancing mothers' knowledge about childcare for
the provision of a safe child's life in all pediatric oncology children with cancer blood in India. The study results revealed
health care settings. that 38.53% of the mothers had inadequate knowledge, and
Concerning mothers' knowledge about childhood 34.86% of mothers had moderate knowledge. The same
cancer and chemotherapy, the current study results revealed results were attained by Samaan (2020), who assessed
that the highest percentages of mothers didn't know or had mothers' care for their children with leukemia undergoing
incomplete knowledge about cancer and its causes and chemotherapy concluded that 67.5% of the mothers had low
symptoms. Also, mothers had incomplete knowledge related total knowledge scores regarding leukemia and chemotherapy.
to chemotherapy and its side effects The overall level of Moreover, 24.4% of the mothers had a fair total score of
mothers' knowledge about childhood cancer and knowledge. Meanwhile, only 8.1% of them had a good total
chemotherapy was unsatisfactory. These results indicate the score of knowledge.
mothers' need for knowledge and instructions about childhood Concerning mothers' performance provided for their
cancer and chemotherapy. The inadequate mothers' knowledge children with cancer, the current study results highlighted that
may exacerbate familial stress and negatively affect their the majority of the mothers were not able to provide care for
children's clinical outcomes. Adverse events associated with their children. Mothers reported incomplete care for their
insufficient education may include unexpected medical children as regards the side effects of chemotherapy. The
problems. highest percentages were not oriented by the precautions taken
As emphasized by Hockenberry and Wilson (2019), to protect the child at home after a chemotherapy session.
nurses working with children who have cancer have a Inappropriately, all mothers had an unsatisfactory
substantial supporting role in helping the mothers understand performance level regarding the care of their children with
the various therapies, preventing or managing expected side cancer and undergoing chemotherapy. These results could
effects or toxicities, and observing for late effects of have a negative impact on their ability to provide proper care
treatment. Education is a constant feature of the nursing role, for their children. The overall level of the mothers’
especially in new treatments, clinical trials, and home care. performance was unsatisfactory. These results could have a
Pediatric nurses are influential in helping families avoid negative impact on their ability to provide adequate care for
seeking unproven and potentially unsafe traditional their children.
management methods. Similarly, Taha et al. (2019) confirmed that 98% and
These results were consistent with Taha et al. 100% respectively of the mothers don't know the care should
(2019); they found that most mothers of children with be provided for their children before and during
leukemia had wrong or incomplete knowledge related to chemotherapy. All the mothers who participated in their study
etiology, symptoms, and childhood cancer treatment. Besides, had insufficient reported-practice before receiving the nursing
the vast majority of the mothers had incomplete items of instructions.
reported-practice regarding their children's care before, The current study results clarified that there were no
during, and after chemotherapy sessions. Similarly, statistically significant relationships between the total mean
Mahmoud and Abd Elaziz (2015) evaluated the effect of a scores of mothers' knowledge and total mothers' practice
psycho-educational training program for 60 parents who have regarding childhood cancer and chemotherapy and their age,
a child with cancer blood on their experience and level of education, social status, place of residence, their
psychological well-being. The study results summarized that children's age, and gender and the child's rank in the family
most of the pre-test parents had insufficient knowledge related (p=>0.05). So, it could be concluded that personal variables
to the definition, causes, symptoms, and treatment modalities have no impact on the mothers' knowledge and performance.
of childhood cancer. These results were supported by Kaur, Chanu, and
Regionally in Iraq, in a previous study carried out by Sorte (2017), who assessed the effectiveness of a structured
Obaid, Ajil, and Al-Ganmi (2014) to assess knowledge educational program on knowledge regarding home
about chemotherapy for leukemic child and their 70 mothers management of side effects of chemotherapy among parents in
and to find out the relationship between the mother's India. The results illustrated no statistically significant
knowledge and the demographic characteristics for mothers, association between knowledge score and their selected
child and child's illness. The study results demonstrated a demographic variable in terms of age of parents, level of
knowledge deficit of mothers in some aspects related to education, age of the child, gender, and child diagnosis. These
chemotherapy treatment. Most mothers who have a child with results are contradicted with Taha et al. (2019), they found
that there were highly statistically significant positive
correlations between mothers' total mean score of knowledge (5) Egypt Demographics Profile (2020). Available at
and reported practice and their level of education. These www.indexmundi.com/egypt/ demographics _profile. Accessed on
26/9/2020.
results also contradicted the study by Priya et al. (2019); they
found a significant association between knowledge with the (6) Hamad, S., & Shaker, N. (2019). Coping Strategies among
Caregivers of Children with Acute Leukemia at Nanakali Hospital
child's age and the number of children. In practice, an in Erbil City. Erbil Journal of Nursing and Midwifery, 2(2), 155 -
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educational status of the mother. (7) Hassan, G.A., & Ibrahim, H.S. (2018). The effect of supportive
nursing intervention on the burden and coping strategies of
caregivers of children with cancer. Journal of Nursing Education
Conclusion and Practice.;8(7):125. Available from:
The current study results concluded that there was an https://doi.org/10.5430/jnep.v8n7p125
obvious lacking in knowledge and performance of the mothers (8) Haugen, M., Zupanec, S., & Landier, W. (2020) Improving Care
having children with cancer undergoing chemotherapy. The Through Patient and Family Education in Pediatric Oncology. In:
overall level of mothers' knowledge and performance was Hinds P., Linder L. (eds) Pediatric Oncology Nursing. Pediatric
Oncology. Springer, Cham. https://doi.org/10.1007/978-3-030-
unsatisfactory. There were no statistically significant 25804-7_6
relationships between the total mean scores of mothers' (9) Hockenberry, M. J., & Wilson, D. (2019). Wong's Nursing Care of
knowledge and performance regarding childhood cancer and Infants and Children11th ed, Elsevier Health Sciences. London.pp
chemotherapy and their age, level of education, social status, 405-408.
place of residence, occupation, children's age, gender, and (10) Howard, S.C., Zaidi, A., Cao, X., Weil, O., Bey, P., Patte,
child's rank in the family. C……...& Lacheteau, G. (2018). The My Child Matters program:
effect of public-private partnerships on pediatric cancer care in
low-income and middle-income countries. Lancet Oncology
Recommendations: The study recommended that; ;19(5): e252-e266.
 Development and application of an educational (11) Jackson, A.C., Liang, R.P., Frydenberg, E., Higgins, R.O., &
program for mothers in pediatric oncology units are Murphy, B.M. (2016). Parent education program for special health
care needs children: a systematic review. Journal of Clinical
mandatory to provide a framework for mothers' role Nursing. 2016;25(11-12):1528-1547. doi:10.1111/jocn.13178
for their children with cancer. (12) Kamel, H., Baraka, H., Khalid, H., & Ibrahim, A. (2009). Egypt
 The pediatric oncology health care institutions should National Cancer Registry, El-Minia profile.
establish a committee responsible for teaching (13) Kaur, R., Chanu, S.E., & Sorte, D.Y. (2017). A Study to Assess
children newly diagnosed with cancer and their the Effectiveness of Structured Teaching Program on Knowledge
mothers about the disease and its management Regarding “Home Management of Side Effects of Chemotherapy”
among Parents. Pediatric Therapeutics 7: 333. doi:10.4172/2161-
modalities. 0665.1000333
 Healthcare professionals, including pediatric (14) Khademi, F., Rassouli, M., Khanali, L., Heidarzadeh, M.,
oncology nurses, should consider developing Shirinabadi, M., & Borumandni, N. (2019). Caring power of
informational booklets for mothers to refer to specific mothers who have a child with cancer and its predictors. Iranian
Journal of Pediatric Hematology and Oncology; 9(3):173-183.
cancer varieties and treatment protocols.
(15) Mahmoud, S., & Elaziz, N. A. A. (2015). Effect of Psycho-
 There should be arrangements for social programs Educational Training Program for Parent's Having Child with
like mother's meetings etc. by various organizations Leukemia on Their Experience and Psychological Wellbeing.
to increase public awareness about childhood cancer. Journal of Education and Practice, 6(12), 13- 29.
 This study's replication is warranted; this would (16) Marcdante, K., & kliegman, R. (2019). Nelson Essentials of
enhance opportunities to generalize the findings to Pediatrics, Principles of Cancer Treatment, 8th ed, Philadelphia,
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(17) Motlagh, M.E., Mirzaei-Alavijeh ,M., & Hosseini, S.N. (2019).
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Acknowledgment: Pediatrics; 7(6): 9541-9548.
The authors are thankful for the great help and (18) National Cancer Control Plan of Egypt 2016-2020
cooperation received from the mothers of children with cancer (19) Newman, A., Crane, S., Spruit, J., Alharrasi, S., & Bell, C. (2020).
Palliative Care in Pediatric Oncology, Pediatric Oncology Nursing,
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members of the Oncology Center, Minia Governorate, to https://doi.org/10.1007/978-3-030-25804-7
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Effect of Kegel Exercise on Improving Manifestations of Uterine Prolapse among

Pre menopausal Women
Shaimaa Gamal Ramadan Hassan 1, Manal Farouk Moustafa 2, Hoda Abd Elazim Mohamed 3, Ahmed Samier Abd El-Malek
(1) Clinical instructor- Technical Institute of Nursing - Minia University

(2) Professor of Obstetric &Gynecological Nursing & Reproductive Health -Faculty of Nursing- Assiut University.
(3) Professor of Women Health and Obstetrics Nursing- Faculty of Nursing - Minia University.
(4) Professor of obstetrics & Gynecology- Faculty of Medicine - Minia University.
Corresponding Author: Shaimaa Gamal Ramadan Hassan
Abstract
Background: The symptoms of uterine prolapse can be extremely debilitating & have an appreciable impact on
quality of life (Streicher. L , 2013). Pelvic floor exercises can improve the symptoms in mild and moderate cases and
sometimes prevent the pelvic organs from slipping down further (Hassan & Mahmoud, 2017). Aim of the study:
To evaluate the effect of Kegel exercise on improving manifestations of uterine prolapse among pre-menopausal
women. Research design: Quasi-experimental design was adopted to conduct this study. Setting: The study was
conducted at gynecological outpatient clinics at Minia University Hospital for Obstetric & Pediatric and El - Minia
General Hospital. Subjects: A Purposive sample composed of 102 pre-menopausal women was recruited for the
current study and divided equally by using simple random sample into study &control groups. Tools of data
collection: Three tools were used as following: 1- A structured interviewing questionnaire, 2- Pelvic Organ Prolapse –
symptoms score (POP-ss), 3- Follow up evaluation sheet (diary record). Results: The current study reveals; that there
were a strong negative correlation between uterine prolapse symptoms and women compliance to performance of
Kegel exercise after 6 weeks and 3 months of the intervention with statistical significant differences at (P value ≤
0.046 and P value ≤ 0.003). Conclusion & Recommendations: Implementation of Kegel exercises had a highly
significance effectiveness' in improving manifestations of uterine prolapse among pre-menopasual women. In addition
applying an educational program about Kegel exercises for women was recommended.
Keywords: Kegel exercises, Manifestations of prolapse, Uterine prolapse.
Introduction require no treatment. Some women with a more advanced

Uterine prolapse is a health concern affecting condition prefer observation to other treatments, but should be
millions of women worldwide. When it defined by symptoms examined regularly (Buckler, 2017).
has prevalence of 3–6 % and up to 50 % when based upon According to Priyanka, et al, (2010), the main
vaginal examination (Barber & Maher, 2013). The mean symptom of uterine prolapse is seeing or feeling of bulging in
prevalence in low-income countries is 19.7% (range 3.4%- the vagina. The presentation of symptom may be varying
56.4%) (Jokhio, et al., 2013) .However; A population based among individuals and it depends on the severity of prolapse.
study (n = 2070) by UNFPA in Nepal found a prevalence of The association between childbearing and Uterine Prolapse
uterine prolapse were 10% included women had ‘something (UP) giving rise to symptoms of pelvic floor dysfunction
coming down in the vagina’ (Walker & Gunasekera, 2011). (PFD) (Elenskaia, et al, 2013).
More recent studies from Ethiopia (Belayneh, et al., 2019 Measures used for reducing the impact of uterine
and Ballard, et al., 2016) and Tanzania (Masenga, et al, prolapse symptoms includes ; training of Kegel exercises and
2018) showed prevalence of UP based on symptoms included life style changes .These exercises strengthens levator ani
up to 64.6% based on clinical examination. muscle through muscular hypertrophy and stronger levator ani
It defined as the descent of uterus and vaginal walls muscle improves support and reduces the burden imposed on
through vaginal canal. Uterus, move downwards due to the ligament (Berzuk & Shay, 2015) .
anatomical or functional deformities of the tissues and During the transition phase to menopause, the
ligaments that support the uterus (Memon & Handa, 2012). maternity nurse plays an important role in prevention of
Pre-menopause is an even a greater risk factor for prolapse through giving the woman health education about
uterine prolapse; it associated with profound reproductive and diet, exercise and follow- up and its importance for early
hormonal changes (Binjwala, et al, 2014). Also, additional detection of any genital abnormalities (Vorvick, 2011).
risk factors associated with UP have been shown as; Birth
weights, MOD (Mode of Delivery) and length of the second Significance of the study
stage of labor (Walker & Gunasekera, 2011). In Egypt and Arab countries half of the women had
The symptoms of uterine prolapse depend on the duration of UP more than 5 years and 6% of women had UP
degree of the prolapse. More significant uterine prolapse may for more than 20 years. Overall more than 60% of women
cause pelvic pain or pressure. It may also interfere with sexual reported symptoms (Fitchett, et al, 2015).
function (Hagen & Stark, 2011). Menopause is a consequence of age; there is a
In a minimal prolapse, women may not develop any straight association between menopause and an increased risk
bothersome symptoms prolapse may be asymptomatic and for UP (Weintraub, et al, 2020 and Sze, et al, 2012). The
P a g e | 75 Shaimaa G., et al
hormonal changes in menopause cause a drop in the systemic the Isaac, S. & Michael, W.B. (2000) formula which is
estrogen concentrations, contributes to alterations in the computed as (N = P x 30 / 100)
composition and strength of collagen. This particular hormone Description:
helps keep pelvic muscles strong. Without it, premenopausal N = Sample size
women at a higher risk of developing uterine prolapse P = Uterine prolapse prevalence in target population
(Alcalay, et al, 2015). N = 340 x 30/ 100 = 102 patients.
Conservative treatments for uterine prolapse during
menopause for pre- menopausal women include; Pelvic Floor Tools of Data Collection:
Muscle Training (PFMT), which used in cases of mild to Three tools for data collection were used in the
moderate prolapse & may help to relieve symptoms present study:
(Bordman, et al., 2014). In addition, Kegel Exercise or Tool I (pre-intervention):
PFMT is safe, effective and an inexpensive therapy. This A Structured interviewing questionnaire was
highlights the need for using preventive measure includes developed by the investigator to collect data and divided in to
Kegel exercise for the improvement of signs and symptoms of three parts;
uterine prolapse; (Golmakani, et al., 2012, Binjwala, et al., Part (1): Personal data of women such as; (Age,
2015 & Priyanka, et al., 2015). marital status, residence, level of education……, etc).
Part (2): Obstetrics & gynecological history of
Aim of the study women such as; (Gravidity, parity, mode of last
The present study was conducted to; evaluate the deliveries……, etc).
effect of Kegel exercise on improving manifestations of Part (3): Medical history such as; (Medical diseases,
uterine prolapse among pre-menopausal women. problems resulting in increasing pressure in abdomen,
problems associated with elimination……, etc).
Research hypothesis
H1. Women who follow Kegel exercise training will Tool II (pre/ post intervention):
have improvement in their manifestations of uterine prolapse Pelvic Organ Prolapse – symptoms score (POP-ss)
than those who do not follow. adopted from (Hagen, et al., 2004):
This tool used & modified by the investigator to
Subjects and Methods score the symptoms of uterine prolapse, it was a structured
Research design: Quasi-experimental research questionnaire included 7questions and modified into 10
design (time series design) was utilized for the purpose of the questions. The total up the scores for Q 1 – Q 10 range 0-40
current study. was calculated by summing the ten individual symptom
Research Setting: The study was conducted at responses. The best possible score would be 0 - meaning
gynecological outpatient clinics at Minia University Hospital haven't been complaint of these symptoms at all , the moderate
for Obstetrics & Pediatric and El - Minia General Hospital. score would be 10- < 40 meaning that some of these
Both hospitals offer care services to all women who have symptoms bother woman all of the time, and the worst or
gynecological problems & living in Minia City districts and severe would be 40- meaning that all of these symptoms
villages related to Minia Governorate. bother woman all of the time.
The investigators used this tool three times through
Subjects: the present study, the first time before intervention, the second
Sample type: Purposive sample composed of 102 time after 6 weeks from intervention and third one after 3
pre-menopausal women with 1st, 2nd degree uterine prolapse months from the intervention to evaluate the program effects
was recruited for the current study and divided equally by after intervention as prolapse symptoms improved by compare
using simple random sample into study group (n=51cases) & the baseline symptoms scores before intervention with the
control group (n=51cases) according to the following symptoms after intervention.
inclusion and exclusion criteria:
Tool III ( pre/ post ):
Inclusion Criteria: Follow up evaluation sheet (dairy record) adopted
 Age group ranged from 40-50 years. from (Priyanka. et al, 2011 & Egyptian Journal of Hospital
 Educated women. Medicine, 2017):
 Women who clinically diagnosed as uterine prolapse This tool was modified by the investigator in the
(1st and 2nd degree). form of dairy record to assess the frequency & duration of
 Multipara women. performance of Kegel exercise (compliance of women). Diary
record was given to women in the study group to record their
Exclusion criteria: compliance of Kegel exercises at their homes. The
 Women with reproductive tract infection & urinary investigator instructed them to document their compliance by
tract infection or any other gynecological put a circle for documenting frequencies of performing Kegel
complications. exercises through a day, time of relaxation / contraction and
 Women with 3 & 4 degree uterine prolapse.
rd th number of relaxation / contraction. The investigator followed
up the study group after using this tool by them 3 times
Sample Size: The determination of the sample size through the current study (The 1st time after 1 month, the 2nd
was based upon the flow number 340 pre-menopausal women time after 6 weeks and 3rd time after three months from the
(The attendants' rate of pre-menopausal women -in each clinic intervention).
for both hospitals was estimated during 2017 before starting
the study). Sample size was 102 & it was calculated by using
Supportive material: prolapse – symptoms score (POP-ss) for assessing prolapse
It was designed by the investigator in form of symptoms. Each interview took about 15 to 20 minutes for
handout (booklet) after revising extensive relevant literature each pre- menopausal woman to be completed.
review such as (Abrams, et al., 2012) & (Boyle, et al., 2014). (Implementation phase):
It was written in a simple Arabic language & it was developed The investigator conducted the educational sessions
and supported with photos and illustrations to help the woman about Kegel exercise for pre- menopausal woman in the study
understanding the content of the booklet. This handout group. The total number of Kegel exercise training sessions
consisted of description about anatomy of female reproductive was 1 - 2 sessions (2 days/week) through 4 weeks varied
system, complete description about uterine prolapse, and according to understanding of each participant. Duration for
complete description of Kegel exercises. each session was ranged from 20 to 35 minutes & it was
conducted after organization with gynecologist in the
Validity & Reliability: The questionnaire was outpatient clinics before the women left the clinic.
piloted on panel of 5 experts of Obstetrics and gynecological The first session took about 20 minutes and at the
staff, and nursing professors who reviewed the instruments for beginning of this session, the investigator introduces her-self,
clarity, relevance, comprehensiveness, understanding, explained the objective of the research; gave them an
applicability and easiness. Alpha Cronbach’s test was used to educational booklet about Kegel exercises and then illustrated
check the stability of the internal consistency of instrument. the content of the booklet; through gave the women simple
information about anatomy of the female reproductive system,
Pilot study anatomy of the female pelvis, and anatomy of pelvic floor
It was carried out on 10% of the total study sample muscles.
(10 pre-menopausal women). It was conducted to evaluate the The second session (practical session) took about
applicability and clarity of the tools, assessment of feasibility 25 minutes; the investigator gave the women a detailed
of fieldwork and to detect any possible obstacles that might explanation about Kegel exercise and helps the women to
face the investigator and interfere with data collection. identify the correct muscle for Kegel training individualized
Necessary modifications were done based on contents for by asked them to lie down on the bed in supine position with
more simplicity and clarity. The subjects were not included to knees bent and focus on the perineal area and completely relax
the actual sample. the perineal area. Then two fingers were put inside the vagina,
and the woman was asked to contract her pelvic floor muscles
Fieldwork: just like when she holds the urine and she had to try to pull the
After the conduction of the pilot study as well as the investigator's finger upward and inward.
actual study, an official permission and consent was obtained After identifying these muscles, the pre-menopausal
from the dean of the Faculty of Nursing, as well as the women in the study group were asked to contract the pelvic
Director of Minia University Hospital for Obstetric and floor muscles during examination of the vagina, and then after
Pediatric & El- Minia General Hospital & the head of internal ensuring proper contraction of the muscle, they were asked to
medicine department at both hospitals. All women aged do these exercises twice daily, each time 15–20 times
between 40-50 yrs who clinically diagnosed as uterine depending on their ability to contract their pelvic floor
prolapse ( 1st and 2nd degree) by the gynecologist was muscles for 5–10 s and relax for 5–10 s and repeating this
included in this study. Then the investigator was started to exercise for 20 times (for 5 min). After 2 min of rest, they
collect data through four phases included: 1) Interviewing; 2) again had to perform this exercise for 3 times of 5 min. so that
Implementation; 3) Follow up and 4) Evaluation phases. a total of 20 minutes of exercise is performed at each time.
However, the investigator asked them to repeat
(Interviewing phase): exercise 1 to 2 times per day from the first day until one
At the beginning of this phase, the investigator month, then (2-3 min) and repeated 1 to 2 times from the first
visited data collection site from 9:00 Am to 1:00 Pm , for 2 day after one month post – intervention until two months and
days per week (Sunday and Tuesday). This phase was applied then (3-5 min) and repeated 2 to 4 times from the first day
to control and study groups of pre- menopausal women. after two months post – intervention until three months.
The investigator held the first interview with each The investigator used tool III (follow up sheet) which
woman in the out patient gynecological clinics during includes the duration of exercise per day, performing exercise
examination by the doctor or after examination before leaving according to training program and instructed them for
the clinics introduced her-self, Oral consent for participation recording their compliance at home. It was taken from them at
in the study was obtained from selected pre-menopausal the end every 4 weeks to ensure women's compliance.
women for ethical issues & scheduled times and frequency of However, control group of pre-menopausal women
sessions and follow up, mobile phone numbers were saved to received routinely care from the hospital at outpatient
all selected women to assure adherence to the intervention. gynecological clinics.
The investigator collected data using the first, second
and third tools from control and study group. The investigator (Follow up phase)
asked pre- menopausal woman questions about their socio- The investigator used her telephone number for
demographic characteristics such as (age, marital status, calling with women in the study group every 2 weeks to find
….ect), obstetrics and gynecological history included out if they were regularly performing the exercises and have
(Gravidity, parity, ….ect), and medical history included any other problems facing them to determine degree of her
(Medical complaints, problems resulting in increasing compliance with pelvic floor muscle exercises at home and
pressure in abdomen, …..ect). checked women progress. However, the investigator calling
The structured interviewing sheet was filled by the women in the control group to ensure routine hospital care.
investigator and she used the second tool (Pelvic organ
(Evaluation phase) menopausal women in the study and control groups to assess
Evaluation phase was done at pre intervention as a the progress of uterine prolapse symptoms by using the second
base data and after 6 weeks & 3 months at the outpatient tool (Pelvic organ prolapse – symptoms score (POP-ss).
gynecological clinic. The investigator interviewed pre-
Results
Table (1): Distribution of pre-menopausal women regarding to their socio-demographic characteristics (n=102)
Items Study (n=51) Control (n=51) Sig. test P-value
No. % No. %
Age / Years
 40-˃45 28 54.9 24 47.1 t = 0.760 0.449
 45-50 23 45.1 27 52.9 NS
Mean ± SD 44.8 ± 3.39 45.3 ±3.38
Marital Status
Married 74 80.4 38 74.5 2 = 1.25 0.533
Divorced 4 7.8 3 5.9 NS
Widow 6 11.8 10 19.6
Residence
Rural 37 72.5 36 70.6 2 = 0.826
Urban 14 27.5 15 29.4 0.048 NS
Level of Education
Read & write 20 39.2 21 41.2
Basic education 18 35.3 20 39.2 2 = 1.55 0.670
Secondary 8 15.7 4 7.8 NS
University 5 9.8 6 11.8
Occupation
House wife 39 76.5 35 68.5 2 = 0.375
Work 12 23.5 16 31.4 0.788 NS
Table (1): There was no statistical significance difference between the two groups regarding to sociodemographics
characteristics
Table (2): Distribution of Pre-Menopausal Women Regarding to Uterine Prolapse- symptoms Pre and Post Intervention
(n=102)
POP-ss Study (n=51) Control (n=51) t test P – value
Mean ± SD Mean ± SD
Pre-Intervention 26.0 ± 7.37 26.5 ± 7.7 0.353 0.725
Post 6 weeks 19.5 ± 6.02 26.5 ± 7.7 5.08 0.000**
Post 3 months 15.4 ± 5.37 27.0 ± 7.5 8.97 0.000**
Table (2) Shows that there were a highly statistical significant difference between both groups (study and control) at (P.value
≤ 0.000) regarding to uterine prolapse- symptoms post- intervention compared with no statistical significant difference at (P. value =
0.725) pre- intervention respectively
Table (3): Distribution of pre-menopausal women regarding to their degree of uterine prolapse symptoms (n=102)
Degree of uterine Pre Intervention Post 6 weeks Post 3 months
prolapse symptoms Study (n=51) Control (n=51) Study (n=51) Control (n=51) Study (n=51) Control (n=51)
No. % No. % No. % No. % No. % No. %
 Mild
10 19.6 12 23.5 18 35.3 12 23.5 38 74.5 12 23.5
 Moderate
21 41.2 20 39.2 30 58.8 20 39.2 12 23.5 15 29.4
 Severe
20 39.2 19 37.5 3 5.9 19 37.3 1 2 24 47.1
Fisher's exact (P – 0.397 (0.096) 15.4 (0.002**) 34.5 (0.000**)
value)
Table (3): It reveals that there was a highly statistical significant difference between study and control groups regarding to
degree of uterine prolapse symptoms post- intervention at (P value ≤ 0.002) after 6 weeks and at (P value ≤ 0.000) after 3 months
compared with no statistical significance difference at (P value = 0.096) pre- intervention respectively
Table (4): Relation between socio-demographic characteristics with uterine prolapse degree of symptoms among pre-
menopausal women
Degree of Symptoms
Mild Moderate Severe
Socio demographic characteristics
Study Control Study Control Study Control
No. No. No. No. No. No.
Age
Degree of Symptoms
Mild Moderate Severe
Socio demographic characteristics
 40-˃ 45 10 9 10 11 8 10
 45-50 0 3 12 8 11 1
P value 17.93 (0.000**)
Educational level
Read & write 2 4 4 8 14 9
Basic education 3 7 10 3 5 10
Secondary 3 1 5 3 0 0
University 2 0 3 5 0 1
P value 19.25 (0.004**)
Occupation
House wife 4 11 16 8 17 16
Work 6 1 6 11 2 4
P value 7.14 (0.028*)
Table (4): It illustrates the relationship between sociodemographics characteristics with uterine prolapse symptoms. It was
noticed that there was a highly statistically significant relation between the pre-menopausal women's uterine prolapse symptoms with
their age and educational status at (P value ≤ 0.000) and statistically significant with their occupation at (P value ≤ 0.028).
Table (5): Relation between Problems resulting in increasing pressure in abdomen with uterine prolapse degree of symptoms
among pre-menopausal women
Problems resulting in increasing pressure in abdomen
Chronic Cough Constipation Obesity
Symptoms
 Mild 5 5 4 4 1 1
 Moderate 10 10 7 7 4 4
 Severe 2 2 13 13 5 5
P value 16.9 (0.024*)
Table (5): This table illustrates the relation between problems resulting in increasing pressure in abdomen with uterine
prolapse symptoms. It was observed that there was statistically significant relation between problems resulting in increasing pressure
in abdomen with uterine prolapse degree of symptoms at (P value ≤ 0.024) respectively
Table (6): Relation between uterine prolapse degree of symptoms with gravidity and parity among pre-menopausal women
Uterine Prolapse degree of Symptoms

Items Mild Moderate Severe
Gravidity
1-3 10 9 10 6 12 10
4-5 0 3 7 10 4 1
More than 5 0 0 5 3 3 9
P value 20.5 (0.001**)
Parity
None 0 0 1 3 1 0
1-3 10 9 9 3 13 10
4-5 0 3 7 10 2 1
More than 5 0 0 5 3 3 9
30.6 (0.001**)
Table (6): This table shows the relation between uterine prolapse degree of symptoms with gravidity and parity. It was,
observed that there was a highly statistical significant relation between uterine prolapse degree of symptoms with gravidity and parity
at (P value ≤ 0.001).
Discussion manifestations of uterine prolapse than those who do not

The aim of this study was to assess the effect of follow.
Kegel's exercises on Improving Manifestations of Uterine Regarding to the sociodemographics characteristics
Prolapse among Pre- menopausal Women. Findings of this the current study findings reveals that the majority of pre-
study discussed to accept the research hypotheses; Women menopausal women among study group were married and
who follow Kegel exercise training will have improvement in nearly three-quarters between control and study groups were
rural respectively.
This finding agreed with those of Bruno, et al., make it on time is usual and increase women self-efficacy to
(2012) who studied randomized controlled trial on Efficacy perform which increase PFM strength.
of pelvic floor muscle training for treating pelvic organ This study findings was in the same line with a recent
prolapse in women, the rural and married women who had randomized controlled trial to Intensive supervised versus
POP their age was more than 40 years. Also, Jokhio, et al unsupervised pelvic floor muscle training for the treatment of
(2020) who studied population based study on prevalence of stress urinary incontinence; a randomized comparative trial by
pelvic organ prolapse in women, associated factors and impact Felicissimo, (2010) found that commitment to PFMT was as
on quality of life in rural Pakistan added that the incidence of effective for women with POP and increases their compliance
prolapse affected by age was 25% of cases with age 36-40 and exercise adherence, which lead to successful effect.
years but the most common age was 40-60 years old 60%. In Moreover, the current study findings revealed that
relation to education levels in the present study, it was found there was a relationship between socio-demographic
that the largest percentages of study and control groups characteristics with uterine prolapse symptoms. It was noticed
respectively were read and write. However, the lowest that there was a highly statistically significant relation
percentage of study and control groups respectively had between the pre-menopausal women's uterine prolapse
Bachelor degree. Concerning occupation, the finding symptoms with their age and educational status at (P value
represented that the highest percentage among study and ≤0.000) and statistically significant with their occupation at (P
control groups were housewife between both groups were read value≤ 0.028).
and write. These findings disagreed with Hassan, Osman and These findings reflected that the pre-menopausal,
Fayez (2015) who studied prevalence, risk factors and educated and workable women may had source of information
severity of symptoms of pelvic organ prolapse among about risk factors for uterine prolapse including vaginal
Emirati women and approved that 98% of women in their childbirth, advancing age, more births and they tried to avoid
study were educated and workable. these factors
Furthermore, as regards to uterine Prolapse In relation to this result, several epidemiological
Symptoms, the current study findings displayed that, there studies as Dumoulin, Hay-Smith (2010) who studied Pelvic
were statistical significant differences between both groups floor muscle training versus no treatment, or inactive control
regarding to improvement of prolapse staging post treatments, for urinary incontinence in women; they have the
intervention after 3 months at ( P value ≤ 0.043) respectively, similar finding when examined the association between uterine
which accepted the first research hypothesis which is women prolapse symptoms and stages and participant characteristics
who follow Kegel's exercises will show less signs and such as age, education, and parity.
symptoms than before. These factors were theoretically hypothesized as
In accordance with this finding Priyanka, et.al, significant confounders of POP this comparable between
(2015) who studied A pre-experimental study to assess the younger and older participant educated, non- educated.
effectiveness of nursing intervention package on management Moreover, it was observed that there was statistically
of pelvic organ prolapse; reported that, the intensity of significant relation between problems resulting in increasing
symptoms reduced to 1.3 to 0.7 after 4 months of intervention, pressure in abdomen with uterine prolapse degree of symptoms.
also the total mean score decreased to 19.70 to 11.2 at 6 week This may be regarded to that there is evidence that a vaginal
and 6.22 at 4 months to show the effectiveness of Kegel's delivery, and increased abdominal pressure significantly
exercise on managing POP. weakens and stretches the pelvic floor muscles and increase
The findings of this research regarding uterine susceptibility to uterine prolapse.
prolapse symptoms agreed with study done by Subhagan These findings supported by Shrestha, et.al, (2014)
(2010), who applied educational program for 3 months who found in their study majority of respondents ( 81.3% )
about POP for women and proved that; women's knowledge, increasing pressure on abdomen and carrying heavy loads as
symptoms, and quality-of- life significantly improved in 3 causes of uterine prolapse and increase its symptoms.
months. While these findings disagreed with study done by Moreover, it was, observed that there was a highly
Stüpp, et al., (2011) published randomized controlled trial statistical significant relation between uterine prolapse degree
who studied the Kegel's exercises on POP. Results showed of symptoms with gravidity and parity at (P value ≤ 0.001). As
that, there was no difference between the training group and over the last few years, there has been increasing interest in the
control group regarding to treatment of pelvic organ prolapse. role of levator ani-muscle injuries in the development of
Also, the findings of this study disagreed with McClurg, et al., uterine prolapse; there was relation between levator ani
(2014) who examined the combination of PFMT with defects and uterine prolapse; women with levator ani defects
surgery or insertion of vaginal pessary. The study founded are at least twice as likely to show clinically significant uterine
that application of PFME only not improve POP symptoms. prolapse. Ani muscle strongly affected by women gravidity
Moreover, McClurg, et al., (2014) suggested that, pelvic floor and parity. This result supported by Acharya, (2016) who
exercises help to improve a mild prolapse and related studied Contributing Factors of Utero-vaginal Prolapse among
symptoms. Pelvic floor muscle training resulted in significant Nepali Parous Women and Divya, et al. (2015) who studied
anatomic improvement of anterior and posterior vaginal wall Knowledge Regarding Utero -vaginal Prolapse among
prolapse and better muscle strength. Women in Sree Balaji Medical College and Hospital who
Regarding compliance to Performance of Kegel reported that uterine prolapse strongly affected by mode of
Exercises, the current study results displayed that nearly two delivery and parity with statistical significance differences.
third were moderate compliance compared with the relation
between women compliance to performance of Kegel Exercise Conclusion & Recommendations
with uterine prolapse symptoms after 1 and 3 months The current study findings concluded that Kegel
These findings reflected that the adherence to exercise had been demonstrated to be effective in inducing
performing exercises daily help increase it effect and may
significant improvement in manifestations of uterine prolapse (8) Bordman R, Telner D, Jackson B, Little D (2014): Step by-step
among pre-menopausal women. approach to managing Pelvic Organ Prolapse. Canadian Family
Physician; 53: 485-487. Available from: URL:
http://www.ncbi.nlm.nih.gov.
In the light of the findings of the present study, the (9) Buckler H, (2017) : The menopause transition endocrine changes
following recommendations are suggested by the and clinical symptoms. JBMS; 11(2):61-5.
investigator: (10) Divya, Hemavathy, Sathiyalatha S. (2015): Knowledge Regarding
 Providing standardized plan of care based on Kegel Utero -vaginal Prolapse among Women in Sree Balaji Medical
exercises training for treatment of uterine prolapse College and Hospital, Chennai. Journal of Nursing and Health
Science ; 4(1).
that may have positive impact on women future
(11) Dumoulin C, Hay-Smith J. (2010): Pelvic floor muscle training
health and their QOL. versus no treatment, or inactive control treatments, for urinary
 Applying an educational program about performance incontinence in women. Cochrane Database Syst Rev Jan 20;(1):
of Kegel exercise for women after labor (postpartum) CD005654.
to avoid complications such as uterine prolapse. (12) Elsayed, F., Ahmed, M., & Gaheen, M. A. S. A. (2016):
Knowledge and Practices of women regarding risk factors of
 Further researches are needed in a larger probability uterine prolapse. IOSR Journal of Nursing and Health Science
sample in different geographical areas in Egypt, (IOSR-JNHS), 5(6), 60-7.
especially rural areas to figure out the main aspects (13) Felicissimo MF, Carneiro MM, Saleme CS, Pinto RZ, da Fonseca
of these problems & to implement PFMT (Kegel AM, da Silva-Filho AL. (2010): Intensive supervised versus
exercise) for women with uterine prolapse unsupervised pelvic floor muscle training for the treatment of
stress urinary incontinence: a randomized comparative trial. Int
undergoing treatment Urogynecol J Pelvic Floor Dysfunct; 21:835-40.
(14) Ferreira C, Barbosa P, Oliveira S, Antônio F, Franco M & Bø
K.;(2011): Inter-rater reliability study of the modified Oxford
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The current study findings concluded that Kegel (2):132–138.
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Relationship between Self-Esteem and Aggressive behavior among Foster Care Children
at Minia Governorate, Egypt
Sherifa Rabea Mohamed 1,, Nefissa Mohammed Abd El-Kader2, Hanan Ibrahim Abd EL Aziz 3, Fatma Nagy Kotb 4
(1) Assistant lecturer of psychiatric Mental Health Nursing, Faculty of Nursing, Minia University
(2) Professor of Psychiatric Mental Health Nursing, Faculty of Nursing, Cairo University
(3) Professor of Psychiatric Mental Health Nursing, Faculty of Nursing, Cairo University
(4) Assistant Professor of psychiatric Mental Health Nursing, Faculty of Nursing, Minia University
Abstract
Background: Children who are deprived from parental care for any reason are eligible to enter the foster care. Foster
care children are at increased risk for developing emotional and behavioral problems for a variety of reasons. This
study aimed at assessing the relationship between self-esteem and aggressive behavior among foster care children at
Minia governorate. Research Design: A descriptive correlational research design was utilized in this study. Study
subjects: 51 foster care children in age group 6-12years.were included in the study. Tools; Aggressive behaviors scale
and Hare Self-Esteem Scale were used. Results: Majority of participants were males. More than two thirds of the
foster children (74.5%) had low level of self-esteem and foster boys had high mean scores of physical aggression than
girls and there was a significant negative correlation between aggression and self-esteem (r = 0.33). Conclusion: there
was a significant negative correlation between aggression and self-esteem. Recommendation: Frequent assessment of
aggressive behavior and self-esteem among foster care children are needed.
Key Word: Foster Care Children, Self-Esteem, Aggressive behavior.
Introduction: Robins, 2018). Parental neglect or lack of warmth is known to

Foster care services are provided for children who both undermine healthy self-esteem development and cultivate
cannot live with their original families due to birth out of children’s aggressive behavior (Mwakany & Yizhen 2019).
wedlock, family breakup, poverty, parental death, or child Children in foster care have been found to report higher levels
abuse, and includes runaway children (Yoon et al., 2019). of internalizing and externalizing behaviors than the general
Compared with the general population, children in foster care population, a higher prevalence of behavioral problems exists
are at greater risk of having higher rates of mental health for children entering foster care and these problems may also
problems, low self-esteem, developmental health impact an individual throughout their lifetime, in a study of
problems and behavior problems (Carthya et al., 148 foster children, 82% of them reported physical
2018). Characteristics of the foster placement itself might also aggression, 14% beat-up, 41% kicking, and 69% pushing
influence the likelihood that a foster child will develop (Linares, et al., 2016). Similarly; Thompson et al., (2016)
problematic aggressive behaviors. reported that the prevalence of behavioral problem in foster
Self-esteem refers to an overall evaluation of one’s children has ranged from approximately 20 to 80%. The
worth or value as a person (Thompson et al., 2016). Levels of prevalence of behavior problems in a US study among 2–14
self-esteem during childhood influence the longer term course year, exhibited by foster children has been estimated to be
of development into adulthood (Robins & Trzesniews, 2018). 47.9% olds and 29– 49% among Australian children
In this respect; Coopersmith (1981), reported that self-esteem (Jacobsena, et al., 2020). In Egypt, Fawzy & Fouad, (2010)
as self-worth which is a product of development that serves as reported that, 23% of children had low self-esteem in a study
an important protective factor for positive development conducted in 4 orphanages at Sharkia governorate.
(Linares et al., 2016). Foster care children are at risk of
developing low self-esteem and related psychological Aim of the study
problems due to their experience of separation from their This study aimed to assess the relationship between
parents, and tend to grow up in a more difficult environment self-esteem and aggressive behavior among foster care
with a greater sense of stigma (Hiemstra et al., 2020). children at Minia governorate.
Children's aggression remains a critical global
concern that may cause harm to other children's behavioral, Subjects and Methods
emotional and psychological, social, and academic functions Research design:
(Kim & Lee, 2020). Aggression, in socio-psychological A descriptive correlational research design was
perspective, was defined as a psychological phenomenon utilized in this study.
which depicts a large category of intentional behavior of
bringing harm to other or self by means of physical or verbal Setting
attacks. The behavior of aggression can lead to violence such This study was conducted in foster care centers at
as school bulling, murder, self-injury, and suicide. Being a Minia governorate which includes two foster cares (Minia
bully in childhood was demonstrated to be correlated with institution for boys and Minia institution for girls).
higher aggression in adulthood (Yu, et al., 2020). Minia institution for boys in Minia city includes five
floors that receive children from one day after birth to 18
Significance of the study years of old (about 123 children). However, Minia institution
Levels of self-esteem during childhood influence the for girls localizes in Minia city consists of four floors and
longer term course of development into adulthood (Orth & receives female children from 6 years old up to marriage age
P a g e | 83 Sherifa R., et al
(about 39 children). They provide food, shelter, health care, Cronbach's alpha coefficients test. The Cronbach’s alpha of
clothes and education. the questionnaires was 0.76, indicate good reliability.
.
Subjects: Content Validity: The tools were submitted to five
A purposive sample consisted of 51 children from the experts in psychiatric mental health nursing to test their
foster care children aged from 6-12 years old (23 of them were validity (Minia, Assiut and Cairo Universities, Faculty of
females and 28 were males) included in the study. Nursing, Psychiatric Nursing department) and the necessary
modifications were done.
Inclusion Criteria:
 Both genders aged from 6-12 years old. Pilot study
 Length of stay was more than one year on the foster Pilot Study was conducted on 10% from the total
care. number which equal 5 foster care children of study sample to
test the study process and to evaluate the efficiency, clarity, of
Tools of Data Collection: tools that was used in the study. Subjects who participated in
A well-designed questionnaire was used to collect the the pilot study were excluded from the actual study.
data of the foster care children. It comprised of three parts.
Part (I) included demographic data as age, gender, Field work
educational level, reason of entry foster care and duration of Each foster care child interviewed to collect the
stay. necessary data, the researcher went to Minia male and female
institutions for two days per week from 9-11am (Saturday and
Part (II): Aggressive behavior scale: Tuesday). The questionnaire was filled out by the researcher
Aggressive behavior scale (Adel, 1993): Arabic and also the researcher clarified the meaning of the questions
structured scale designed by Adel Ahmed Hussein (1993) for for the children to facilitate understanding the meaning of the
measuring aggressive behavior among foster care children. statements.
This scale consists of 36 items including forms of aggression.
Verbal aggression toward others is 12 items, 16 items of Administrative Design:
physical aggression, 4 items aggression toward things and 4 An official letter obtained from the dean of the
items aggression toward self. Responses of the scale ranged Faculty of Nursing, Minia University, as well as the director
from 0 for No, 1 for Sometimes to 2 for Yes. of Social Solidarity & directors of male and female institution
The levels of aggressive behavior were: asking for permission to collect data. Oral consent obtained
 From 0-24 : Mild aggressive behavior from the children after explaining the nature and purpose of
 From 25-48: Moderate aggressive behavior. the study through direct personal communication to gain their
 More than 48: Severe aggressive behavior acceptance and cooperation.
Part (III): Hare Self-Esteem Scale (HSS, 1975). Ethical Consideration

Hare Self-Esteem Scale developed by Hare, A written initial approval obtained from the Research
1975.The HSS measure self-esteem of school aged- children Ethical Committee of the Faculty of Nursing, Minia
across three domains (peer, school, home) and allows for a University, there is no risk for study subjects during
general assessment of self-esteem when is summed. These application of this research, the study follows common ethical
three areas are the major points of an indicator of interaction participation in clinical research, and privacy was provided
for a child where self-esteem is developed. It consists of 30 during data collection. Anonymity and confidentiality was
items (10 items per subscale). Response scale ranges from 1 assured through coding the data; and a child has the right to
(strongly disagree) to 4 (strongly agree). The scale was refuse to participate in the study without any rationale.
modified to use “foster parents” instead of “parents,” because
this research focuses on children in foster care. Higher score Statistical Analysis
on this scale indicates a higher self-esteem. Participants’ Recorded data were analyzed using the statistical
scores ranged from 30 to 120 (Hugan, 2005). package for social sciences; version 26.0 Quantitative data
were expressed as mean± standard deviation (SD). Qualitative
Reliability: The reliability of the tool were done by data were expressed as frequency and percentage. Also,
the statistician and revised by the supervisors. The internal Pearson correlation was used.
consistencies of the questionnaire were calculated using
Results
Table (1): Descriptive statistic of demographic characteristics of the studied sample (N= 51).
Variables N %
Gender
 Male 28 54.9
 Female 23 45.1
2. Age group
 6-9 years 21 41.2
 > 9-12 years 30 58.8
Education Level
 Illiterate 0 0
 Primary Education 100 100
Reasons for entry foster care
 Orphan 9 17.6
Variables N %
 Foundling or abandonment 26 51.0
 Divorce or parent separation 16 31.4
Table (1) shows the descriptive statistics of the 51 foster care children included in the study. In total, more than half of the
participants were males (54.9), 58.8% of them were in age group ranged between ˃ 9:12 years old, and all children were in primary
school (100%). In addition to, more than half of the studied sample was foundling (50.9%), while 17.6 of children entered foster care
due to orphans and about one third of them entered because of parents' separation (divorce) (31.37%).
Figure (1): Levels of aggressive behavior among foster children N=(51)
Figure (1) shows the frequency distribution of aggressive behavior levels. It can be noted from figure that 42 (82.4%) of the
studied sample had severe aggression, while only 9 (17.6%) had moderate level of aggressive behavior.
Table (2): Relation between gender and aggressive behavior among foster children (N=51).
Male (28) Female (23)
Types of aggressive behavior T P
Mean ± SD Mean ± SD
Verbal aggression 28.11 ± 1.23 28.91 ± 2.48 1.509 0.1
Physical aggression 43.46 ± 7.4 36.30 ± 6.73 3.559 0.001*
Aggression toward things 10.64 ± 0.48 9.60 ± 1.40 3.641 0.001**
Aggression toward self 9.85 ±± 0.35 8.22 ± 1.85 4.579 0.000**
Total aggressive behavior 92.07 ± 7.78 83.04 ± 7.38 4.216 0.000**
*p-value <0.05 S; **p-value <0.001 HS
Table (2) reveals that; mean score for physical aggression was higher among males than females (43.46 ± 7.46 & 36.30 ±
6.73) respectively; while mean score for verbal aggression was higher among females than males (28.91 ± 2.48 & 28.11 ± 1.23)
respectively. The total mean scores for aggressive behaviors were higher among males than females (92.07 ± 7.78 & 83.04 ± 7.38)
respectively. There was highly statistically significant difference between gender and nearly all subtypes of aggressive behavior
(P=0.001, 0.001, 0.000 & 0.000) respectively.
Table (3): Relation between age group and aggressive behavior among foster children (N=51).
Types of aggressive behavior Children at age group 6-9 Children at age group10-12
years (21) yrs. (30) T P
Mean± SD. Mean± SD
Verbal aggression 28.66 ± 2.43 28.33 ± 1.49 0.60 0.5
Physical aggression 40.85 ± 8.46 39.80 ± 7.66 0.46 0.64
Aggression toward things 10.52 ± 1.12 9.93 ± 1.08 1.89 0.06
Aggression toward self 8.23 ± 1.94 9.73 ± 0.58 3.97 0.000
Total aggressive behavior 88.28 ± 10.44 87.80 ± 7.62 0.19 0.8
Table (3) clarifies that; the mean scores for physical aggression and aggressive behavior toward things were higher among
children in age group 6-9 yrs. than children in age group 10-12 yrs. (40.85 ± 8.46 & 10.52 ± 1.12) respectively, while mean score for
aggressive behavior toward self was higher among children in age group from 10-12 yrs. than children in age group 6-9 yrs. (9.73 ±
0.58). Children in age group 6-9 yrs. were highly aggressive than other age group children (88.28 ± 10.44 & 87.80 ± 7.62)
respectively. There was highly statistical significant difference between age group and aggressive behavior toward self (P = 0.000).
Table (4): Relation between reasons of entry for foster care and aggressive behavior among foster children (N=51)
Types of aggressive behavior Foundling or Orphan Divorce or parent
abandonment. separation F P
(N=26) (N=9) (N=16)
Verbal aggression 28.07 ± 2.39 28.44 ± 1.58 29.12 ± 0.80 1.50 0.23
Physical aggression 39.80 ± 6.60 39.22 ± 8.72 41.50±9.69 0.30 0.73
Aggression toward things 10.11 ± 1.07 10.00 ± 1.50 10.37 ± 1.02 0.38 0.68
Aggression toward self 8.34 ± 1.76 10.00 ± 0.00 9.87±0.50 9.30 0.000
Total aggressive behavior 86.34±7.59 87.66±8.63 90.87±10.39 1.34 0.27
Table (4) shows that; the mean scores for verbal and physical aggression were higher among children who entered foster care
for reason of parents' separation (divorce) than orphan and foundling children (29.12 ± 0.80 & 41.50±9.69) respectively; while the
mean score for aggressive behavior toward self was higher among foundling children (10.00 ± 0.00). There was significant difference
between reason of entry foster care and aggressive behavior toward self (P=0.000).
Figure (2): Levels of self-esteem among foster children N=(51)
Figure (2) shows the frequency distribution of self-esteem levels. It can be noted from that 37 (74.5%) of the studied sample
have low self-esteem, while only 14(27.4%) have middle level of self-esteem.
Table (5): Relation between gender and subitems of self-esteem among foster children (N=51):
Subitems of self-esteem Male (28) Female (23) T P
Mean ±SD Mean ±SD
Peer self-esteem 14.07 ± 0.85 17.04 ± 1.82 .76.7 0.000
Home self-esteem 15.75 ± 0.88 14.95 ± 2.28 176.1 0.097
school self-esteem 14.32 ± 3.70 18.39 ± 2.58 777.4 0.000
Global self-esteem 44.14 ± 3.84 50.39 ± 3.66 .78.6 0.000
Table (5) illustrates that; foster females had higher mean score for peer and school based self-esteem than males’ foster
children (17.04 ± 1.82 & 18.39 ± 2.58) respectively; while foster male had high home based self-esteem (15.75 ± 0.88). There was
highly statistically significant difference between gender and nearly all subitems of self-esteem (P=0.000, 0.097, 0.000 & 0.000)
respectively.
Table (6): Relation between age group and subitems of self-esteem among foster children (N=51)
Subitems of self-esteem Children at age group 6-9 years Children at age group10-12
(N=21) yrs. T P
Mean± SD. (N=30)
Mean± SD
Peer self-esteem 15.95 ± 2.53 15.03 ± 1.49 1761 0.11
Home self-esteem 15.47 ± 2.20 15.33 ± 1.26 0.29 0.77
School self-esteem 16.19 ± 2.69 16.13 ± 4.47 0.05 0.96
Global self-esteem 47.61 ± 4.95 46.50 ± 4.84 0.80 0.42
Table (6) shows that; the mean scores of global self-esteem were slightly high among children in age group from 6-9 yrs.
(47.61 ± 4.95). There was no significant difference between age group and subtypes of self-esteem (P=0.42).
Table (7): Relation between reasons of entry for foster care and sub items of self-esteem among foster children (N=51).
Divorce or parent
Foundling or Orphan
Sub items of self-esteem separation
abandonment (N=26) (N=9) F P
(N=16)
Peer self-esteem 15.61 ± 2.54 15.33 ± 0.50 15.12 ± 1.58 0.29 0.74
Home self-esteem 15.96 ± 2.04 14.88 ± 0.92 14.75± 1.00 3.27 0.04
School self-esteem 15.92±4.72 15.33 ± 2.87 17.00 ± 2.36 0.64 0.53
Global self-esteem 47.50 ± 6.11 45.55 ± 2.92 46.87 ± 3.26 0.52 0.59
Table (7) shows that; children who entered foster care for reason of parent separation (divorce) had lower mean score for
self-esteem based home (14.75± 1.00). There was significant difference between reason of entry foster care and self-esteem based
home (P=0.04).
Figure (3): Correlation between aggressive behavior and self-esteem among foster children N=(51)
*. Correlation is significant at the 0.05 level (2-tailed).
Figure (3) reveals that; there was statistically significant negative correlation between aggressive behavior and self-esteem
among foster care children (r= - 0.33 at p = 0.01).
Discussion (children enter foster care because of divorce) especially

The present study results revealed that foster boys physical aggression. The researcher explains the parental
constituted slightly more than half of studied subjects, while separation has also been noted as one of the factors that
girls represented less than half of the sample. This reflected influence aggressive behavior in children. Parental separation
the general population distribution; the gender ratio was 106.2 is a common relationship phenomenon in the community
males per 100 females, (51.5% males to 48.5% females) today. Not only, reasons for the breakdown of the family are
(Central Agency for Public Mobilization and Statistics, unfulfilled worse financial status, emotional needs, different
Oct., 2020). These results are not consistent with these of attitudes towards gender roles (especially concerning work
Megahead, (2019) who found that the females represented distribution within the family and responsibility of fathers),
about 68 % while males 32% of the total foster care children. diverse educational and pedagogical principles, but also;
As regards the reasons of entering foster care at communication problems, absence of dyadic coping and
Minia governorate, abandoned children (foundlings) and conflict solving strategies, different priorities regarding spare
orphans represented the major reasons. This could be related time and family time, strong professional engagement and
to absence of the care giver and it may be related to low socio- long workdays of men. From the female perspective, alcohol
economic status of others relatives. Oosterman et al., (2007) abuse was problematic, whereas men estimate sexual
reported that; family disintegration, which is characteristic of problems as a source of conflict. In disagreement with study
modern societies and statistics which indicate increasing the of Ali et al. (2018) who reported that mean scores of verbal
rates of divorce in recent years, causing a negative impact on aggression among institutionalized children were high than
family care for their children, coupled with weak family ties mean scores of physical aggression.
between members of the extended family, which made the On the other hand, nearly three quarters of the foster
search for child care in the foster care the alternative choice in care children had low self-esteem, while slightly more than
many cases. one quarter had middle level of self-esteem. Although these
The current result reflected that boys in foster care children has got adequate professional care from the institute,
displayed more frequency on the severity of physical the officers are not able to provide them with their
aggression. The researcher believed that this difference may psychological needs, such as the love and understanding
be the result of social norms where boys were seen more children would normally receive from their parents. In such an
aggressive than girls. This result agreed with the result of environment then, such children are at higher risk of
Riedel, (2013) who reported that boys in foster care display developing low self-esteem than other children
more frequency on the severity of aggressive behaviors (Apinuntavech et al., 2009). Girls in foster care are exiting
according to foster parents. the system with low self-esteem and negative expectations for
According to the results of current study, aggressive themselves.
behavior was highly among children of separated parents
Foster females had highly significant peer and school Recommendations
based self-esteem than males’ foster children. The researcher  Every effort must be done to reduce dependence on
attributed this finding to many reasons such as; girls make care through foster care, and make it only the last
good relationships and had the ability to gain empathy from choice and focus instead on care through alternative
their teachers and peers. families of relatives and neighbors, especially to
Foster girls had highly significant global self-esteem orphans, those who come from broken families, or
than foster boys; this could be attributed to girls seem to suffer some circumstances of illness or economic
perform academically higher and this may also cause a rise in hardship.
self-esteem. Foster boys on the other hand may feel  Frequent assessment of aggression and self-esteem
inadequate in many areas. They try to find their way and among foster care children.
create their identity. It is when they do not get such a chance  Effective comprehensive programs designed to
and do not get the kind of respect and acceptance from the prevent and reduce the occurrence of aggression
society; they feel negatively motivated and has a decrease in among foster care children.
the level of self-esteem. This result is in agreement with
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Early Identification of Risk Factors for Primary Postpartum Hemorrhage at Admission

Doaa Maged Khalf1, Hoda Abd El-Aziam Mohmed2; Abdelrahman Hegazy Abdelwahab3
(1) Bachelor of Nursing, Faculty of Nursing, Minia University

(2) Professor of Women Health and Obstetric Nursing, Faculty of Nursing, Minia University
(3) Lecturer of Obstetrics and Gynecological Faculty of Medicine, Minia University
Abstract
Background: Postpartum hemorrhage (PPH) is the world‘s leading cause of maternal mortality, accounting for one-
third of all maternal deaths worldwide. Aim of the Study was early identification of risk factors of primary
postpartum hemorrhage. Research Design: A descriptive cross-sectional research design was utilized. Subject and
setting: The study was carried out over a period of six months in obstetrics and gynecology department at Minia
University Hospital for Obstetric and Pediatric. Tools for Data Collection: two tools were used; Tool I: Socio-
demographic characteristics, and Tool II: Risk factors assessment tools. Results: The study revealed that, study group
had low risk factors of current PPH had(previous uterine incision, History of PPH ), moderate risk factors of current
PPH in women had (prior cesarean birth or prior uterine incision, History of one previous PP), high risk factors of
current PPH in women ( had two or more moderate symptoms of risk factors, platelets level <100,000/mm 3,
hematocrit level <30, placenta previa and suspected placenta accretes) with statistically significance differences.
Conclusion: previous uterine incision, previous PPH, abnormality in platelet level, hematocrit level and coagulopathy
were the most significant risk factors for primary PPH. Recommendation: Encourage regular antenatal visit to early
detection of risk factors of PPH, and providing the women health education about PPH risk factors.
Keywords: Postpartum, Pregnant women, Primary postpartum hemorrhage, Risk factors
Introduction Reexamination of the patient’s vital signs and vaginal

Postpartum hemorrhage (PPH) is the world‘s leading flow before leaving the delivery area may help detect slow,
cause of maternal mortality, accounting for one-third of all steady bleeding (Ononge et al., 2016).
maternal deaths worldwide. PPH causes up to 60% of all Early assessment and aggressive treatment of PPH
maternal deaths in developing countries. The majority of these are important for reducing morbidity and mortality rates. A
deaths occur within 4 hours of delivery, indicating they are a critical first step in managing persistent PPH is rapid
consequence of events in the third stage of labor recognition that clinically significant bleeding (unresponsive
(Murakami et al., 2015). to initial measures) has occurred, with effective
Postpartum hemorrhage remains an important cause communication of the situation to the appropriate team
of premature mortality of women worldwide; an estimated members, both clinical and laboratory staff. Subsequent
500,000 women die from this cause every year with up to of measures include immediate resuscitation with definitive
quarter deaths occur due to hemorrhage. Post-Partum action to arrest the bleeding (obstetric, surgical, and/or
hemorrhage may occur in 1-5% of deliveries in developed as hematologic) and ongoing assessment and monitoring of the
well as in developing countries and it is still most common response to treatment. Persistent severe PPH requires early
cause of maternal morbidity and mortality involvement of the most experienced members of the team
(Gul & Jabeen, 2018). (Nyfløt et al., 2017).
Postpartum hemorrhage is an obstetrical emergency Nursing care during postpartum period is
that takes place following cesarean or vaginal delivery. multifaceted requiring knowledge of normal physiologic
Prevention can be achieved through timely diagnosis, process as well as potential risks. Anticipatory guidance
provision of essential resources and equipment, and correct during postpartum period can have a significant impact on
management of the third stage of labor. PPH can be classified postnatal outcomes. So, the nurse must work toward providing
into two categories: primary and secondary PPH. Primary care and education that facilitate holistic family wellness. As
PPH (early PPH) takes place within the first 24 hours well as complete assessment and obstetric history are very
following delivery, whereas secondary or delayed PPH important, this might include medical history as; history of
transpires after 24 hours to 12 weeks following delivery medical disease, routine medications and allergies, obstetric
(Jabbar, Perveen & Kumari, 2019). history as; gravid, parity, history of postpartum hemorrhage,
Risk factors for postpartum hemorrhage include a history of complications during pregnancy, time and mode of
prolonged third stage of labor, multiple delivery, episiotomy, delivery, presence of tears or lacerations during delivery, and
fetal macrosomia, and history of postpartum hemorrhage. anesthesia or medications, infant status as; breast or bottle
However, postpartum hemorrhage also occurs in women with feeding (Downey, Kruse, & Plonczynski, 2019).
no risk factors, so physicians must be prepared to manage this
condition at every delivery. Strategies for minimizing the Significance of the study
effects of postpartum hemorrhage include identifying and According to the study done by Mohamed, (2018)
correcting anemia before delivery, being aware of the who investigated the maternity outcome of primary post-
mother’s beliefs about blood transfusions, and eliminating partum hemorrhage case in El-Minia maternity Hospital 2016-
routine episiotomy. 2017: 2 years study reported that the incidence of primary
postpartum hemorrhage (PPH) was 1.88 % in 2016 and 189
P a g e | 90 Doaa M., et al
cases (1.69%) in 2017 in El-Minia University Maternity  Women were diagnosed with secondary PPH.
Hospital.( Mohamed, 2018).  Preterm labor and gestational age less than 36 weeks.
Postpartum hemorrhage (PPH) is a major cause of  Home delivery.
maternal mortality and severe morbidity all over the world.
The World Health Organization (WHO) estimates that, PPH is Control group:
a cause of approximately 25% of maternal deaths recently; the Females who were admitted to hospital for vaginal or
industrialized countries have witnessed a slow but steady cesarean section delivery in last trimester of pregnancy of any
escalation in the incidence of PPH. Developing countries age and parity and not suffered from primary PPH during
experience a much higher burden of PPH; it is also a labor.
momentous cause of maternal death in the developed world.
Death from PPH occurs in about 1 per 1000 deliveries in low- Tools of the study
resource countries compared with 1 per 100,000 deliveries in To achieve the goal of the study, data was collected
high-resource countries. Globally, PPH causes 44,000 to through using the following
86,000 deaths per year considering it the leading cause of
death in pregnancy (El Badawy, et al., 2017). Tools:
Early identifying maternal risks for postpartum Tool I: Socio-demographic characteristics including
hemorrhage is still an important and useful key point in daily (age, residence, educational level, occupation and income).
practice because a high risk pregnancy can then be closely
monitored by a special team to modify their risk Tool II: Risk factors assessment tool designed by
factors. As a result, this may lead to a reduction of (The Association of Women’s Health, Obstetric and Neonatal
maternal morbidity and mortality (Lertbunnaphong, et al., Nurses, 2015.) to determine level of risk factor of primary
2010). postpartum hemorrhage at admission for PPH divided into
three parts, to assess low risk factors (5) included (no previous
Aim of the study uterine incision, singleton pregnancy, ≤4- previous vaginal
Early identification of risk factors for primary births,,,etc.) moderate risk factor (11) included (induction of
postpartum hemorrhages and measure the association between labor (with oxytocin) or cervical ripening, multiple gestation,
these factors and the occurrence of primary PPH at admission. >4 - previous vaginal births, prior cesarean birth or prior
uterine incision, large uterine fibroids, history of one previous
Research Question PP.. etc) and high-risk factors (8) included (Active bleeding
 What are the levels of women risk factors for primary more than “bloody show, has 2 or more moderate symptoms
postpartum hemorrhage at admission? of risk factor, suspected placenta accrete or percreta, Known
coagulopathy, History of more than one previous PPH,,,etc.)
Subjects and Methods (The Association of Women’s Health, Obstetric and
Research Design Neonatal Nurses, 2015).
A descriptive cross-sectional research design was
utilized to fulfill the aim of this study. Procedure:
An official letter was requested from the Dean of the
Research setting faculty of Nursing at Minia University to director of Minia
This study was conducted at Minia university university hospital for maternity and child, asking for
hospital for maternity and child at antenatal care department, permission to collect data. Meeting with selected hospital
delivery room and immediate post-partum room. manager to explain the objectives and aim of the study who
helped to gain their cooperation and to allow interviewing
Subjects: women during minimal workload activities.
The target population included all women in last The investigator was attending to selected hospital to
trimester of pregnancy were admitted to hospital for vaginal or collect the data from 9.00 AM to 1.00 PM in two days each
cesarean section (CS) delivery during a period of six month. week (Sunday and Monday) for six months. The investigator
Sample included two groups study group who are at was collected data from antenatal care department, delivery
risk of PPH, which control group not suffer from PPH room and immediate post-partum room for six months. The
during labor. investigator was collect data from 3-6 women each week.
All women were informed that their participation is
Inclusion Criteria: voluntary and reassurance was given to the women about the
 Females showing the clinical diagnosis of primary confidentiality of their responses. The investigator explained
PPH . the aim and nature of study briefly through direct personal
 Age (20:45 years) communication that it was take time from 40-50 minutes with
 Females who were admitted to antenatal unit at the participants. Oral consent was obtained from the
MUHOP. participants before inclusion in the study.
 Women have blood loss 500ml or more for vaginal After that the investigator was distribute all
delivery, 1000 ml or more for cesarean section. questionnaires to women who participated in the study and
asked them to fulfill them and the investigator spend this time
Exclusion Criteria: with women during fulfilling the questionnaires. The
 Prenatal chronic disease. investigator was reminding women to answer all questions
 Females with pregnancy induced diseases that present in questionnaires. Duration of data collection was
(gestational diabetes and preeclampsia and those started from middle July 2019 to the middle of December
taking anti-coagulant drugs during pregnancy). 2019. At the end of data collection the investigator gave
women advices and instructions about risk factor for primary
post-partum hemorrhage. Pilot study:
It was carried out on 10% of the total study sample
Validity and Reliability (10 women). It was clarity of the tools, assessment of
To establish validity, The questionnaire was be feasibility of fieldwork & to detect any possible obstacles that
piloted on panel of five experts in the field of obstetric and might face the investigator with interfere with data collection.
gynecological staff and Nursing professors who reviewed the Necessary modifications were done based on contents for
instruments for clarity ,relevance, comprehensive more simplicity, and clarity. The subjects were included to the
understanding ,applicability and easiness ,To establish actual sample.
reliability, statistically done alpha Cronbach way to check the
stability of the internal consistency of instrument was 0.651 Statistical design
Data entry was done using compatible personal
Ethical consideration: computer. Statistical analysis done by using statistical package
A written initial approval was obtained from the of social science (SPSS, IBM version 25) and excel for
dean of the faculty of nursing and from the research ethical figures. The content of each tool was analyzed, categorized
committee of the faculty of nursing, Minia University, and and then coded. Data were presented using descriptive
approval to conduct the study was obtained from the dean of statistics in the form of frequencies and percentages for
the faculty of nursing, Minia University. qualitative variables, and means and standard deviations for
Oral informed consent was obtained from women quantitative variables. Statistical significance used at P value
who participated in this study after explaining the nature and <0.05. Odd's Ratio (OR) and their 95% confidence intervals
purpose of the study. Participants were informed that their (95% CI) were calculated to compare risk factors for PPH in
participation in the study was completely voluntary and both groups.
acceptance of participants was obtained.
Results
Table (1): Distribution of the study sample regarding their socio-demographic characteristics (n= 120).
Study group Control group
Socio-demographic Test of significance
(n= 60) (n= 60)
characteristics
No. % No. % X2 P - value
Age / years
Less than 25 13 21.7 13 21.7
25 - 30 10 16.7 11 18.3 1.100 .777
31- 35 26 43.3 29 48.3
More than 35 11 18.3 7 11.7
Mean ± SD 25.9 ± 14.1 25.4 ± 13.8
Residence
Urban 33 55.0 35 58.3 2.136 .144
Rural 27 45.0 25 41.7
Educational level
Illiterate 19 31.7 11 18.3
Basic education 16 26.7 12 20.0 6.133 .105
Secondary 10 16.7 10 16.7
University education 15 25.0 27 45.0
Occupation
Worker 14 23.3 20 33.3 1.477 .224
House wife 46 76.7 40 66.7
Income
Low 49 81.7 41 68.3 2.844 .092
High 11 18.3 19 31.7
Table 1: shows that, 43.3% of study group and 48.3% of control group aged between 31 – 35 years with mean age 25.9 ±
14.1 and 25.4 ± 13.8 years respectively.
Regarding residence, 55.0% of study group and 58.3% of control group lived in urban area, 26.7% of study group and 20.0%
of control group have basic education level.
Concerning occupation, 76.7% of study group and 66.7% of control group were housewives and 81.7% vs 68.3 of them had
low income level respectively.
There were no statistically significance differences between study and control groups regarding their socio-demographic
characteristics
Table (2): Distribution of the study sample regarding their low risk factors of primary post-partum hemorrhage (n= 120)
Study group Control group Test of significance
Low risk factors
No. % No. % OR (95% CI) P - value
No previous uterine incision
Yes 12 20.0 38 63.3 .145 (.064 - .329) .0001**
No 48 80.0 22 36.7
Singleton pregnancy
Yes 53 88.3 56 93.3 .541 (.150 – 1.954) .343
No 7 11.7 4 6.7
Less than or equal 4- Previous vaginal births
Yes 24 40.0 27 45.0 .581 (.150 – 1.954) .657
No 36 60.0 33 55.0
No History of PPH
Yes 42 70.0 55 91.7 1.107 (.034 - .334) .02*
No 18 30.0 5 8.3
Not known bleeding disorder
Yes 38 63.3 56 93.3 .123 (.039 - .387) .0001**
No 22 36.7 4 6.7
**significant at P value < 0 .01
Table (2): presents that, study group had low risk for current PPH in previous uterine incision, and known bleeding disorder
by less than one folds (OR= .145, and .123 respectively) and history of PPH by more than one folds (OR= 1.107) with statistically
significance differences with P – value ≤ .0001, .0001, and .02 respectively.
Table (3): Distribution of the study sample regarding their moderate factors of primary post-partum hemorrhage among
study sample (n= 120).
Moderate risk factors
Induction of labor
Yes 34 56.7 16 26.7 .179 (.082 - .395) .0001**
No 26 43.3 44 73.3
Multiple gestation
Yes 9 15.0 1 1.7 10.412 (1.275 – .008**
No 51 85.0 59 98.3 84.998)
More than 4 - previous vaginal births
Yes 36 60.0 33 55.0 .581 (.150 – .657
No 24 40.0 27 45.0 1.954)
Prior cesarean birth or prior uterine incision
Yes 43 71.7 20 38.3 7.231 (3.198- .0001**
No 17 28.3 40 61.7 16.347)
Large uterine fibroids
Yes 15 25.0 2 3.3 9.667 (2.102- .001**
No 45 75.0 58 96.7 44.460)
History of one previous PPH
Yes 8 13.3 3 5.0 1.247 (.140 – .05*
No 52 86.7 57 95.0 1.954)
Family history in first degree relatives who experienced
PPH
Yes 5 8.3 7 11.7 .821 (.425 – .845
No 55 91.7 53 88.3 1.828)
Chorioamnionitis
Yes 16 56.7 5 8.3 4.0 (1.359 – .008**
No 44 73.3 55 91.7 11.774)
Estimated fetal weight greater than 4 kg
Yes 10 16.7 3 5.0 2.20 (2.012 – .032*
No 50 83.3 57 95.0 7.214)
Morbid obesity (body mass index [BMI] >35
Yes 25 41.7 19 31.7 2.347 (1.067 – .032*
No 35 58.3 41 68.3 5.162)
Polyhydramnios
Yes 36 60.0 10 16.7 7.500 (3.196 – .0001**
No 24 40.0 50 83.3 17.601)
**significant at P value < 0 .01 *significant at P value < 0 .05
Table (3): shows that, study group had moderate risk for current PPH in multiple gestation by more than ten folds (OR=
10.412), large uterine fibroids by more than nine folds (OR= 9.667), prior cesarean birth or prior uterine incision, polyhydramnios by
more than seven folds (OR= 7.231& 7.500 respectively), and chorioamnionitis by four folds (OR= 4.0) with statistically significance
differences.
Table (4): Distribution of the study sample regarding their high factors of primary post-partum hemorrhage among study
sample (n= 120).
High risk factors
Active bleeding more than “bloody show”
Yes 7 11.7 2 3.3 3.830 (.762 – .05*
No 53 88.3 58 96.7 19.258)
Has 2 or More moderate symptoms of risk factors
Yes 56 93.3 4 6.7 196 (46.692 – .0001**
No 4 6.7 56 93.3 822.757)
Suspected placenta accretes or percreta
Yes 21 35.0 3 5.0 10.231 (2.855 – .0001**
No 39 65.0 57 95.0 36.666)
Known coagulopathy
Yes 8 13.3 2 3.3 4.462 (.906 – .05*
No 52 86.7 58 96.7 21.967)
History of more than one previous PPH
Yes 10 16.7 2 3.3 2.636 (.491 – .05*
No 50 83.3 58 96.7 14.157)
Hematocrit <30 AND other risk factors
Yes 39 65.0 5 8.3 20.429 (7.091 – .0001**
No 21 35.0 55 91.7 58.852)
Platelets <100,000/mm3
Yes 40 66.7 2 3.3 58.000 (12.834 – .0001**
No 20 33.3 58 96.7 262.113)
Placenta previa or low-lying placenta
Yes 38 63.3 0 .0 11.769 (4.391 – .0001**
No 22 36.7 60 100.0 31.546)
**significant at P value < 0 .01 *significant at P value < 0 .05
Table (4): result of presents table show that, study group had high risk for current PPH in women had two or more moderate
symptoms of risk factors by more than one hundred folds (OR= 196), platelets <100,000/mm 3 by more than fifty folds (OR=
58.00), hematocrit <30 by more than twenty folds (OR= 20.429), placenta previa and suspected placenta accretes by more than ten
folds (OR= 11.769& 10.231 respectively), with statistically significance differences.
Discussion This result come in the line with (El Badawy et al.,
Postpartum hemorrhage (PPH) is a major cause of 2017) who founded that more than two-thirds of the study
maternal mortality and severe morbidity all over the world. group and most of the control group had no history of PPH.
The World Health Organization (WHO) estimates that PPH is This result was confirmed by (Belfort., 2019) who studied
a cause of approximately 25% of maternal deaths ''Postpartum hemorrhage: Management approaches requiring
(Andrikopoulou & D'Alton, 2019). This study aimed to early laparotomy'' and stated that the uterine incision increases the
identification of risk factors for primary postpartum risk of PPH. Also this result comes in the line with (Dionne et
hemorrhage. al., 2015) who stated that there association between low-risk
Regarding the socio-demographic characteristics of factors and PPH. This result might be due to pregnant women
the study and control groups, the current study showed that known they suffered from bleeding disorders will continue
less than half of the study group and control group aged antenatal visits to decrease risk factors for any postpartum
between 31 – 35 years This result comes in the line with (El complications and uterine incision is an unusual cause of post-
Badawy, et al., 2017) who studied ''assessment of risk factors partum hemorrhage as concluded by Zhang et al., (2020)
for primary postpartum hemorrhage at Zagazig university Regarding distribution of the study sample by their
hospitals'' and reported that the most of them were in the age moderate risk factors of primary post-partum hemorrhage, the
group 19-34 years (81.4% of cases and 66.1% of controls). current study results showed that study group had a moderate
This result comes in to agree with Miller et al., risk for current PPH as multiple gestations, history of one
(2017) who studied "postpartum hemorrhage following previous PPH, prior cesarean birth or prior uterine incision
vaginal delivery: risk factors and maternal outcomes" and fetal weight greater than 4 kg, morbid obesity and
reported that less than one-third of the cases and control group polyhydramnios, with statistically significant differences in
their age was in between 27:35 years. These results come to which P value<.008,.05,.0001and .0001 Respectively.
differ with (Gudeta, et al., 2018) who studied ''magnitude of This result comes in the line with (El Badawy et al.,
post-partum hemorrhage among women who received 2017) who stated that There are many risk factors for primary
postpartum care at Bedele hospital southwest, Ethiopia, 2018'' PPH as increasing maternal age, previous APH and PPH,
and reported that less than half of the studied sample their age macrosomia, maternal anemia, obesity, vaginal delivery, labor
were in between 20:24 years. induction, delivery trauma, retained placenta, and placenta
Regarding distribution of the study sample by their previa. Maternal anemia, retained placenta, macrosomia, and
low risk factors of primary post-partum hemorrhage, the previous PPH were the most significant risk factors for
current study showed that the study group had a low risk for primary PPH.
current PPH in women had a previous uterine incision, more This finding might be labor induction may increase
than four previous vaginal birth, and known bleeding disorder duration of labor which may increase frequency of PPH and
with statistically significant differences in which P – value ≤ retained placenta causes uterine atony by preventing uterine
.0001, .02, and .0001 respectively. contraction, which compresses the myometrial spiral arteries.
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Rosenberg, M., . . . Vangen, S. (2017). Risk factors for severe postpartum
Conclusion hemorrhage: a case-control study. BMC pregnancy and childbirth, 17(1), 17.
Based on the findings of the present study it was (17) Oberg, A. S., Hernandez-Diaz, S., Palmsten, K., Almqvist, C., & Bateman,
B. T. (2014). Patterns of recurrence of postpartum hemorrhage in a large
concluded that population-based cohort. American journal of obstetrics and gynecology,
Previous PPH, abnormality in platelet, hematocrit 210(3), 229. e221-229. e228.
and coagulopathy were the most significant high risk factors (18) Ononge, S., Mirembe, F., Wandabwa, J., & Campbell, O. M. (2016).
for primary PPH while the moderate risk for current PPH were Incidence and risk factors for postpartum hemorrhage in Uganda.
Reproductive health, 13(1), 38.
multiple gestation, history of one previous PPH, prior (19) Ramler, P. I., van den Akker, T., Henriquez, D. D., Zwart, J. J., van
cesarean birth or prior uterine incision, and polyhydramnios. Roosmalen, J., van Lith, J. M., . . . van Goeverden, R. (2019). Women
receiving massive transfusion due to postpartum hemorrhage: A comparison
over time between two nationwide cohort studies. Acta obstetricia et
Recommendations gynecologica Scandinavica, 98(6), 795-804.
Based on the results of the present study are: (20) Sneha K. Girish B. and Manjunath M. (2017). Haematocrit as diagnostic
 Encourage regular antenatal visit to early detection of tool for assessing Primary Postpartum haemorrhage. Indian Journal of
Clinical Anatomy and Physiology;5(2);210-213.
risk factors of PPH, and providing the women health
(21) Wetta L., Szychowski J., Seals S., Mancuso M., Biggio J, Tita A. (2013).
education about PPH risk factors. Risk factors for uterine atony/ postpartum hemorrhage requiring treatment
 Nurses should encourage pregnant women for treatment after vaginal delivery. Am J Obstet Gynecol ; 209 (1): 51.
of some risk factor as anemia and encourage hospital (22) Zhang Y., Ma N., and Pang X. (2020). Uterine incision dehiscence 3 mo
after cesarean section causing massive bleeding: A case report. World J Clin
delivery for women at risk of PPH. Cases; 6 ; 8 (11): 2392 – 2398.
Effect of immediate pain management on oxygenation level among early extubation

patients post heart surgery
Mona Sayed Elgazar, Inshrah Roshdy Mohammed, Yasser Shaban Mubarak, Marwa M. Abdelbaky,
(1) Clinical instructor at the medical surgical department, Minia University, Egypt.
(2) Assistant professor at the medical surgical department, Faculty of Nursing, Minia University, Egypt
(3) Assistant profesior at the cardiothoracic surgery department, Faculty of Medicin, Minia University, Egypt
(4) Lecturer at the medical surgical department (critical care nursing), Faculty of Nursing, Minia University, Egypt
Abstract
Pain is the most severe in patients after open thoracic surgery. Patients undergoing surgery report slightly higher pain
intensity than other surgery types. The aim of the study: is to evaluate the effect of immediate pain management on
oxygenation levels among early extubated patients post-heart surgery. Subjects and Methods: Quasi-experimental
design; a sample of 60 patients (male and female) divided equally into two groups; study group (n=30) and control
group (n=30). Setting: cardiothoracic ICU and cardiothoracic department at the cardiothoracic hospital that belongs to
Minia University Hospitals, Egypt. Tools: Three tools: I: Socio-demographic and medical Assessment, II:
oxygenation level assessment and III: Numeric Pain Scale. Results: Mean age of study and control groups were
(38.4±5.4) & (37.2±4.8) year respectively. (40%) from the study group suffered a myocardial infarction and did
coronary angioplasty, (43.3%) of the control suffered coronary artery stenosis (33.3%) among them did coronary
angioplasty. Related to the pain scale there was a significant difference between study and control groups at p-value
<0.05. Also regarding oxygenation level which presented by a significant difference between both groups about
breathing sound and arterial blood gases test at 1st, 3rd and 7th day of the study, presented by p-value <0.05.
Conclusion: This study concluded that pain management has a positive effect on a patient's oxygenation level which
was presented in improving patients breathing sound and arterial blood gases which reflected on the patient's
outcomes post-cardiac surgery. Recommendations: All cardiac surgery patients should receive pain management
strategies before their operations and the pain management strategies should be included in the protocol of care for
cardiothoracic patients.
Keywords: Pain, oxygenation, extubated, heart & surgery
Introduction As early weaning is accompanied by early pain management,

Cardiac surgery is one of the most important which in turn reduce post-cardiac surgery pulmonary
procedures that can resolve many cardiac problems. The most complications (Patman, S., 2019). Each surgical intervention
important of which are myocardial revascularization, valve is associated with the patient’s perception of pain.
repair or replacement, repair of congenital or acquired Postoperative pain is due to intraoperative damage to
structural abnormalities, placement of a mechanical assist tissues/organs, and its intensity and extent are generally
device, and heart transplantation (Gunay, etal. 2016). The proportional to the extent of the surgery.\ In cases of a large
post-operative phase is the most critical period for cardiac trauma, in addition to superficial and deep somatic pain, the
patients, which may result in many complications as visceral component of postoperative pain is also involved,
pulmonary, cardiovascular, neurological, and renal, that triggered both by smooth-muscle contraction, caused by
prolong hospitalization, increase costs and have a direct effect compression and tension of the visceral structures and by
on survival (Nair, S., & Kazi, A. 2019)). inflammatory lesions (Xavier, G., et al 2019).
In prospective studies of Egyptian patients after Pain is the most severe in patients after open thoracic
open-heart surgery, 86% of the patients had postoperative surgery. Patients undergoing surgery with the use of
complications with morbidity and mortality rates of 23%and cardiopulmonary bypass report slightly higher pain intensity
1.7% respectively (WHO, 2108). Coronary artery bypass than those in whom extracorporeal circulation is not
grafting (CABG) and heart valve surgery are the most used. Extracorporeal circulation is essentially associated with
commonly performed procedures in cardiac surgery the induction of the systemic inflammatory response
worldwide. The further development of surgical skills and syndrome, with potential end-organ dysfunctions. It has been
technical settings enables complex surgery in increasingly old shown that women after cardiac surgery report higher pain
and morbid patients with poor left ventricular function and a intensity and a significantly higher number of pain areas than
multitude of comorbidities. To minimize as far as possible the men, and that elderly patient have a higher pain threshold
pain experienced by cardiac surgery patients, surgical (Yazdannik, A., etal.2016).
procedures should be performed using minimally invasive Moreover, persistent pain after cardiac surgery may
techniques. Minimally invasive surgery has grown in lead to pulmonary dysfunction, decreased oxygenation mainly
popularity, and the potential benefits of reducing surgical due to difficulty in coughing. Pain during movement prevents
trauma include decreased postoperative bleeding, reduced patients from mobilization, breathing exercises, and
incidence of sternal wound infections, and shortened recovery rehabilitationEventually, uncontrolled pain after surgery may
period after surgery (Oshvandi, K., et al 2020). result in slower rehabilitation, longer intensive care unit and
The majority of possible complications may be hospital stays, more readmissions, higher long-term
resolved by early activity in the early postoperative period. (Bjørnnes AK, et al., 2016)
P a g e | 96 Mona S., et al
The critical care nurse has a vital role in the Exclusive Criteria: Patients will be excluded if:
postoperative care of cardiac patients. The nurse is mostly (1) Chronic obstructed pulmonary disease (COPD).
responsible for monitoring and assessing the cardiovascular, (2) Diabetic patient.
respiratory, and renal status to create an effective care plan. (3) Congenital anomalies in the heart.
Also in planning and implementing effective pain (4) Upper and lower respiratory infection.
management strategies to control the pain post-operatively
(Zanini, M.,etal., 2006). Setting
The current study was carried out at the
Significance of the study cardiothoracic ICU and cardiothoracic surgery departments at
By 2030, nearly 23.6 million people will pass away the cardiothoracic hospital that belongs to Minia University
from cardiovascular diseases. This incidence gives rise to 17.9 Hospitals. The cardiothoracic surgery department consists of 4
million deaths (32.1%) in 2015. Deaths at a given age from rooms with 16 beds, and the cardiothoracic intensive care unit
CVD are more common and are increasing in much of the (CICU), which contains 8 beds.
developing world, while rates have declined in most of the
developed world since the 1970s. Arteria coronaria disease Study Duration:
and stroke account for 80% of CVD deaths in males and 75% The study data collections were collected over a
of CVD deaths in females. period of eight months, starting from July 2018 to February
The absence of immediate pain management leads to 2019.
many complications as delayed extubation, increase the rate of
pulmonary infection, atelectasis, and prolonged stay in Tools of Data Collection
ICU.So effective pain management will help patients to The current study data were collected by using three
maintain their oxygenation level and hemodynamic stability tools. The content of the tools was established after an
which will reduce hospital stay and treatment cost. Thus I will extensive literature review. Such as (Brunner and Suddarth's
perform this study to evaluate the effect of pain management Textbook of medical& surgical nursing (2018), Critical Care
on oxygenation level and pulmonary function among early Nursing Books (2011), Morton etal a holistic approach (2018)
extubation patients following cardiothoracic surgery and the online researches that related to the current study.
(Azevedo et al., 2016).
My experience in the cardiothoracic surgery unit as a First Tool: Socio-demographic and medical Assessment
nursing staff member for ten years ago found target patients sheet:
who had done cardiac surgery and did not receive effective  Is an interview assessment sheet, was developed by
pain management remain one factor leads to of high rate of the researcher and it was included two parts.
pain-related complications as regarded to units record o 1st part covers socio-demographic data of
the patient as age, gender, marital status.
Subjects and methods o 2nd part covers medical data as medical
Aim of the Study diagnosis, type of cardiac surgery, presence
The present study aims to evaluate the effect of of any chronic disease........ etc.
immediate pain management on oxygenation level among
early extubated patient post heart surgery Second Tool: oxygenation level assessment sheet:
It was developed and collected by the researcher for
Hypothesis the studied subjects following cardiothoracic surgery and after
Pain management strategies will improve their extubation to assess their patients' oxygenation level, this
oxygenation levels among early extubated patients post heart assessment was collected through the following three parts.
surgery?  1st part: Mechanical Ventilation parameter: It will
be collected before the removal of the patient's ETT
Research Design according to the cardiothoracic unit policy. It
Quasi-experimental research design (study & control includes seven items, friction of inspired oxygen,
study) was utilized to fulfill the purpose of this study tidal volume......etc).
 2nd part: specific Respiratory system assessment
Subjects as Tracheal Secretions characteristics and breath
The study included convenient adult patients sound. this part was assessed three times during the
undergoing elective heart surgery selection at the first week (1st, 3rd and 7th days)after the patient's
cardiothoracic surgery unit during the conducting of the study. extubation.
Patients enrolled in the study classified equally into two  3rd part: laboratory Investigation findings as
groups (study and control groups). Arterial Blood Gases test (ABGs) to assess patient's
Both groups of the current study were selected oxygenation level (PH, PaO2, PaCO2, HCO3, SaO2) it
according to the following inclusion and exclusion criteria: was assessed three times per day (once per nursing
shift). And the researcher has recorded all the ABGs
Inclusive Criteria: findings for study subjects who extubated to estimate
(1) Conscious extubated patients who will be able to its mean average.
practice chest physiotherapy.
(2) Patient with valvular replacement. Third Tool: Numeric Pain Scale
(3) Patient with Coronary Artery Bypass Grafting It was developed by (McCaffery, M., Beebe, A., et
(CABG). al. 1989). it was ranked from zero to ten. The patient who got
a zero mark means no pain sensation but who was get ten
marks means he had the worst pain imaginable. It was cardiac surgery by the investigator about the purpose and
assessed twice per nursing shift through the 1 st three days for nature of the study.
patients after their extubation.
Implementation phase
Preoperative education for patients undergoing open-heart The implementation of the study for patients (both
surgery regarding specific non-pharmacological pain groups) was stated during their preoperative period to identify
management strategies. It was prepared by the researcher after the patient who met inclusion and exclusion criteria. The three
reviewing extensive literature, it includes specific practices as study tools were collected from the control group firstly by the
following researcher then they were started to collect study group
(1) Positioning (high fowler's position, semi fowler's through following steps, the first step was an initial
position) assessment by using the first tool, after that, the preoperative
(2) Relaxation technique measures. educational sessions for patients about specific pain
(3) Turning and moving practices. management strategies through demonstration by researcher
and re-demonstration by patients until their performance was
Tools validity and Reliability accepted. All these pain management measures were
The tool's content was examined by a panel of five formulated by a researcher in an educational brochure was
experts, four in the field of Medical-Surgical Nursing given to the patients to remember them about these practices
Department at Faculty of Nursing Minia university and one training preoperatively. The brochure was offered in the
cardiologists from the cardiothoracic unit. The three tools Arabic language and it included clear instruction about steps
were tested for content reliability using Cronbach’s alpha test of practices, frequency and supported by photo. Teaching
it was (0.94). sessions for patients were taken from 3-4 sessions for one
week preoperatively. The duration of each session for the
Pilot Study study group was ranged from 20 to 30 minutes.
A pilot study was carried out on 10% (6 patients) of
the total sample to test feasibility, objectivity, and Evaluation phase
applicability of the data collection tools. The pilot study The study tools collected from both groups (study
sample was not included in the study sample because the and control) were evaluated according to schedule
study tools were needed more modification. measurements that were previously mentioned in the study
tools description.
Ethical Consideration
Official permission to conduct the study was Statistical analysis of data
obtained from the ethical committee of the Faculty of Nursing, Data were summarized, tabulated, and presented
Dean of the Faculty of Nursing, Minia University, Hospital's using descriptive statistics in the form of frequency
Director, and agreement from Egypt academic for research distribution, percentages, means, and standard deviations as a
center and technology. subject's participation in this study has measure of dispersion. A statistical package for the social
voluntarily participated, oral consent was obtained from the science (SPSS), version (20) was used for statistical analysis
patients and the researcher informed about the purpose, of the data, as it contains the test of significance given in
procedure, benefits, nature of the study, follow up, and he /she standard statistical books. Numerical data were expressed as
has the right to withdraw from the study at any time without mean and SD. Qualitative data were expressed as frequency
any rationale. Confidentiality and anonymity of each subject and percentage. Probability (P-value) is the degree of
were ensured through coding of all data and protecting the significance, less than 0.05 was considered significant. The
obtained data. smaller the P-value obtained, the more significant is the result
(*), less than 0.001 was considered highly significant (**),
Study procedure and the correlation coefficient was done by using the Pearson
Preparatory phase correlation test. ANOVA test was used to compare two
The current study was conducted by preparing the different means among study and control group in the current
different data collection tools, in addition to obtaining oral study
agreements from the study subjects who were scheduled for
Result
Table (1): Distribution of studied subjects (study and control groups) according to their socio-demographic data (N=60)
Study group Control group X2
(N=30) (N=30) P-value
N % N %
Age
18 - <33 10 33.3 12 40 1.020
33 - <48 11 36.7 11 36.7
48 - 60 9 30 7 23.3 .059
Mean SD 38.4±5.4 37.2±4.8
Gender
Male 17 56.7 19 63.3 1.009
Female 13 43.3 11 36.7 .061
Marital status
Married 23 76.7 22 73.3 0.989
Unmarried 7 23.3 8 26.7 0.68
Educational level
Don’t read and write 3 10 4 13.3 1.114
(N=30) (N=30) P-value
N % N %
Read and write 5 16.7 8 26.7
Preparatory 11 36.7 10 33.3 .056
Secondary 7 23.3 5 16.7
University 4 13.3 3 10
Residence
Rural 20 66.9 19 63.3 1.205
Urban 10 33.3 11 36.7 .051
Occupation
Owner of a craft 7 23.3 9 30 1.077
Farmer 9 30 8 26.7
Employer 12 40 9 30 .055
does not work 2 6.6 4 13.3
Table (1): showed that the mean average age of the study group was (38.4±5.4) year and in the control group was (37.2±4.8)
year. As regard to gender and marital status, (56.7% and 76.7%) respectively among the study group were male and married, nearly
similar to the control group, (63.3% and 73.3%) respectively. Concerning the educational level, it was found that (36.7%) of the
study group and (33.3%) of the control had preparatory education. Moreover, (66.7%) of the study group and (63.3%) of the control
were lived in rural areas. Finally, the occupational level, (40%) of the study group and (30%) of the control were an employer.
Table (2): Distribution of studied subjects (study and control group) according to their medical data (N=60).
(N=30) (N=30) P-value
N % N %
Medical diagnosis
Myocardial infarction 12 40 10 33.3 1.110
Mitral valve stenosis 8 26.7 7 23.4
Coronary artery stenosis 10 33.3 13 43.3 .060
Type of cardiac surgery
Coronary Angioplasty 12 40 10 33.3 1.300
Mitral valve replacement 8 26.7 7 23.4
Coronary artery bypass graft 6 20 8 26.7 .051
Stent placement 4 13.3 5 16.6
Risk factor *select more answer
Smoking 6 20 9 30 1.998
Physical inactivity 14 46.6 10 33.3
High blood pressure 9 30 13 43.3 .049*
Obesity 7 23.4 8 26.7
Chronic disease
Yes 27 90 26 86.7 0.997
No 3 10 4 13.3 .062
Past cardiothoracic surgery
Yes 7 23.4 3 10 2.001
No 23 76.6 27 90 .041*
Past hospitalization
Yes 19 63.3 17 56.7 1.004
No 11 36.7 13 43.3 .057
Table (2) presented that, (40%) of the study group suffered from myocardial infarction and they did coronary angioplasty
surgery, similar to (43.3%) of the control group suffered from coronary artery stenosis but only (33.3%) among them were did
coronary angioplasty. (20 &46.6 %) respectively of the study group were had a risk factor of smoking and physical inactivity. And
(30 &33.3 %) of the control group had the same risk factors. Also, (90%) & (86.7%) among both groups were suffered from chronic
disease. Moreover, (76.6 & 90%) from the study and control group respectively were didn't have a history of cardiothoracic surgery
and were not hospitalized previously and the highest percentage from both groups (63.3 & 56.7%) respectively were admitted
previously to the hospital
Table (3) Distribution of mean average scores of mechanical ventilator parameter for studies groups before their extubation
(N.=60)
Mean score of Mean score of X2 P-value
Tidal volume 451.6±72.84 448.6±71.7 1.008 .056

Fio2 0.44±0.15 0.48±0.18 1.103 .051
Rate 16.3±2.05 17.2±2.11 1.019 .054
PEEP 7.86±1.67 8.14±1.57 0.986 .063
PS 13.10±2.0 14.15±3.3 1.030 .053
ETT size 8.4±0.46 8.5±0.94 0.938 .052
Cuff pressure 18.69±3.9 18.86±4.8 0.763 .061
N.B. the mechanical ventilator parameters were assessed once before extubation
Table (3) shows that there was no statistical significance difference between both groups of the study (study & control
groups) regarding the 7th item of mechanical ventilator parameters.
Table (4) Comparison between (study and control group) related Pain score through the first seven days post their extubation.
Mean of Mean of X2 P-value
(N=30) (N=30)
3rd day 5.76±1.18 7.01±1.88 3.462 .020*
5th day 4.14±1.11 6.60±2.10 2.938 .025*
7th day 2.23±0.98 4.42±1.50 3.012 .021*
Table (4) showed that, that the Mean SD score related pain score post extubated of a study group at 3 rd day was 5.76±1.18,
while the control group was 7.01±1.88. On the 5 th day, the mean score of the study group was 4.14±1.11, while the control group was
6.60±2.10. While at 7th day, the mean score of the study group was 2.23±0.98, while the control group was 4.42±1.50. Also, this table
detected that there was a significant difference between the control and study groups related to pain scores at p-value <0.05.
Table (5) comparison between frequency distribution of the study and control groups according to their breathing sound
through the first seven days post their extubation.

(N=30) (N=30) P-value
Normal Crackles Wheeze Normal Crackles Wheeze
N (%) N (%) N (%) N (%) N (%) N (%)
1st day 22 (73.3) 7 (23.3) 1 (3.3) 16 (53.3) 10 (33.3) 4 (13.4) 2.088

.043*
3rd day 17 (56.6) 11 (36.7) 2 (6.7) 10 (33.3) 14 (46.7) 6 (20) 2.263
.040*
7th day 19 (63.3) 10 (33.3) 1 (3.3) 12 (40) 11 (36.7) 7 (23.3) 3.038
.036*
Table (5) revealed that (73.3%) of the study group had normal sound on 1 st day, while (53.3%) of the control group had
normal sound. Also, only (3.3%) of the study group had wheeze on the 7 th day, while (23.3) of the control group had the same sound
on the same day of the study. Also, this table revealed that there was a significant difference between the study and control group
related to breathing sound at the 1st day, 3rd day and 7th day presented by p-value (.043, .040 & .036) at the 1st-week post-extubation.
Table (6) Comparison between (study and control group) related to arterial blood gases value through the first seven days
post their extubation.
Mean of Mean of X2 P-value
(N=30) (N=30)
PH 7.34±0.36 7.30±0.39 1.996 .031*
Pa O2/mmhg 92.03±3.40 90.10±4.8 6.097 .004**
Pa Co2/mmhg 46.2±6.70 49.8±7.5 2.979 .020*
HCO3/meq/L 20.10±3.1 19.3±2.6 4.160 .013*
O2 sat (%) 96.11±4.1 94.5±2.1 5.999 .003**
Table (6) showed the Mean & SD score of the ABGs test it was observed that the PaO2 level for the study group was (92.03
was±3.40) but it was (90.10±4.8) for the control group also regarding the O2 saturation it was (96.11±4.1) for the study group but it
was (94.5±2.1) for the control group. there was a statistically significant difference between the study and control group related to all
items of the ABGs test presented by P-value with (.031*, .004**, .020*, .013* & .003**).
Discussion Regarding demographic data, the current results revealed that

Cardiothoracic surgery is accompanying by the mean age of the study group was 38.4±5.4 years, and the
pulmonary problems incidence, defined as any pulmonary control group was 37.2±4.8 years. As regard to gender and
abnormality that occurs during the postoperative period which marital status, 56.7% and 76.7% of the study group were male
creates detectable syndrome that is clinically important and and married, respectively and 63.3% and 73.3% of the control
affects the clinical course. Cardiothoracic surgery prompts group were male and married, respectively. These results
severe postoperative pain and deficiency of pulmonary supported the study conducted by Kim, H. S., & LaCamera,
function, increases the length of stay (LOS) in hospital, and 2020 about the risk of the non-expandable lung following
increases mortality and morbidity. Some thoracic open-heart surgery, who reported that the mean age of the
physiotherapy techniques are used for respiratory function studied patient was 36.8±5.7.
improvement in oxygenation and decline in respiratory Concerning the educational level, the current results
complications (Vervoort, Meuris, et al, 2020). revealed that one-third of both groups had preparatory
Therefore the study aimed to assess evaluate the education. Moreover, about two-thirds of them were lived in
effect of immediate pain management on oxygenation level rural areas. These results in cohort with the study performed
and among early extubated patients post-heart surgery. by Elsaed, Mohamed & Ebrahim, 2020 titled in Factors
Affecting Post Open-Heart Surgery Outcomes for functional status following coronary artery bypass grafting
Hospitalized Patients, who demonstrated that more than half surgery, who reported that a significant reduction is expected
of studied patients had a university education and residing in in most pulmonary functional parameters following CABG
urban areas. despite normal pulmonary function state preoperatively.
Regarding medical data, the current results presented Severe pain originated from sternotomy may be an important
that, more than one-third of the study group suffered from factor related to pulmonary dysfunction following CABG.
myocardial infarction and did coronary angioplasty surgery. While another study found on the reverse with
and about one-third of the control group suffered from current study results, who represented that pain is known to
coronary artery stenosis and did coronary angioplasty surgery. be an unpleasant sensory and emotional experience associated
These results agree with the study performed by Andonian et with potential and actual tissue damage. Despite major
al., 2020 titled Assessment of the Psychological Situation in advances in postoperative pain management, it continues to be
Adults with Congenital Heart Disease, who detected that more a significant problem for many patients after major surgery.
than one-third of studied patients undergoing coronary Pain following cardiac surgery is common, and, despite being
angioplasty. largely avoidable, is moderate to severe in up to 75% of
Also, less than half and the majority of both groups patients. Pain can prolong hospital stays and cause significant
suffered from physical inactivity and had a chronic disease. morbidity including psychological distress and in some cases,
While about three-quarters and about two-thirds of the study chronic pain (Choinière et al., 2014).
group didn’t have a history of cardiothoracic surgery and were
not hospitalized previously. These results supported with the Conclusion
study performed by Pencina et al., 2019 titled in Quantifying These results concluded that pain management
Importance of Major Risk Factors for Coronary Heart Disease, measures were had a positive effect on the patient's breathing
who presented that chronic disease as HTN and DM affected sound and arterial blood gases level which improves the
coronary heart disease. patient's outcomes post-cardiac surgery.
Related to mechanical ventilator parameters: The
current results detected that there was no statistically Recommendations
significant difference between both groups of the study related  All cardiac surgery patients should receive an
to (Tidal volume, Fio2, Rate, PEEP, PS ….etc) at p-value explanation about pain management strategies before
>0.05. this result was taken before extubation of both groups their operations.
of the study and it reflects the same mean parameters received  Pain management strategies should be included as an
by both groups of the study. important element in the protocol of care for
The current results revealed that the Mean & SD of cardiothoracic patients and emphasizing teaching for
pain score for the study group at the 3rd day, 5th day and 7th them during preoperative education.
day were (6.76±1.05, 5.04±1.30 and 4.10±1.40, respectively)  All cardiac intensive care unit nurses should receive
but the control group was (8.01±1.88, 7.60±2.10 and an explanation about the nonpharmacological pain
5.42±1.50, respectively) at the same period. Also, detected management measures based on evidence from
that there was a significant difference between the study and researchers.
control group related to Pain score at p-value <0.05.  Replication of the current research on a large
These results were regular with the study performed probably samples with using other non-
by Yaban, 2020, about the usage of non-pharmacologic pharmacological pain management measures on
methods on postoperative pain management by nurses, who cardiac surgery patients.
stated that the application of nonpharmacologic methods,
known as pain controlling methods other than drugs, alone or References
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Effect of Educational Program on Nurses Performance about Colostomy Care

Hanaa Abd El-latief shahat Ali, Jehan Sayyed Ali, Sahar Hamza Taha.
(1) B.Sc. in Nursing- Faculty of Nursing _Minia University,

(2) Professor of Medical Surgical Nursing -Faculty of Nursing _Minia University,
(3) Lecturer of Medical Surgical Nursing- Faculty of Nursing _Minia University
ABSTRACT
Background: Colostomy is a stoma which is formed after removing the large bowel or colon and is opening in the
abdominal wall that’s made during surgery. The care of patients with colostomy is a complex, challenging and lengthy
process .The nurse can play a clinically relevant role in the care of patient undergoing ostomy surgery pre and post-
operative education. Aim of the study: to evaluate effect of educational program on nurses' performance about
colostomy care. Subjects &Methods: Research design: a quasi-experimental design was utilized to fulfill the
purpose of this study. Sample: Randomized sample conducted on 40 nurses caring for patient with colostomy
.Setting: two setting: 1st setting at Oncology Center &2ndsetting at Minia University Hospital. Tools: Two tools
were used for data collection: First Tool: included two parts: part I: socio demographic data sheet for the nurses,
part II: structured knowledge questionnaire second tool: observational checklist about colostomy care. Results:
Reveled that the mean age of study sample was 32.95 ± 3.65, the majority (85%) of the studied sample had low
knowledge before educational program implementation while, after 3 months of program implementation the majority
(85%) had a good knowledge about colostomy care. Also all of study sample had weak performance before
educational program implementation while, in post immediately of program implementation more than half of studied
sample (52.5%) had accepted performance and after 3 months the majority of them had a good performance about
colostomy care. Also, there was a highly statistically significant difference in nurses' knowledge and practice pre &
post immediately and after 3 months educational program regarding colostomy care. Conclusion: The study
concluded that, there was a positive effect of the educational program in improving nurses' knowledge and practices
regarding colostomy care. Recommendations: Greater attention and closely observation from hospital on nurses′
performance during care for patient with colostomy and replication of the study should be done on a large sample.
Key word: colostomy, nurses ’performance, educational program.
Introduction the tasks of nurses, they need enough expertise to care for
Colorectal cancer (CRC) has a major international patients (Duruk & Uçar, 2018).
health concern because of its high incidence and mortality Therefore, the understanding of nursing skills and
rates (Favoriti, et al., 2016). The CRC, which comprises expertise influences patient education and healthcare
approximately 1 million and 400 new cases and about 700 satisfaction. Nurses should be qualified before hospital
deaths, is the third most prevalent type of malignancy in the discharge to determine the physical, psychological, and
United Nations Association and the 4th largest global cause of cultural needs of the patient (Nazike Duruk, 2017).
cancer mortality worldwide (Arnold, et al., 2016).
Over the past few years, the prevalence of CRC has Significance of the Study
increased enormously; in particular, the number of newly United Ostomy Association (UOA) 2015 stated that
diagnosed CRC cases has increased from 700 to 83000 in over 750,000 Americans currently have an ostomy. However,
1990 to 1 million and 31 1000 in 2012 (Ferlay, et al., 2015 about 36 % of the surgeries performed are colostomies.
&Rafiemanesh, et al., 2016). The colostomy is a stoma that While, in Hong Kong (2017), there are approximately 15,000
is formed after removing the large bowel or colon and is an patients with a stoma. Furthermore, in the Netherlands in
opening in the abdominal wall that's made during surgery 2017, there are about 32,000persons with a permanent stoma.
(Laughlin & Rullier, 2018). Other report estimates that 650,000 people in Egypt currently
The most secure type of treatment can include acute have a stoma and about 3000 new surgeries are performed
diverticulitis, rectal cancer, trauma, or bowel-inflammatory each year with a colostomy (Sheikh et al., 2013).
conditions (Huang, et al., 2020). Physical and psychological Evidence-based practice (EBP) has demonstrated
issues including anxiety, shame, depression, and a negative that preoperative ostomy education is more effective than
physical image affect patients with a stoma postoperative. Instituting a coordinated EBP approach
(Betty Lebona, et al., 2016). preoperatively to ostomy care resulted in 75% of participants
Nurses can play a major part in the understanding achieving ostomy independence in 5 days or less (Bryan &
and have an important role in adjustment to the colostomy Dukes, 2017). Preoperative ostomy nurse education programs
patients and their families. This position is only effective if the are associated with a greater probability for improvement in
nurses have expertise and skills help (Chindaprasirt, et al., the ostomy patient outcomes (Subih & Neil, 2016).
2017).
Initial evaluation and education help for patients in Aim of the Study
the colostomy surgery, before and after surgery, however, The current study aimed to assess the effect of
Patient care and education quality are influenced by the educational program on nurse's performance about colostomy
expertise and capacity of nurses. Since patient care is one of care.
P a g e | 103 Hanaa A., et al

Research hypothesis: (< 12 score), moderate knowledge 60% - 75% (12-15
(1) There will be a significant difference between the score), high knowledge ≤75% (15- score or above)
pre-test and post-test of knowledge level regarding (Nabeel, et al., 2013).
colostomy care among study sample nurses.
(2) There will be a significant difference between the Second Tool: “Observational Checklist Sheet about
pre-test and post-test of practice level regarding Colostomy Care”:
colostomy care among study sample nurses.  This sheet was filled by the researcher, it was
(3) There will be a positive relationship between selected adopted from (Potter ,et al., 2016),it consists of 4th
socio-demographic variables and nurses domains for evaluating nursing practice about
performance. colostomy care :
o 1st domain assessment of the stoma and
Research Design peristomal skin including (7) steps.
A Quazi- experimental research design was utilized o 2nd domain Applying new ostomy
to fulfill the aim of this study. appliance including (25) step.
o 3rd domain irrigation of the stoma
Setting including (27) step.
The current study was carried out at two settings: 1st o 4th domain emptying the pouch including
setting oncology center (Surgical department, inpatient (8) steps.
chemotherapy department), 2ndsetting Minia University
Hospital (General surgical department). Scoring System:
The score for each domain rank from (0-1-2), not
Sample done was given a score (0), done in-correctly was given a
The sample was selected by randomization method score (1), done correctly given a score (2) the score for each
(40) of all nurses who were working in the selected settings item were summed to create a total score 134 items.
that mentioned before and were participate in the study would Total observational checklist about colostomy care (≤
be included. 60%) was considered satisfactory, (< 60%) was considered
unsatisfactory.
Inclusion Criteria for the nurses:- Total scores were classified as (weak performance <
All nurses are on duties. 60%, acceptance performance 60 % - 75%, good performance
knowledge ≤75%.
Exclusion Criteria for the nurses:
Nurses who aren’t will to participate in this study. Tools validity
The study tools were developed after reviewing the
Study Duration: related literature .To determine content and face validity, these
The total data collection was collected over a period tools were tested by a Jure committee that consists of five
of six months starting from July 2019 to December 2019. medical-surgical nursing experts. Recommendations were
followed, the questions that were not appropriate were taken
Data Collection Tools: out and some questions needed clarification and modifications
Tools of data collection were developed by the were done.
researcher after extensive review of literature and similar
studies conducted elsewhere. After that the developed Tools reliability
questionnaires are revised by 5 panels of medical surgical Tools were tested for content reliability using Alpha
nursing staff, a structured knowledge questionnaire was Cronbach’stest.it was (0.96) for the first tool, (0.86) for the
developed. second tool.
Data collection: The data was collected by using two tools: Pilot study
The First Tool: A pilot study was conducted on (4 nurses) 10% of the
Part I: Socio demographic data sheet for nurses total sample to test feasibility, objectivity, and applicability of
including (age - gender - working department – educational the data collection tool .To estimate the needed time to fill the
status-occupation-years of experiences, etc. data collection. Based on the results of the pilot study, no
Part II : Structured knowledge questionnaire to refinement/modifications were done for data collection
assess nurses knowledge about colostomy care , it was instruments; nurses who shared in the pilot study were
modified by the researcher after extensive literature review included in the actual study sample.
and it includes 20 questions about colostomy care such as
meaning of colostomy, indication, types, normal appearance Ethical Consideration
of the stoma, types of pouches ……etc. An official permission to carry out the study was
obtained from the ethical committee of the faculty of nursing,
Scoring System: dean of nursing faculty, Oncology Center director and Minia
 Each correct answer was given a score of one and University Hospital director.
incorrect answer a score of zero, it was assigned for Subject's participation in this study was voluntary,
each answer representation (correct, incorrect) they were informed about the importance, aim, nature, and
respectively. purpose of the study, and they had the right to withdraw from
 Total score for knowledge questionnaire about the study at any time without any rationale. Oral and written
colostomy care classified as (low knowledge <60% consents were obtained from subjects; they were informed that

the obtained data will not be included at any further researches the ostomy appliance, colostomy irrigation and pouch
without a second consent. Confidentiality and anonymity of emptying.
each subject were ensured through coding of all data and  Then allow nurses to asking questions, discussion
protecting the obtained data. and reach high level of understanding.
 This phase also was taken three sessions for each
Procedure group (10 nurses), each session took about (30-45
The current study was achieved through three minutes).
phases, Assessment phase (pre- test), implementation phase  During first session the researcher explained
(conducting education program) post-test immediately, and knowledge and demonstrated steps of colostomy
follow up phase. care that mention before, applied the procedure of
pouch emptying, assessment of stoma and
1-Assessment phase :-(pre-test) peristomal skin care ,according to checklist in front
Once official permission were granted ,the of study sample group.
assessment phase (pre-test) collected through(six weeks) to  Second session: the researcher applied the procedure
test studied sample actual level of knowledge and practice of changing an ostomy appliance and colostomy
regarding colostomy care. irrigation, according to checklist in front of study
The researcher collected the sample through three sample group.
days per week (In morning &evening shift). The study was  Third session: post-test immediately was done for
carried out in the period from july2019through December. each group by using 1st tool&2nd tool (Appendix A&
 During assessment phase the researcher held the first Appendix B).
meeting with nurses to introduce herself and giving
an explanation about the nature and purpose of the 3-Evaluation phase (follow up)
study .they were informed that about participation in Three time of evaluation were done for each nurse:
this study is voluntary and they had the right to (1) First time of evaluation (pretest) done before
withdraw at any time, oral approval of nurses to share implementation of the knowledge questionnaire and
in the study was achieved. observational checklist about colostomy care.
 After obtaining the acceptance from nurses to (2) Second time of evaluation (immediate posttest ) done
participate in the current study, the researcher immediately after explanation of knowledge
provided an over view and clarification about the questionnaire about colostomy care & application of
assessment questionnaire then the self- administered procedures to patient in front of nurses about
questionnaire was distributed to each nurse to assess (assessment of stoma and peristomal skin care,
data related to socio-demographic status(Appendix changing an ostomy appliance, colostomy irrigation
A) ,the questionnaire took about 15 minute to be and emptying the pouch).
completed. (3) Third time of evaluation(posttest) done after 3
 The total sample (40) was divided in to small group months of assessing nurses about knowledge &
(4 group) each group consists of (10) nurses, each practice related to colostomy care of patient.
group received (3) session.  The entire study sample received brochure as a guide
 The time of each session was taken (35 to 45) (Appendix E) (in Arabic) it was developed by the
minutes. researcher and revised by 5 panels of medical
 First session of assessment phase (pre-test) the surgical nursing staff, it was included (knowledge&
researcher assesses knowledge of nurses about practice related to colostomy care.
colostomy care by using 1st tool (Appendix A).
 Second &Third session of assessment phase (pre-test) Statistical analysis of data
the researcher assess practice of nurses about The collected data were organized, tabulated,
colostomy care by using 2nd tool (Appendix B). categorized analyzed, and data entry was performed using the
statistical package of social science (SPSS) version (20).
2- Implementation phase:( post-test immediately) Descriptive statistics were applied (e. g mean, standard
 During implementation of education program, the deviation, frequency and percentage). Pearson's correlation
nurse in the study sample received the knowledge coefficient was applied between quantitative variables. A
about colostomy care and the researcher applies the significant level value was considered when p<0.05.The
following procedures to the patient in front of nurses: smaller the p-value obtained, the more significant is the result
how to assess stoma and peristomal skin, changing (*), less than0.001was considered highly significant (**).The
P- value is the probability of error of the conclusion.
Results:
Table (1): Distribution of Study Subjects Regarding their Socio demographic Characteristics (n=40).
Study (n=40)
Socio Demographic Variables
No. %
Age / years
 20-<26 3 7.5
 26 -<30 10 25
 30 -<35 18 45
 35->35 9 22.5
Mean ± SD 32.95 ± 3.65
Gender

Study (n=40)
Socio Demographic Variables
No. %
Male 8 20
Female 32 80
Educational status
Bachelor 10 25
Technical Institute 12 30
Diploma 18 45
Occupation
Head nurse 4 10
Bed side nurse 36 90
Working Department
Oncology Surgical Dep. 17 42.5
Inpatient Chemotherapy 13 32.5
General Surgical Dep. 10 25
Years of experience
< 5 years 8 20
5-10years 10 25
> 10 years 22 55
Table (1) Reveals that; more than one third of study sample (age was between 30<- 35years and their mean age ± SD was
32.95 ± 3.65, their educational level was Diploma in nursing(45%) and working in Oncology Surgical department). The highest
percentage of study sample (80%) was females. Also, as regard to their occupation results shows that more than two thirds working as
a bed side nurse. Finally, more than half of them )55%) had > 10 years of experience.
.
Figure (1): Distribution of Study Subjects Regarding to their Age, Gender & Years of Experience (n=40)
Figure (1): Reflected that highest percentage (45%) were belongs to 30-<35year of age& least percentage (7.5%) were in
20-<26years and their mean age ± SD was 32.95 ± 3.65. Regarding to gender the highest percentage from them constituted (80%)
were females. Regarding to Years of experience, most of studied sample experiences was more than ten years constituted (55%), on
opposite side the least percentage of them was less than five years constituted (20%).
Table (2): Distribution of Nurses knowledge Level regarding colostomy care educational program (n = 40)
Level of knowledge Pretest Posttest After 3 m.
No. % No. % No. %
Low Knowledge 34 85 0 0 0 0
Moderate Knowledge 5 12.5 29 72.5 6 15
High Knowledge 1 2.5 11 27.5 34 85
Fisher (P – Value) 168.8 (0.001**)
* Statistical significant (P ≤ 0.05) ** highly Statistical significant (P ≤ 0.01)
Table (2) Shows that, the majority of study group had low level of knowledge pre implementing colostomy care educational
program, and more than two thirds of study group constituting had moderate knowledge level post-test, however the most of study
group after education program had high knowledge with highly statistically significant differences (p= 0.001**).

Figure (2): Nurses Practice Mean Score regarding colostomy care educational program (n = 40).
Fig (3): Reflected that Mean ± SD in pre-test was (26.8 ± 11.5)&in posttest was (91.3 ± 13.7 )and after 3 months was (107.7
± 8.09 ) and there was a highly statistical significant respectively .
Table (3): Distribution of Nurses Practice Level Regarding Colostomy care Educational Program (n = 40)
Level of Practice Pretest Posttest After 3 m.
No. % No. % No. %
Weak Performance 40 100 8 20 0 0
Accepted Performance 0 0 21 52.5 7 17.5
Good Performance 0 0 11 27.5 33 82.5
Fisher (P – Value) 187.3 (0.000**)
* Statistical significant (P ≤ 0.05) ** highly Statistical significant (P ≤ 0.01)
Table (3): Shows that, all of studied sample in pretest had weak performance level regarding colostomy care, while in post-
test more than half of them had accepted performance, and after 3 months the majority had a good performance. There were statistical
significant among pre, post, and after 3months of implementing colostomy care educational program with p-value (0.000**).
Table (4): Correlation between Nurse’s Total Knowledge Scores and Total Practice Scores Regarding Colostomy Care
educational program (n = 40).
Total knowledge Scores
Pretest Posttest After 3 months
r p r p r p
Total practice Scores 0.105 0.519 0.364 0.021* 0.304 0.047*
* Statistical significant (P ≤ 0.05)
Table (4): shows that, there were a positive correlation between total knowledge and total practice scores regarding
colostomy care educational program (n=40) where in posttest (r value=0.364 & p= 0.021) more than(r value) in pre-test and after 3
months this reflected that there was a statistical significant in posttest and after 3 months.
Table (5): Correlation between selected Socio-demographic Characteristics (Age, Educational status and Years of experience)
and Nurses Level of Practice of Implementing colostomy care educational program (n=40)
Socio Demographic Variables Level of Practice
Pre post Immediately After 3 months
r p r p r P
- Age 0.003 0.841 0.041 0.801 0.148 0.361
- Educational status 0.330 0.038* 0.192 0.235 0.079 0.627
- Years of experience 0.142 0.382 0.137 0.398 0.080 0.0625
Table (5) Shows that, there were no statistically significant correlation between the selected Socio-demographic
Characteristics (Age & Educational status& Years of experience) of studied sample and their level of practice Pre& post Immediately
&After 3 months colostomy care educational program, except with educational status, there was a significant correlation with the
level of practice pre- educational program with p-value (0.038).
Table (6): Correlation between selected Socio-demographic Characteristics (Age, Educational status and Years of experience)
and Nurses Level of Knowledge of Implementing colostomy care educational program (n=40)
Socio Demographic Variables Level of Knowledge
Pre post Immediately After 3 months
r P r p r P
- Age 0.145 0.290 0.023 0.889 0.028 0.865
- Educational status 0.212 0.190 0.303 0.058 0.149 0.360
- Years of experience 0.253 0.115 0.053 0.746 0.044 0.788

Table (6) Shows that, there were no statistically significant correlation between the selected Socio-demographic
Characteristics (Age & Educational status& Years of experience) of studied sample and their level of knowledge Pre& post
Immediately &After 3 months colostomy care educational program.
Discussion (Ahmed, 2016) who stated that more than one third of study
The world's third most common cause of cancer samples of nurses their experienced more than ten years.
death is colorectal cancer (American Cancer Society .2017). Concerning to occupation the present studied
Intestinal ostomy is a procedure to treat a variety of conditions findings showed that more than three quarter of nurses
such as acute diverticulitis, rectal cancer, trauma or bowel working as bed side, and a small number of them working as a
disease (Lewis, 2014). head nurse , this result supported by (Geleta, 2017) who
The nursing function for patients with colostomy report that the majority of nurses working as bed side nurse
changing from a bed side nurse to a therapist or to enter stoma (80%) working as bed side, (20%) working as a supervisors ,
or a nurse with expertise in stoma care. Patients have the most This finding is also similar to (Subih & Neil, 2016) In their
significant and central function in health education to assist Jordanian report, that ostomy care is a responsibility of the
and persuade patients in self-care. They consider health bedside nurses who act pre- and postoperatively as nurses for
educators in virtually every health care community to improve stoma care.
and promote patient health awareness in taking charge and
getting acquainted with their condition (Walker, 2016). Section II: is concerned with the assessment of
nurse's knowledge level regarding colostomy care.
In the next part, the discussion will concentrate on The current study results found that more than two
the main results: third of the studied sample in pre educational program hadn’t
Section I: will be dedicated to socio-demographic knowledge about colostomy care such as (Definition of
characteristic of studied groups regarding to colostomy care. colostomy ,causes, indication, return to work after
The present study showed that the majority of studied colostomy).In the current study was found difference
group's age ranged from thirty to below thirty five years with between pre-test and post immediately and after three month .
the mean age ± SD was (32.95 ± 3.65); this may be due to the The current research findings showed that over half
desire of Mania Oncology center& Mania university hospital the samples analyzed had a correct response to the definition
roles in old years and to provide high-quality health care of colostomy, causes of colostomy, colostomy indication, etc.
services, through employing new graduates of the faculty of These observations are similar (Pandey & Dhungana, 2017)
nursing or nursing technical institute in additional to diploma that two third of the sample responded correctly and also,
nursing This result in our study may be due to increase the supported results by (Carlson, et al., 2017).
number of diploma nurses than qualified nurses due to old However, in the current study more than half of the
system of nursing teaching . studied sample had a moderate knowledge about colostomy
The results of the current study were accepted (Arun care in immediate posttest and after 3 months of educational
Kadam, et al., 2014), which reported that the majority of program implementation had a good knowledge about
samples studied age ranged between 30 and 34 years. Further colostomy care.
confirmation was given for in (Mohamed, et al., 2017) by the This result is in line with one study (Pearson &
study, which stated that over half of the studied sample age Helistrom, 2016), which stated that the post-educational
was between 29 and 34 years. program has more than half of the study sample had a
Conclusions also confirm the findings of the research moderate information , while after three months they had good
by (Gem mill, et al. 2015) who reported that most of the and high information on colostomy care.
sample age study ranged from 20 to 30 years. Also nursing workers with fewer than three years of
Findings of the current study showed that more than experience. As the nurse does not know all facets of
two thirds of the total studied samples were females. This colostomy treatment, they have even had some work
result may be explained by the fact that nursing is a universal experience. Like previous research, a lower level of awareness
feminine profession especially in our society culture. among nurses with several years of work experience has
Furthermore, the findings confirms that the bulk of the sample proved to be due to an insufficient education status
analyzed (93.3 %) were female (Betty Lebona et al. 2016). (Pancorbo, et al. 2017), and the current study has shown that
Concerning to educational level; the present studied nurses with a long working experience (< 10 years) have little
demonstrated that, more than one third of the studied sample knowledge of colostomy care (61, 7%) because of lack of
were diploma in nursing , more than a quarter of the studied education in which about half of them have diploma in
sample were technical institute and about a quarter of the nursing.
studied sample were Bachelor of science in nursing( BSc). This result agree with (Nabeel et al., 2013)
This may be explained by a little number of faculty′s conducted a study on Nursing care standards of colostomy
graduates had employed in the university hospital and other care. The results showed that all nurses (100%) had
work in schools or ministry of health hospitals. Also the result inadequate knowledge of the requirements for colostomy care
supported finding by (Hashem & Abusaad, 2016) More than in pre-testing while they know the standards for knowledge
half of nurses were diploma in nursing .But this result dis regarding-colostomy care at satisfactory level in immediately
agree with (Betty Lebona, et al., 2016) Who stated that the post and after 3 months.
majority of sample group studied BSc . Furthermore, a study on developments in skills and
Concerning to years of experience current study procedures in the care of patients with intestinal Stoma
found that more than half of studied sample experienced more (Hashem & Abusaad, 2016) support this result. The findings
than ten years; this finding was in the same line with study by revealed that most nurses surveyed had no knowledge of the
intestinal stoma in pre-test while, they all had a good

understanding of intestinal stoma care in immediately post and and that improvements of each other have an impact. In
after three months of education program implementation. addition, the present study showed that after three months, the
The current study also dis agree with (Betty Lebona, majority of nurses with good knowledge had competent
et al., 2016) who found that a high percentage of participants practice, while over half had poor knowledge and incompetent
(75.9 %) were knowledgeable about colostomy care, also dis colostomy practices before the introduction of the program.
agree with the study done in Albanian revealed that 74 % of This finding proves that, the nursing educational
the respondents were knowledgeable towards colostomy care program intervention had a positive impact in the knowledge
in pre -test (Duruk & Ucar, 2018). and practice scores of colostomy care and knowledge in the
studied nurses after intervention of the educational program,
Section III: Evaluation of studied group′s practice But the outcome disagrees (Nabeel, et al., 2013).
about colostomy care. Who said that the awareness of stoma care and experience
With regard to overall colostomy nursing practices, with respect to the standards of colostomy for nursing care
the results in the current study have explained that the level of was weak, optimistic (r=0.15, p=.3). This meant that the art of
colostomy care practices by nurses has been effective over colostomy was not affected by experience. This is due to the
immediate post-patients and after 3 months of the educational possible awareness of colostomy, but due to the inexperience,
program implementation. These results were confirmed by lack of formal training, which can impact the practice rates,
(Richboarg, etal., 2016), who reported that stoma care nurses the nurse cannot provide treatment.
with expert ostomy care and training can enhance patient
outcomes in their study in Jordan. Conclusion
This result was also confirmed by (Golik, et al., Based on the results of the present study it can be
2018) that continuous learning is one of the roles of nursing concluded that: After providing the education for studied
employees and the specificity of stoma nursing requires nurses had a good level of knowledge and practice related to
additional skills and expertise. The clarification shows that the colostomy care.
clinical practice of stoma treatment requires skills to be
updated and sufficient information to deal particularly with Recommendations
the patient and their families. (1) Greater attention had to be paid to nurses’
performance during colostomy care.
Section IV: As regards the relationship between (2) Educational needs should be assessed for staff and
selected socio-demographic variable of the studied nurses newly employed nurses working in Oncology Center
and their total knowledge: & Minia University Hospital.
The current study found that no statistical correlation (3) Training program should be arranged for nurses
between knowledge and selected socio-demographic variable, about colostomy care procedures and receive regular,
that is agreed with (Betty Lebona, 2016) who stated that no periodic courses to update nurse's knowledge, based
association between the demographic variables such as age, on evidence guidelines about colostomy care
gender, educational qualification, with level of knowledge procedures.
regarding colostomy care.
These results were followed by (Golik et al. Acknowledgment
2018&Swierzewski 2015), which reported that nurses who The researchers would like to acknowledge the
provide advancing treatment for Stoma patients should have a contribution of all participants who kindly agreed to take part
bachelor's degree in nursing and practice, so that they are able in the study. They generously gave their time and attention to
to advise, instruct and collaborate with doctors in stoma care conduct this study. This study would have been impossible
from both patients and staff in other units. without their generosity.
But disagreement (Hashem& Abusaad, et al., 2016)
was found that there was a significant relationship between the References
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Nurse’s knowledge and Practice regarding Medication Errors in Critical Care Units: Descriptive study
Al Shaimaa Moustafa Fathy1, Nahla Shaaban Khalil2, Naser Mohamed Taha3, Marwa M.Abd-elbaky4
(1) B. sc in critical care nursing, Faculty of Nursing, Minia University, Egypt.

(2) Assist Professor of Critical care Nursing Department, Cairo university
(3) Professor of Cardiology, Faculty of Medicine, Minia University, Egypt.
(4) Lecturer of Medical Surgical Nursing, (critical care nursing), Faculty of Nursing, MiniaUniversity, Egypt.
Abstract
Medication administration should be an error-free process as possible. Critical care nurse need to be diligent in
discouraging interruptions to prevent harm to the patients who are being cared for. Medication administration errors
are a constant occurrence on the unit, and patient safety must be a focus. Aim: to assess nurse’s knowledge and
practice regarding medication errors in critical care units. Design: Descriptive exploratory design was utilized to
conduct the current study. Settings: The study was conducted in the following critical care units affiliated to Al minia
University Hospital ; Intensive care, neurosurgical care, cardiac care, chest care and finally stroke unit. Sampling: A
convenient sample consisted of 60 nurses was obtained from previously mentioned settings regardless of their
personal characteristics. Tools: Two tools were used; First; A structural interviewing questionnaire to collect
demographic data of the studied nurses and their knowledge regarding medication administration errors. Second;
medication administration checklist to assess nurses' practice concerning medication administration errors. Results:
The study findings showed that nurse’s mean knowledge (Mean+SD =10.7+2.29) and practice (Mean+SD =
23.1+4.58) scores were unsatisfactory regarding medication administration errors. Moreover, no significant
differences were found among them by them regarding demographic characteristics' Conclusion: the mean nurse's
knowledge and practice were low. Recommendations: The study recommended implementation of comprehensive,
interactive, and continuous educational programs regarding drug administration errors
Keywords: Nurse’s, knowledge, Practice, Medication &Errors
Introduction veins that often requires calculation of infusion drop rate. On

Many factors influence safe medication management. the other hand, these patients are mostly in poor condition or
Some argue that registered nurses (RN) may have insufficient unconscious and unable to monitor and report adverse drug
knowledge and skills to perform safe medication management
reactions. Therefore, there may be more medication errors in
others point to normalization of risk‐inducing behavior and
interruptions, or use of technology, design flaws, time such sectors that can have serious consequences.
constraints, and poor communication, lack of leadership, as (Kaboodmehri et al., 2019)
well as outdated policies and guidelines. (Odberg et al., Medication errors lead to an increase in the duration
2019).A study defined medication error (ME) as an error in of hospitalization and disability and death in up to 6.5% of
prescribing, dispensing or administering of a drug, irrespective hospital admissions. (Abukhader & Abukhader,
of whether such errors lead to adverse consequences or not
2020).Reducing errors and adverse events whilst maintaining
(Dinkohs, 2016).
Each year, in the United States alone, 7000–9000 patients’ safety is dependent on a precise and timely
people die as a result of a ME. As specified by the Institute of evaluation of patients and interventions, which includes
Medicine (IOM), 400 000 cases of preventable patient injury patient’s risk assessment for developing inevitable and non-
because of MEs occur each year in emergency clinics in the inevitable complications. The process of assessment and
USA. It is observed that 19% of MEs in the ICU are life- evaluation of patients’ safety risk is often challenging because
threatening and 42% are sufficient or clinically importance to of the vulnerable nature of acutely or critically ill patients
warrant additional life-sustaining treatments. Besides, the total
cost to manage patients with medication-associated errors combined with the stressful critical care environment (Shalaby
exceeds $40 billion each year. In agreement with that, MEs et al., 2018).
extend hospital stays by 2 days and increase the costs by
$2000–$2500 per each patient. (Alrabadi et al., 2020) Significance of the study
Errors can occur at different stages of the medication The World Health Organization (WHO) has
use process. Medication errors occur when weak medication emphasized that one in every ten patients is injured because of
errors or adverse events during their hospital process in
systems and/or human factors such as fatigue, poor
developed countries, that this rate is even higher in developing
environmental conditions or staff shortages affect prescribing, countries (World Health Organization. 2014)Error
transcribing, dispensing, administration and monitoring prevalence rates reported in a United Kingdom study found
practices, which can then result in severe harm, disability and that 12% of all primary care patients may be affected by a
even death. (Abdelhamed, 2020) prescribing or monitoring error over the course of a year,
The incidence of medication errors in sectors such as increasing to 38% in those 75 years and older and 30% in
patients receiving five or more drugs during a 12-month
emergency rooms and Intensive Care Units (ICUs) is higher
period. Critical ill patient need special care and have increased
due to a large number of patients. In particular, patients who incidence for medication error especially when caring with
admitted to ICUs receive medications mostly through their poor experienced nurse.
P a g e | 111 Al Shaimaa M., et al
included three main categories; nursing performance during
Aim of the study medication preparation (20 items), nursing practices during
The present study aimed to assess nurses' knowledge medication administration (10 items), nursing practices after
and practice regarding medication errors in selected critical medication administration (5 items).
care units at Minia University Hospital.
Scoring system of observational checklist of drug
To achieve the aim of the study, the following research administration
questions were formulated: Each complete and correct done step obtained one
Research Questions: score, and" not done" or incorrect action step obtained take
(1) What is the nurses’ knowledge level about zero score. The Satisfactory practice level was ≥80 % and
medication errors in Critical Care Unitss? more. And unsatisfactory practice level was < 80 %
(2) What is nurses’ practice level regarding drug
medication administration error in Critical Care Tools validity and Reliability:
Unitss? Content validity was done to identify the degree to
(3) What is the relationship between nurses' knowledge which the used tools measure what was supposed to be
and practice regarding drug medication measured. The developed tools were examined by a panel of
administration errors in Critical CareUnits? five experts in the field of medical surgical nursing
department and medical staff related to critically ill specialty
Subjects and Methods in {Minia University and Cairo University - Faculty of
Subjects Nursing. All jury members agreed that current study tools
All nurses on duty and work in critical care units and were valid and relevant to the aim of the study. Reliability was
administer medication to their patients were included in the done to identify the extent to which the tools items were
current study regardless of their demographic characteristics measurable with the study concept and its correlation with
each other, and the interclass correlation coefficient revealed
Research design r=0.9.
Descriptive exploratory research design was utilized
in the study. Pilot study:
A pilot study was carried out on 10 % of the study
Setting sample to test feasibility, objectivity, and applicability of the
The current study was carried out at five critical care data collection tools. Carrying out the pilot study gave the
units affiliated to Minia University Hospitals (traumatic investigator the experience to deal with the included subjects
intensive care unit, neurosurgical intensive care unit, and to be familiar with the data collection tools. Based on the
cardiology care unit, chest intensive care unit, stroke unit). results of the pilot study, no modification or refinement was
. done and the subjects were included in the actual sample.
Tools for data collection
Two tools were designed and used for data Ethical considerations:
collection. These tools were formulated by the researchers An official permission to conduct the study was
after extensive literature review. obtained from the ethical committee in the faculty of nursing
at Al Minia University. As well, written consents and
Tool 1: knowledge assessment structured questionnaire: It permission were also obtained managers of critical care units
included two parts: affiliated to al Minia university hospitals. Moreover, nurses
Part one: it included nurses' demographic such as who participated in this study were provided information
sex, age, educational level, work area and years of experience. concerning the purpose, benefits, and nature of the study.
Part two: medication errors knowledge Each nurse had the right to withdraw from the study at any
questionnaire time without any rational. Confidentiality and anonymity of
This questionnaire was utilized to assess nurses' knowledge each subject were ensured through coding of all data and
regarding medication the questionnaire. it included 21 items protecting the obtained data.
that covered three categories of knowledge as follows ;
general medication administration errors (7 items), Procedure:
medication preparation (3 items), and medication The researchers initiated data collection through
administration (11 items) . contact with the studied nurses to explain the aim and nature
of the study. Structured knowledge questionnaire were
Scoring system of knowledge questionnaire received by nurses in selected critical care units. The time
Each correct answer was scored one grade and each allowed for nurses to complete the knowledge questionnaire
false answer was scored zero score. Finally the scores were was 45 minutes later, according to the schedule shift of nurses,
calculated summed up. The total scores ranged from 0 to 21. the researchers put their plan to observe the nurses during
The Satisfactory knowledge level was considered to be ≥75%. administration of medications to their patients in morning and
And unsatisfactory knowledge level < 75. afternoon shifts utilizing observational checklists. The data
collection lasted for seven months starting from September
Tool (2): Observational checklist of medication errors: 2019 to March 2020.
The observational checklist was developed by the
researchers based on thorough literature review and used to
evaluate nurses' practices in medication administration. The
entire checklist included 35 action steps. The checklist

Statistical design deviation. As well, T- test was used for comparison between
The collected data was reviewed, organized, two means. Qualitative data was presented in the form of
categorized and tabulated. Later, data entry and analysis was numbers and percentage. It was analyzed in the form of chi
carried out through SPSS20 statistical software package square, fisher exact test. ≤0.05 was adopted to be the level of
.Quantitative data was presented in the form of mean, standard significance in the current study.
Results
Table (1) Distribution of nurses demographic data (n=60)
Characteristics N %
Age
20-29 year 48 80
30-39 year 6 10
> 40 year 6 10
Mean+SD = 26.7+1.30
Years of experience
1-3yrs 31 51.7
4-6yrs 18 30
7-10yrs 9 15
<10yrs 2 3.3
Qualification
Diploma 13 21.7
Technical 37 61.6
Bachelor 10 16.7
Time
Morning 33 55
Evening 17 28.3
Night 10 16.7
Table (1) Revealed that most of nurses, their age ranged between( 20-29) years with the mean age (26.7+1.30) years.
regarding nurses level of education , nearly two thirds of nurses (61.6%) were technical institute graduation . concerning years of
experience ,their years of experience ranged from( 1-3) years. finally , regarding the time of shift the nurses works , it revealed that
more than half of nurses working in morning shifts(55%).
Table (2) Frequency distribution of critical care nurses knowledge level regarding medication administration errors in CCUs
(N=60)
Variable Staff nurses knowledge level
NO Unsatisfactory Satisfactory
N % N %
General knowledge of mediations administration errors 48 80 12 20
1.
Mean+SD =3.67+1.31
Medication preparation errors 25 41.7 35 58.3
2.
Mean+SD =1.58+0.67
Medication administration errors 55 91.7 5 8.3
3.
Mean+SD =5.48+1.44
Total knowledge 59 98.3 1 1.7
4
Mean+SD =10.7+2.29
Table (2): It is apparent that most of nurses obtained unsatisfactory knowledge level(91.7% &80%) with (Mean =5.48+1.44
& (3.67+1.31)) regarding general knowledge &medication administration errors respectively .On the other hand, (58.3%)only had got
satisfactory level regarding Medication preparation errors with Mean (1.58±0.67).
Table (3): Critical care nurses mean practice score regarding medication sub items (N=60)
Staff nurses performance
Performance dimensions
Mean +SD Min Max Range
Preparation of medication 13.65+2.97 9 20 11
During medication administration 6.07+1.61 3 10 7
After medication administration 3.37+0.84 1 5 4
Total practice .23.1+4.58 14 32 18
Table (3): As can be seen that the overall mean practice score was (23.1+4.58) out of( 32) .so, they gained (13.65+2.97) out
of (20) in Preparation of medication. While they got low mean score( 3.37+0.84) out of (5 )after medication administration.

Satisfactory
Figure (4) Frequency distribution of critical care nurses practices level regarding medication administration errors (N=60)
Figure (4) Illustrated that almost two thirds (63.30%) had unsatisfactory practices in Preparation of medication. While (90%)
had satisfactory practices after medication administration
Table (4) Correlation of nurses total knowledge with practices sub items regards medication administration(n=60).
Medication administration
mediations administration
Preparation of medication
Medication preparation
General knowledge of
During medication
After medication
administration
administration
errors
errors
errors
Variable
total knowledge of mediations administration errors r .045- .248 .130 -.174- .251
1
p .733 .056 .320 .185 .053
Medication preparation errors r .089 .197 .292* .305*
- 1
p .499 .131 .024 .018
Medication administration errors r .080 .037 -.148-
- - 1
p .546 .780 .259
Preparation of medication r .549** .458**
1
p .000 .000
During medication administration r .467**
1
p .000
After medication administration r
1
p
Table (4) Showed that there were a fair positive correl ation between critical care nurse practice after medication
administration with their knowledge about medication preparation errors, their practices in medication preparation, and during
medication administration. (r= .305, P – Value < .018, r= .458, P – Value < .0001, r= .467, P – Value < .0001 respectively). Likewise,
there was reasonable positive relationship between critical care nurse practice during medication administration with their medication
preparation (r=.549, P value < .001).
Table (5) Correlation of nurses total knowledge with practices sub items (n=60).
Preparation During After
Variable Total
of medication medication Total practice
knowledge
medication administration administration
Preparation of medication R .549** .458** .927** .182
1
P .000 .000 .000 .164
During medication administration R .467** .794** .009
- 1
P .000 .000 .943
After medication administration R .646** .139
- - 1
P .000 .290
Total practice R .147
- - - 1
P .262
Table (5) Positive correlation between total practice of critical care nurse and their performance in preparation of
medication and during medication administration (r = .927, P – value < .0001& r = .794, P – value < .0001 respectively), fair positive
relationship between critical care nurse performance during medication administration with their preparation of medication and total

observation performance of critical care nurse with their performance after medication administration (r = .549, P – value < .0001& r
= .646, P – value < .0001 respectively), and moderate positive correlation between critical care nurse performance after drug
administration with their drug preparation and during drug administration (r = .458, P – value < .0001& r = .467, P – value < .0001
respectively).
Table ( 6 ): Frequency distribution of critical care nurses MCQ responses regards general knowledge of medications
administration and preparation errors (No =60)
Items General knowledge of mediations administration
False True
N % N %
1- Definition of Medication administration Error . 37 61.7 23 38.3
2-Hazards of medication error? 16 26.7 44 73.3
3- Prevention of medication errors? 16 26.7 44 73.3
4-Nursing roles in the medication administration process 32 53.3 28 46.7
5-patient "rights" should be checked by nurse before medication administration? 54 90 6 10
6-Examples of medication errors? 36 60 24 40
7- Examples of medication error report be filled out and submitted? 9 15 51 85
Medication preparation related errors
8-To make sure you have the right medication, 20 33.3 40 66.7
9-To make sure you have the “right individual. 44 73.3 16 26.7
10-When the medication is received; you must read the _________and compare it to the
21 35 39 65
_________and copy the information to the patient's __________.
Table ( 6 ): Shows that that most of nurses (90%) obtained false answer in question no (5) pertained to patients' rights. As
well,( (73.3%, 61.7%,60%and53.3% )obtained false answers pertained to right individual ,definition ,examples of medication errors
and role of nurse in medication administration. On the other hand, nearly three fourth (73.3) gained correct answer in question no
(2&3) pertained to hazards and prevention of medication errors. While (66.7%, 65% respectively) had true answer regarding question
no (8-10) related to right medication and documentation of medication.
Table (7): Frequency distribution of critical care nurses MCQ responses regards medication administration errors (No =60)
Medication Administration related errors
Items False True
N % N %
11Time for documentation of medications administration: 53 88.3 7 11.7
12-For “right dose” you must check 15 25 45 75
13-If you pour more liquid medication into the measuring cup than is needed, you: 28 46.7 32 53.3
14-During medication administration, you find a medication container that is not listed on the Medication
22 36.7 38 63.3
Administration Record (MAR). What should you do?
15-If you have a medication listed on the Medication Administration Record (MAR) but it is not in the
33 55 27 45
medication cart/drawer/bubble pack, what should you do?
16- Position the client should be when you are inserting a suppository? 15 25 45 75
17- Examples of medication need monitoring of vital signs? 39 65 21 35
18- Examples of medication should be administered slowly? 40 66.7 20 33.3
19- The minimum amount of time a patient must be observed after taking IV medication for the first time? 58 96.7 2 3.3
20- Recommended route for heparin injections is 15 25 45 75
21-Advising about medication knowledge is recommended for: 13 21.7 47 78.3
Table (7): As can be seen that most of nurses (96.7% and 88.3 % respectively) had got false answer in question no( 11&19)
related to time of documentation and minimum amount of time a patient must be observed after taking IV medication. On the other
hand, three fourth of nurses (75%) had got true answer related to question no (16, 20) related to recommended route for heparin
injections and right position for inserting a suppository.
Table (8): Frequency distribution of critical care nurses (done\not done) practices during preparation of medication (No =60)
Items
Not done Done
N % N %
1- Checks that there is a valid, clear prescription for each drug on the medication administration record
1 1.7 59 98.3
signed by the prescribing doctor
2- Washes hands prior to handling medication 27 45 33 55
3- Prepares tray for the drug with the necessary equipment for the drug round 26 43.3 34 56.7
4- Double checks the drug name and dosage with the prescription sheet 38 63.3 22 36.7
5--Reads the medication prescription without difficulties 2 3.3 58 96.7
6- Labels the medication 15 25 45 75
7 -Label syringes and bags with the medication name 27 45 33 55
8- Checks the expiry date of the drug 15 25 45 75
9- Checks the specific instructions regarding administration of certain drugs are adhered to e.g. If
41 68.3 19 31.7
medications are favorably ingested on an empty stomach
10 -Administers dose correctly 8 13.3 52 86.7
11- Observe the patients for occurrence of side effects 28 46.7 32 53.3
12- Checks if the resident has any known allergies. 30 50 30 50
13- Checks the prescribed time each drug is to be 7 11.7 53 88.3

Items
Not done Done
N % N %
14- Checks when the drug was last administered 6 10 54 90
15- Check that medication is administered at the right time that is not ≥60min earlier or late 3 5 57 95
16- Checks the prescribed dose of each drug in the chart 6 10 54 90
17- Checks the prescribed route and form of each drug 0 0 60 100
18- Uses medicine pots, cups or spoons to avoid making contact with the drug. 31 51.7 29 48.3
19- Crushed medicines, the nurse establishes that these have been sanctioned by a medical practitioner or
pharmacist. A clean pestle and mortar is used and it is cleaned after each resident with warm water and 47 78.3 13 21.7
detergent and wiped with a dry hand towel.
20- Checked drugs for the same name and strength if in a monitored dosage system. 23 38.3 37 61.7
Table (8): It is apparent that nearly two thirds and three fourth of nurses (68.3%& 78.3% respectively) didn’t Checks
instructions regarding administration of drugs, Crushed medicines, the nurse establishes that these have been sanctioned by a medical
practitioner or pharmacist. A clean pestle and mortar is used and it is cleaned after each resident with warm water and detergent and
wiped with a dry hand towel.. On the other hand, most of nurses (100%,98.3%,96.7%,90%,88.3%,86.7%) checked the prescribed
route and form of each drug, checked that there is a valid, clear prescription for each drug, reads the medication prescription without
difficulties, checks the prescribed dose, checked the prescribed time and finally administered dose correctly.
Table (9): Frequency distribution of critical care nurses done\not done practices during and after administration of drug (No
=60)
Items During administration of drug
Not Done Done
N % N %
21- Verifies the patient's identity prior to administering medication 1 1.7 59 98.3
22- Communicates information sensitively to the resident prior to and during administration
36 60 24 40
of medication
23-Administered all medicines are personally by the dispensing nurse immediately following
13 21.7 47 78.3
preparation
24- Stays with the resident until the drug has been swallowed. 19 31.7 41 68.3
25- Not to leave medicines for the resident to se lf-administer at a later time. 0 0 60 100
26- Documents any delay or omission in the nursing notes/ 46 76.7 14 23.3
27- Dispose non administered and wasted drugs or sharps in the appropriate designated
15 25 45 75
sealed container.
28- Signs their usual abbreviations on the medication administration record / prescription
36 60 24 40
sheet as soon as the medication has been administered
29-Stay with patient for several minutes, and observe for any allergic reaction 30 50 30 50
30- Cleans their hands between residents 40 66.7 20 33.3
After administration of drug
31- Monitors the tasks to the administered medication 12 20 48 80
32- Records monitoring data related to administered medication 35 58.3 25 41.7
33- Reports the abnormal findings to physician 0 0 60 100
34-Demonstrate knowledge related to administered medication with patient. 24 40 36 60
35- Make sure that information is soundly understood by patients 27 45 33 55
Table (9):Showed that two thirds (60%) of nurses didn't Communicates information sensitively to the resident prior to and
during administration of medication step no (22),(58.3%) of nurses didn't Records monitoring data related to administered
medication. On the other hand, most of nurses (98.3%) Verifies the patient's identity prior to administering medication step no (21).
As well,(78.3%&75%) three fourth of nurses Administered all medicines are personally by the dispensing nurse immediately
following preparation and Dispose non administered and wasted drugs or sharps in the appropriate designated sealed container step no
(23,27) .While all nurses(100%) Reports the abnormal findings to physician.
Discussion group (55%) works in morning shift. This may due to routine
Regarding the demographic characteristics of the and increase work load at this time.
study subjects, the current study revealed that, the most of the This result come in the line with (Sa’ed et al., 2019)
critical care nurses aged was between (20-29) years and their who conducted a cross-sectional study named ''Knowledge
mean average ± SD was (26.7 ± 1.30) years: This may be due about the administration and regulation of high alert
to the desire of university's hospital to provide high-quality medications among nurses in Palestine'' and reported that most
health care services, through employing new graduates of the of them were between the ages of 25-30 years, But the current
faculty of nursing or nursing technical institute in critical study contrasts with the same author who reported that most
units. of nurses had 5–10 years of total experience. And the majority
As regards their qualification result found that more of nurses had a bachelor degree in nursing.
than half of them (61.6%) had graduated from technical Moreover, the current study contraindicated with
institute degree in nursing. This may be explained by a little (Alhashemi, Ghorbani, & Vazin, 2019) who contemplated a
number of faculty's graduates had employed in the university case–control study entitled “Improving knowledge, attitudes,
hospital and other work in schools or ministry of health and practice of nurses in medication administration through
hospital. On the other hand, the highest percentage of them enteral feeding tubes by clinical pharmacists” and detailed that
constituted (96.7%) had from (1-3) years of experience the mean age of nurses was 32 years, and almost two third of
working at critical units.. Finally, more than half of the study them were ladies. By far most of participants in two groups
had a four-year college education in nursing. Further, But the deviation of the nurse's preparation for medication is
current study come in the line with the same author who 50.66±11.85, while in drug administration it was
reported that the mean years of experience among participants 122.19±14.65 and in nurses’ practices post drug
in a critical care unit and as a nurse was two and five years. administration, it was 44.17±14.76. In relation to the nurse's
In addition this outcome comes in concur with total practice for drug administration it scored 267.05±29.62.
(Farag, Eweda, & Elsayed, 2017) who conducted a study Besides, (Wabe, Raju, & Angamo, 2011) who
titled ''Nurses Knowledge and Practice in Dealing with High studied “Knowledge, attitude and practice of patient
Alert Medications'' and reported that short of what one third of medication counseling among drug dispensers in North West
the contemplated nurses were from (41 to less than 50) years Ethiopia” reported that post medicine practice requires
old, while; of them, one fifth were <30 years old and the improvement. This finding might be ascribed to the remaining
experience years of the most were <18 years in the relegated workload that makes the nurses practice described by low-
departments. level of performance.
Regarding Frequency distribution of critical care Concerning frequency distribution of critical care
nurse's knowledge level regarding medication nurses practices level regarding medication administration
administration errors in CCUs, the present study revealed errors, the present result showed that only more than one-
that most of nurses obtained unsatisfactory knowledge third of them had satisfactory practices in the preparation of
regarding general knowledge & MAEs respectively. This may medication, only more than one third of them had satisfactory
due to inadequate training in the area, the absence of regular practices during medication administration, the majority of
group discussion to refresh their knowledge regarding them had satisfactory level of practice after drug
medication errors , lack of motivation, increased nursing administration and only one third of them had total
workload which made the delay of nurses abilities and satisfactory performance about drug administration.
motives to acquire and update their knowledge. On the other This result come in the line with who studied (Abd
hand more (58.3%) only had got satisfactory level regarding Elmageed et al, 2020) “Knowledge, Attitude and Practice of
medication preparation errors. Nurses in Administering Medications at Mansoura University
This result comes in the line with (Mansour, 2019) Hospitals” that greater than three quarters of the nurses have
who studied “Effect of Maternity Nurses Knowledge and helpless practice score with respect to drug preparation, trailed
Practices Regarding the Medication Errors on Laboring by marginally greater than three fifths of them revealed poor
Women Safety in Labor Unit” and reported that greater than practice level regarding medication administration as well.
half of the studied sample had incomplete satisfactory Besides, marginally under two fifths of the nurses have
information. helpless practice post administering drug. Ultimately, around
But his result differs with (Samundeeswari & half of the nurses have poor total practice level.
Muthamilselvi, 2018) who studied ''Nurses Knowledge on
Prevention of Medication Error'' and reported that one third of Regarding the correlation matrix between nurses
the studied nurses are on average in the information of ME. total knowledge with practices sub items regards
Short of what one third of nurses have poor information, medication administration, the present study showed that
slightly above quarter of nurses have very low level of there were a fair positive correlation critical care nurse
knowledge and only 8% of nurses had good information on practice after medication administration with their knowledge
prevention of ME. about medication preparation errors, their practices in
Additionally, the current study contraindicated with medication preparation, and during medication administration
(Dyab, Elkalmi, Bux, & Jamshed, 2018) who studied (r= .305, P – Value < .018, r= .458, P – Value < .0001, r=
“Exploration of Nurses’ Knowledge, Attitudes, and Perceived .467, P – Value < .0001 respectively). Likewise, there was
Barriers towards Medication Error Reporting in a Tertiary reasonable positive relationship between critical care nurse
Health Care Facility: A Qualitative Approach” and reported practice during medication administration with their
that the nurses were knowledgeable about Medication Error medication preparation (r=.549, P value < .001).This may due
Reporting, however there was vulnerability towards detailing to lack of knowledge may have an effect on nurses practice.
innocuous MEs. In addition, (Kaur & Charan, 2018) who So they need for courses to update their knowledge and
conducted “a study to assess the knowledge regarding improving their practice .
medication error among staff nurses at SGRD hospital, This come in accordance with (Bakr Abo El–Ata et
Amritsar, Punja” reported that almost two third of nurses were al., 2019) who revealed that there were an exceptionally
on average knowledge followed by less than one third of them statistical significant correlation between knowledge and
having poor score level. practices in MEs (r=0.26 and p value=0.02). this outcome was
upheld by (Abd Elmageed et al, 2020) who reported that
Regarding critical care nurses mean practice there is a measurably statistically significant relation between
score for medication’s preparation, administration, and nurses’ knowledge, practice and attitude in drug
after administration .the current study revealed the overall administration.
mean practice score of critical care nurse was 23.1+4.58 out of
32. Along these lines, they picked up 13.65+2.97 out of 20 in Regarding the Correlation matrix of nurses total
preparation of drug. While they had low mean score knowledge, practices sub items the present study
3.37+0.84 out of 5 in After medication administration. This demonstrated that there were solid positive correlation
may due to lack of continuous educational programs and between total observation performance of critical care nurse
practice sessions regarding medication administration. and their performance in preparation of medication and during
This result come in accordance with (Abd Elmageed medication administration (r = .927, P – value < .0001& r =
et al, 2020) who delineated that the mean and standard .794, P – value < .0001 respectively), fair positive relationship

between critical care nurse performance during medication This outcome comes in accordance with (Bucknall et
administration with their preparation of medication and total al., 2019) who studied “Nurses’ decision‐making, practices
observation performance of critical care nurse with their and perceptions of patient involvement in medication
performance after medication administration (r = .549, P – administration in an acute hospital setting” and stated that
value < .0001& r = .646, P – value < .0001 respectively), and most of the contemplated sample do checking for patient
moderate positive correlation between critical care nurse identification, the medication name, checking the dose, the
performance after drug administration with their drug route, and the time as well as patient education about
preparation and during drug administration (r = .458, P – medications, dose calculation, observing the patient while
value < .0001& r = .467, P – value < .0001 respectively). consuming the medications, checking medicine for another
This outcome comes as per (Márquez-Hernández et nurse in name, dose and route.
al., 2019) who studied “Factors related to medication errors in Yet, this finding contraindicated with (Abukhader &
the preparation and administration of intravenous medication Abukhader, 2020) who studied “Effect of Medication Safety
in the hospital environment” and revealed that there were Education Program on Intensive Care Nurses’ Knowledge
measurably huge contrasts found between nurses knowledge regarding Medication Errors” and detailed that the greater part
and performance. of the contemplated test had agreeable information in regards
This result were confirmed by (Bakr Abo El–Ata et to following the international patient safety goals and
al., 2019) who revealed that there was a profoundly positive guidelines of intravenous drug administration.
correlation between practice and knowledge of nurses and
there was an indicative positive correlation between their Regarding critical care nurses MCQ responses
attitude , knowledge and practice. Additionally (Hassan & regards medication administration errors, the present study
Ahmed, 2012) detailed a similar result. showed that most of nurses had got false answer related to the
Likewise (Shahin, Mohamed, & Sayed, 2012) who time of documentation and the minimum amount of time a
studied “'Nurses' knowledge and practices regarding Enteral client must be observed after taking intravenous drug. On the
Nutrition at the critical care”' reported that a profoundly other hand, three fourth of nurses had given true answers
positive correlation between practice and knowledge of related to recommended route for heparin injections and
nurses. A similar result was outlined by (Abd Elmageed et al, position the client for suppository medication.
2020) This come in accordance with (Bakr Abo El–Ata,
Hassan Ibrahim, Saad Mohamed, & Elsayed Ahmed
With respect to Critical care nurses MCQ Allawy, 2019) who studied “Nurses’ Performance Regarding
responses regards general knowledge of medications Administration of Inotropic Medications for Critically Ill
administration and preparation errors, the current study Patients” and revealed that the most of nurses had an
showed that more than one third of nurses know the definition unacceptable degree of knowledge and the majority of studied
of MAEs, slightly less than three quarters of them identified nurses had unsuitable complete practice with almost the
the hazards of MEs and how to prevent them, less than half of majority of studied nurses had had an uplifting attitude toward
them mentioned nursing roles in the MAEs, and only one administering inotropic drugs.
tenth of them answered correctly patient's rights before Likewise, this result come in the line with (Lan et
medication administration. This result agrees with (Shaikh & al., 2014) who studied “Medication errors in pediatric nursing:
Al-Ruzaiqi, 2019) who conducted a study named “knowledge Assessment of nurses' knowledge and analysis of the
and perception of preventable medical errors in sultanate of consequences of errors” and detailed that almost two third of
Oman” and revealed that the most of participants had heard the studied sample had unacceptable level of knowledge
about the MEs and the majority of them were eager to know regarding drug administration.
the MEs. The current result were confirmed by (Zarea,
Furthermore this outcome was upheld by (Teal, Mohammadi, Beiranvand, Hassani, & Baraz, 2018) who
2019) who studied “Associate and baccalaureate degree studied “Iranian nurses’ medication errors: A survey of the
nursing students' knowledge of and attitudes toward types, the causes, and the related factors” and reported that
medication errors and reporting medication errors: greater than half of the studied nurses giving medicine to
implications for curriculum development” and revealed that at patients later or earlier, greater than one third of them give
nursing students, they failed to define MEs, or to know its multiple oral drugs together regardless of their interactions
types, and causes. This study additionally found that students and greater than one third of them administering the
do not know how to report a ME. postoperative pain relieving drugs without a prescription.
But These results come inconsistent with (Di Muzio,
De Vito, Tartaglini, & Villari, 2017) who studied Regarding critical care nurses’ done/not practices
“Knowledge, behaviors, training and attitudes of nurses during done during preparation of medication, the current study
preparation and administration of intravenous medications in revealed that almost two thirds and three fourth of critical care
intensive care units (ICU). A multicenter Italian study” and nurses showed that they didn’t check instructions regarding
detailed that the most of the studied nurses were aware of administration of drugs and crushed medicines, the nurse
MEs. establishes that these have been sanctioned by a medical
practitioner or pharmacist. A clean pestle and mortar is used
Regarding medication preparation errors the and it is cleaned after each resident with warm water and
current study showed that less than two third of study group detergent and wiped with a dry hand towel.. This might be
had false answer regarding they checked right patient in identified with the absence of strategies and roles that
medication preparation errors while two third of them had true controlling drug administration.
answer regarding they checked right medication, medication outcome comes conflicting with (Mahesh, Hajira
name and prescription of medication. Saba, & Gopi, 2016) who studied “Nursing perceptions of

medication administration practices, reasons for errors and stated that over half the participants claimed to administer
reporting of errors in a tertiary care hospital, Bangalore” and medication to patients in accordance with the provided
reported that the majority of nurses consistently checked the guidelines. Also this result come in accordance with
composition of the medication before administration. This (Bucknall et al., 2019) who revealed that the majority of the
outcome is affirmed by (Westbrook, Rob, Woods, & Parry, considered nurse checking patient identification prior to
2011) who detailed that most of the contemplated nurses giving drugs.
didn’t aware of drug protocol. The present study showed that greater than half of
Likewise, the current study showed that the greater critical care nurses didn't records monitoring data related to
part of nurses checked the prescribed route and forms of each administered medication. On the other hand, all nurses
medication, checked that there is a valid, clear prescription for reported the abnormal findings to physician. These findings
each drug, reads the medication prescription without may be related to the work overload or the lack of policy that
difficulties, checked the prescribed dosage, checked the guide medication administration.
prescribed time and administered dose accurately. This finding additionally is in concurred with
This outcome comes as per (Mahesh et al., 2016) (Westbrook et al., 2011) whom found that the studied nurses
who detailed that most of the studied sample consistently neglect to follow medication rules and record drug. This result
checked the expiry date prior to administering the drug and come inconsistent with (Kirubakaran & Amirtham, 2017)
consistently practice sterile technique for administering who studied “Knowledge and practice of intensive care unit
intramuscular and intravenous medications. nurses on intravenous drug administration” and reported the
Likewise, this outcome was affirmed by (Karttunen, majority of the contemplated nurses were whined to nursing
Sneck, Jokelainen, & Elo, 2020) who studied “Nurses’ self‐ practice of the medication administration protocol.
assessments of adherence to guidelines on safe medication
preparation and administration in long‐term elderly care” and Conclusion
revealed that nost members guaranteed to consistently get The majority of the study participant had un
ready medicine as indicated by the relevant guidelines. satisfactory level of knowledge and practice.So these results
(Gilani, 2020) Who studied “Practices of Nurses in showed that there is a wide gap between nurse's knowledge
Administration of Safe Medication” detailed a similar and their practice regarding medication administration errors.
outcome.
This outcome comes as per (Bucknall et al., 2019) Recommendations
who studied “Nurses’ decision‐making, practices and Based on the findings of the present study and the
perceptions of patient involvement in medication researcher was suggested that;
administration in an acute hospital setting” and showed that  Implementation and dissemination of comprehensive,
most of the contemplated nurses checking patient systematic, and continuous educational programs in
identification, the drug name, the dosage, the route and the order to enhance the knowledge and practices of
scheduled time prior to giving drug. nurse’s on medication administration practices which
will decrease the medication administration errors
Regarding critical care nurses’ done/not done and using interactive teaching methods and
practices during administration of drug, the current study technology in order to increase the efficiency of in-
showed that two thirds e nurses didn't communicate service trainings.
information sensitively to the resident before and during  Drug-related information are required in order to
administration of medicine. This outcome come conflicting prevent the errors that may arise during practice to
with (Bucknall et al., 2019) who expressed that the greater ensure quality. Designing safe work environment
part of the contemplated nurses gives patient with required conducive for patient care delivery and reduce the
education about medicine. occurrence of medication administration errors.
On the other hand most of nurses confirmed the  The implications of this research study have
patient's identity before administering medication, three fourth relevance to future nursing research as well as other
of nurses administered all drugs are personally, and they related disciplines in the following ways.
disposed non administered and squandered drugs or sharps.
this outcome comes as per (Karttunen et al., 2020) who
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Application of Modified Ventilator Bundle and Its Effect on Weaning Among Mechanically
Ventilated Patients
Amany Sayed Eweas1, Sahar Yassien Mohammad 2, Jehan Sayyed Ali Sayyed 3, Marwa Mohammad Abd Elbaky 4
and Magda Mohammad Bayoumi 5
(1) Clinical Instructor in Faculty of Nursing, Bani Suief University, Egypt.

(2) Prof. in Medical Surgical Nursing, Faculty of Nursing, Ain Shams University, Egypt.
(3) Prof. in Medical Surgical Nursing, Faculty of Nursing, Minia University, Egypt.
(4) Lecturer in Medical Surgical Nursing, (Critical Care Nursing), Faculty of Nursing, Minia University, Egypt.
(5) Lecturer in Medical Surgical Nursing, Faculty of Nursing, Bani Suief University, Egypt.
ABSTRACT
Background: Modified ventilator bundle is a cluster of key interventions deriving from evidence-based clinical
practice guidelines that when implemented together are expected to improve patient outcomes and reduced the risk of
ventilator associated pneumonia and other related complications common in ventilated patients. Aim: The current
study aimed to apply a modified ventilator bundle and evaluate its effect on weaning among mechanically ventilated
patients. Design: A quasi- experimental research design was utilized. Setting: This study was conducted at the
following critical care units (surgical, medical and cardiac care unites) affiliated to Bani Suief University Hospital in
Bani Suief city, Egypt. Subjects: A Purposive sample of 100 mechanically ventilated patients divided into two
groups, the study group included patients who received the modified ventilator bundle while the control group
included patients who received the routine hospital nursing care. Data collection tools: Two tools were used; First
tool patient assessment sheet include two parts, part one: patient demographic and medical characteristic part two:
physical assessment record. Second tool: Weaning process assessment checklists by used burns wean assessment
program score. Results: The study group of patients obtained higher weaning scores than the control group. As well
the study group demonstrated shorter duration of the connection to mechanical ventilation compared to control group.
Conclusion: Implementation of modified bundle plays a pivotal role on higher weaning score and reduction of
ventilation days. Recommendations: Designing in-service training educational program for critical care nurses to
improve nurses' knowledge and practice regarding a modified ventilator bundle. Furthermore, replication of the study
on a larger probability sample from different geographical locations in order to generalize the results.
Key words: Mechanical Ventilation, Modified Ventilator Bundle, Weaning
Introduction Weaning covers the entire process of liberating the

Mechanical ventilation (MV) has become the most patient from mechanically ventilation support and from
commonly used modes of life support among critical ill endotracheal tube to independent breathing. This process
patients in medicine today. Although MV is a life saving consists of " 3" key steps: first step, when the patient’s clinical
intervention, is capable of producing many of the conditions permit it, ventilation supports are progressively
complications, some of which may be a life threatening as decreased (Ready weaning); second step, a spontaneous
ventilator associated pneumonia (VAP).VAP is a lower breathing trial (SBT) assesses the patient’s capability to
respiratory tract infection that develops in intubated patients breathe autonomously (Ready breathing); and third step, the
for greater than 48 hours .VAP is the most common infection patient is liberated from ventilation support (Ready
in ventilated patients and the second most common hospital extubation) The clinical goals of weaning are twofold: first, to
associated infection that associated with higher mortality rates promptly identify those patients who are ready to begin the
between 20% and 70% and increase hospital lengths of stay process of weaning, and second, to optimize the weaning
from 4-13 days (Ahmed, Sobeih and Abdelsalam, 2019). regime to reduce the transition time from dependence to
Modified ventilator bundle is a series of independence from MV (Vetrugno, et al., 2020).
interventions developed by the institute for healthcare In order to ensure optimal care for mechanically
improvement related to ventilator care that, when ventilated patients, the critical care nurses have a major role in
implemented together, will achieve significantly better prevention of hospital acquired infections overall and VAP in
outcomes than when implemented individually. Performance particular. they can contribute a lot in the prevention of VAP
of this bundle associated with reduced the incidence of VAP, through reducing risk factors, implementing relevant
decrease risk of reintubation or intensive care readmissions, preventive measures, identifying early signs for early and
improvement of weaning strategies and optimizes patient prompt management, Beyond these, ICUs nurses shoude be
recovery, to achieve this goal ventilator bundle includes head monitoring of respiratory function, regular monitoring of vital
of bed elevation 30-45%, peptic ulcer prophylaxis, DVT signs for patients to immediate detections of any
prophylaxis, endotracheal suctioning care, infection control complications, adequate nutritional support, maintenance of
measures, assess for readiness to stop sedation and to start application the “modified ventilator care bundle” and
spontaneous breathing trials, oral care with the chlorhexidine adherence to" weaning protocols (Alsharari. et al., 2020).
and early mobilization (Mart, Brummel and Ely 2019).
P a g e | 121 Amany S., et al

Significance of the Study investigate the effect of the modified ventilator bundle on
Mechanical ventilation is a life saving intervention; weaning.
but it poses significant clinical and economic challenges due
to the risk of complications. Approximately 30% of patients Setting:
treated with MV experience difficult or prolonged weaning The current study was conducted at the following
process (Kasem, .et al., 2019). Patients who experience critical care units (surgical, medical and cardiac care unites)
difficulty in weaning need a longer hospital stay and have affiliated to Bani Suief University hospital in Bani Suief city,
higher morbidity and mortality rate. Consequently, trials to Egypt.
decrease the duration of weaning are desirable to reduce
length of MV connection and its related complications. Subjects
Standardized weaning practices are safe and effective in A Purposive sample of 100 mechanically ventilated
reducing the time spent on MV. However, the evidence patients were assigned in the current study started from
supporting their use in practice is inconsistent. The discordant initiation of MV connection till extubate, the patients were
results of studies may reflect the fact that weaning protocols matched for their age and medical characteristics and were
differ in composition and are implemented in different divided randomly into two equal groups .The first study group
environments by various health care providers. (n=50) the patients received the modified ventilator bundle
Few research studies were conducted nationally on practices completely. The second control group (n= 50) the
the ventilator bundle practices and its effect on weaning from patients received the routine hospital nursing care during MV
MV and their findings illustrated that, implementation of period. Both groups of the current study were selected
modified ventilator bundle practices may enhanced the according to the following inclusion and exclusion criteria:-
weaning process, reduce the incidence of such complications,
improve the quality of patient care, improve the prognosis of Inclusion Criteria:-
patients condition and this in turn would decrease the average  The study included patients from both gender and
length of ICU stay, decrease long term physical, cognitive, their age (between 20-65).
and psychological harm to patients and their family; improve  Patients with glasgow coma scale more than or equal
hospital reimbursement and decrease health care costs. (9 score)
Eventually, this research might generate an attention and  Patients on invasive mechanical ventilation.
motivation for further studies in this area.  No scheduled surgery in the following 72 hours.
Aim of the Study: Exclusion Criteria Patients were excluded if:

The aim of this study is to apply a modified ventilator  Patients who have a brain stem infarction
bundle and evaluate its effect on weaning among  Patients with neuromuscular diseases
mechanically ventilated patients.
 Patients with multiple organ dysfunction syndrome
 Patients with major cardiac- thoracic or abdominal
Research Hypothesis:
surgery
To fulfill the aim of this study, the following research
 Patient admitted with a chest infection or any other
hypothesis was formulated:-
systemic infection
The study group of patients for whom all elements of
the modified ventilator bundle were applied completely would  Patients with acute physiology and chronic health
get higher weaning scores and shorter duration of the evaluation (APACHE) score over 35.
connection to mechanical ventilation compared to the control
group of patients who received the routine hospital nursing Sample size: The sample was calculated by using the
care. following equation according to Epi info, version 3.5. Based
on confidence level of 95%, power 85%, and 20% recurrence
Operational Definition rate (Krishnappa, et al. 2018)
Modified ventilator bundle are a grouping of best t2 x p (1-p)
N =
practices supported by research to decrease the rates of VAP m2
and other complications common in ventilated patients. The Description:
core elements of bundle are included: head of bed elevation  N = required sample size
30º-45º, early mobilization, oral care with chlorhexidine,  t = confidence level at 95 % (standard value of 1.960)
endotracheal suctioning care, daily sedation interruption and  p = total no of mechanically ventilated patient's
daily assessment of readiness to extubate, deep venous admitted in the previous mentioned ICUs
thrombosis prophylaxis peptic ulcer prophylaxis, ventilator  m= margin of error at 5 % (standard value of 0.050).
circuit care and infection control measures.
Tools for Data Collection
Research Design: To collect data pertinent in the current study, two
A quasi-experimental research design was utilized in tools were utilized:-
the current study. Quasi-experiment is an empirical study used
to estimate the causal impact of an intervention on its target Tool 1: Patient Assessment sheet:
population without random assignment. This design according This tool was developed by the researcher after
to Usadọlọ (2016) can be used to examine the relationship revising extensive literature review. It covers two main parts:-
between an independent (cause) and dependent (effect)
variables. Therefore, the design is most appropriate to

1st part: - Patient's Demographic and Medical from the study at any time without any rationale. Informed
Characteristic oral consent was obtained from the patients relative, informed
It consists of (10) items used once for both groups them that obtained data will not be included at any further
which include the patient’s age, gender, marital status, place researches without a second consent. Confidentiality and
of residence, occupation, educational level, smoking habits' , anonymity of each subject were ensured through coding of all
date of ICU admission, medical diagnosis and reason of ICU data and protecting the obtained data.
admission .
Study Procedure
2nd part: - Physical Assessment Record:- Preparatory phase
It consists of (20) items used once for both study and The current study was conducted by preparing of
control groups, which includes patient physical assessment of different data collection tools, in addition, obtaining formal
body systems that include respiratory, cardiovascular and paper agreement which was taken induration about two month
neurological system by used Glasgow coma scale. duration before conducting the study and ended by carrying
out the pilot study.
Tool II: Weaning Process Assessment Checklist:
Using Burns Wean Assessment Program score Implementation phase
(BWAP) for both studied groups once every day after 72 Once the official permission is granted to proceed
hours of MV initiation till extubation .This tool adopted from with the proposed study, the researcher initiated data
Burns, et al. (1990) and it is used to systematically assess and collection by visiting the assigned settings on a daily basis
track weaning progresses of the MV patients. BWAP score, during the day shifts. The enrolled patients and their relatives
which including (26 items) covering two major areas of the were informed individually about the purpose and nature of
assessment of weaning, the first part is a general assessment, the study. Then, the researcher was obtained oral consent from
including (12 items) and the second part is respiratory those who accepted to participate in the study. Next, those
assessment which contains (14 items). patients were divided randomly into two equal groups; the
Scoring System BWAP score requires assignment researcher has started a collection of data from control group
one of 2 responses (yes or no) "Yes "response indicates that firstly by obtained patient's demographic and medical
the items is present scored "1" while "No" response indicates characteristic from patient file and their patient relatives and
that the items is not present scored "ZERO". BWAP score is performed baseline physical assessment of the body systems
calculated by dividing the total number of yes responses by 26 (Tool 1) for enrolled patients on first day. The implementation
(the total number of BWAP factors). A cutoff point for the time for this tool was (1-2 hours).
instrument is 50%. If the score was more than or equal 50%, The control group patients were received routine
this means that the patients were more likely to be weaned hospital nursing care during the MV connection by critical
successfully. And if the score was less than 50%, this care nurses that includes elevating the backrest of bed between
indicates that the patients were more likely to have 30º-45º, daily sedation interruption and daily assessment of
unsuccessful weaning. readiness to extubate ,deep venous thrombosis prophylaxis
and peptic ulcer prophylaxis. In addition used closed
Tools Validity and Reliability suctioning system, patient hygiene, enteral nutrition, drug
The tools content validity was done to identify the administration and patient monitoring.
degree to which the used tools measure what was supposed to While data collection from study group was started
be measured. Developed tool was examined by a panel of five after finishing from the control group, the researcher obtained
experts' opinion in the field of patient's demographic and medical characteristic from patient
critical care medicine and critical care nursing specialty. Tools file and their patient relatives and performed baseline physical
reliability wares done to identify the extent of tools items were assessment of the body systems (Tool 1) for enrolled patients
measured with the study concept and its correlation with each on the first day. The implementation time for this tool was (1 -
other. Cronbach’s alpha reliability it was (0.81) for the first 2 hours).The study group patients were received modified
tool, (0.79) for the second tool. ventilator bundle by the researcher with the cooperation of the
medical and nursing staff.
Pilot Study Modified ventilator bundle are includes: head of
A pilot study was carried out on 10% (10 patients) of bed elevation 30º-45º unless there is contraindicated, routine
the total sample of mechanically ventilated patients in the oral care applied three times per day (once every 8 hrs), early
previously mentioned ICUs to test the feasibility of the mobilization typically within 24–48 hours of ICU admission,
research process, objectivity, and applicability of the study endotracheal suctioning care using open suctioning system
tools. Based on the results of the pilot study, no modifications technique, daily sedation interruption and daily assessment of
were done for data collection tools so; the patients who shared readiness to extubate to assessed patients for neurological
in the pilot study were included in the actual study sample. recovery and readiness for extubation or resedated if required ,
deep venous thrombosis prophylaxis and used anti-embolic
Ethical Considerations stockings, peptic ulcer prophylaxis, ventilator circuit care and
An official permission to conduct the study was maintaining of infection control measures to prevent
obtained from the ethical committee of research, dean of the nosocomial infections, in addition patient hygiene, enteral
faculty of nursing at Minia University, directors of the Bani nutrition, drug administration and patient monitoring.
Suief University Hospital, academic for research center and Evaluation phase
technology. Patients in this study were entirely voluntary who After 72 hours at the fourth day of MV initiation, and
was explained about the aim, purpose, procedure and nature of the control group were received routine hospital nursing care
the study and had the right to refuse of participate or withdraw by critical care nurses, and the study group were received the

modified ventilator bundle by the researcher, the patients were science (SPSS), version (22) was used for statistical analysis
started to be assessed for readiness to wean from the of the data, as it contains the test of significance given in
mechanical ventilator on a daily basis using weaning process standard statistical books. Numerical data were expressed as
assessment checklist (BWAP score) (Tool II) once every day mean and SD. Qualitative data were expressed as frequency
till the patient extubated. The implementation time for this and percentage (%). Chi-square, Fisher's and Pearson tests
tool was (30-45 minutes). were used to compare frequencies and correlation between the
study variables. Probability (P-value) is the degree of
Statistical Analysis of Data significance of the results was considered: (p- value > 0.05)
Data were summarized, tabulated, and presented was considered not significant (NS), (P-value ≤ 0.05) was
using descriptive statistics in the form of frequency considered significant (S) and the (p-value ≤ 0.01) was
distribution, percentages, means and standard deviations (SD) considered highly significant (HS).
as a measure of dispersion. A statistical package for the social
Results
Table (1): Comparison between study and control groups according to their demographic characteristic (n= 100).
Study group (n= 50) Control group (n= 50) X2 P–
Demographic data No. % No. % value
Age / years
20 - 39 11 22.0 6 12.0
40 - 59 30 60.0 34 68.0 2.937 .568
≥ 60 9 18.0 10 20.0 NS
Mean ± SD 48.1 ± 11.3 51.1 ± 9.8
Gender
Male 32 64.0 35 70.0 .407 .523
Female 18 36.0 15 30.0 NS
Marital status
Single 3 6.0 1 2.0 .475
Married 39 78.0 45 90.0 1.245 NS
Widow 8 16.0 4 8.0
Residence
Urban 19 38.0 14 28.0 1.131 .288
Rural 31 62.0 36 72.0 NS
Occupation
Employee 11 22.0 9 18.0
Worker/ farmer 19 38.0 23 46.0 .756 .860
Housewife 16 32.0 15 30.0 NS
Retired 4 8.0 3 6.0
Educational level
Cannot read and write 24 48.0 21 42.0
Basic 2 4.0 6 12.0 2.866 .581
Secondary 16 32.0 13 26.0 NS
Bachelor 8 16.0 10 20.0
NS = not significance
Table (1): shows that, (60.0%) of the study group compared with (68.0%) of the control group their mean age ranged
between (48.1 ± 11.3) and (51.1 ± 9.8) years respectively. As regards gender, (64.0%) of the study group compared with (70.0%) of
the control group were males. According to marital status, (78.0%) of the study group compared with (90.0%) of the control group
were married. Regarding residence, (62.0%) of the study group compared with (72.0%) of the control group lived in rural area,
Related to their educational level, (48.0%) of the study group compared with (42.0%) of control group cannot read and write therefore
the most of them were occupied as worker /farmer (38%, 46%). Lastly, there were no statistically significance differences between
study and control groups according to their demographic characteristic.
Table (2): Comparison between study and control groups according to their smoking habits and reason of ICU admission (n=
100).
Items Study group Control group (n=50) X2 P–
(n= 50) value
No. % No. %
Smoking habits
Smoker 20 40.0 28 56.0 2.564 .109
Not smoker 30 60.0 22 44.0 NS
Reason of ICU admission
Severe cardiac complain 12 24.0 5 10.0
Extremely respiratory complain 5 10.0 7 14.0
Severe cerebrovascular complain 5 10.0 6 12.0 5.033 .656
Hemodynamic instability 10 20.0 7 14.0 NS
Traumatic injury 4 8.0 6 12.0
Inhaled toxic substance 4 8.0 5 10.0
Cardiac arrest 6 12.0 8 16.0
Surgical emergencies 4 8.0 6 12.0
NS = not significance

Table (2): illustrates that, (60.0%) of the study group compared with (44.0%) of the control group don't smoke. Regarding to
reason of ICU admission, (24.0%) of study group compared with (10.0%) of the control group were admitted with severe cardiac
complain. Lastly, there were no statistically significance differences between both studied groups according to their smoking habits
and reason of ICU admission.
76
62
80
24
60 38
40
20
0
Semi coma (9 – 12) Oriented (13 – 15)
Figure (1): Percentage distribution of study and control groups according to their baseline physical assessment of neurological
system according grades of GCS (n= 100).
Figure (1): illustrates that, (62.0 %) of the study group compared with (76.0%) of the control group had a semi coma
between (9- 12), while (38.0%) of the study group compared with (24.0%) of the control group had oriented between (13-15).
Figure (2): Percentage distribution of the study and control groups according to their initial mode of the mechanical ventilator
(n= 100).
Figure (2): illustrates that (70%) of the study group compared to (76%) of the control group on synchronized intermittent
mandatory ventilation mode.
Table (3): Comparison between study and control groups according to their duration of mechanical ventilation / days after
modified bundle implementation (n= 100).
Items Study group Control group (n= X2 P – value
(n= 50) 50)
No. % No. %
Duration of mechanical ventilation / days
4- 6 days 34 68.0 20 40.0 7.890 .005**
7- 9 days 16 32.0 30 60.0
Mean ± SD 6.1 ± 1.6 7.3 ± 1.9
**P – value ≤ 0.01

Table (3) illustrates that, (68.0%) of the study group, compared with only (40.0%) of the control group had a shorter
duration of mechanical ventilation support between (4- 6) days with mean ± SD (6.1 ± 1.6) and (7.3 ± 1.9) respectively after modified
bundle implementation with statistical significance differences (P – value .005).
Table (4): Comparison between study and control groups according to their burns wean after modified bundle
implementation at 1st to 6th observation (n= 100).
Total levels Study Control X2 P–
(n= 50) (n= 50) value
No. % No. %
1st observation (4 day)
Unsuccessfully weaned 21 42.0 37 74.0 10.509 .001**
Successfully weaned 29 58.0 13 26.0
2nd observation (5 day)
Unsuccessfully weaned 15 34.1 31 60.0 9.232 .002**
3rd
observation (6 day)
Unsuccessfully weaned 8 30.8 17 44.7 1.265 .05*
4th observation (7 day)
Unsuccessfully weaned 1 6.3 11 36.7 5.007 .025*
Unsuccessfully weaned 0 .0 4 17.4 1.979 .159 NS
Unsuccessfully weaned 0 .0 1 5.0 .363 .547 NS
NS = not significance *P – value ≤ 0.05 **P – value ≤ 0.01
Table (4): shows that, (58.0%) of the study group while (26.0%) of the control group had successful weaning score at 4t h day
, (65.9%) of the study group while only (34.0%) of the control group had successful weaning score at 5t h day , (69.2%) of the study
group but (55.3%) of the control group had successful weaning score at 6 th day , (93.8%) of the study group compared with only
(63.3%) of the control group had successful weaning score at 7 th day, (100%) of the study group while (82.6%) of the control group
had successful weaning score at 8th day and (100%) of the study group while (95%) of the control group had successful weaning score
at 9th day. there were statistically significance differences between the study and control groups in the 1 st, 2nd , 3rd and 4th observation
(P – value ≤ .001, 002, 05 and .025) respectively.
Mean scores
Figure (3): Means score of burns' wean assessment of the study and control group through six observations (n = 100)
Figure (3): presents that, there were increase mean scores of burns' wean assessment in the study group than the control
group; finding may have relevance to the effect after modified bundle implementation for the study group compared to routine
hospital care .

Table (5): Relation between study and control groups according to their weaned successfully and their smoking habits, and
duration of MV at 1st, 2nd, 3rd observation
1st observation 2nd observation 3rd observation

ITEMS Study Control Study Control Study Control
(n= 29) (n=13) (n= 29) (n=16) (n= 18) (n=21)
No. % No. % No. % No. % No. % No. %
Smoking habits
Smoker 9 31.0 3 23.1 11 37.9 13 81.3 7 38.9 12 57.1
Not smoker 20 69.0 10 76.9 18 62.1 3 18.7 11 61.1 9 42.9
X2 (P – value) 10.951 (.001**) 11.978 (.001**) 3.386 (.05*)
Duration of mechanical ventilation
4- 6 days 28 96.6 12 92.3 27 93.1 15 93.7 10 55.6 8 38.1
7- 9 days 1 3.4 1 7.7 2 6.9 1 6.3 8 44.4 13 61.9
X2 (P – value) 49.575 (.05*) 68.580 (.0001**) 16.054 (.0001**)
*P – value ≤ 0.05 **P – value ≤ 0.01
Table (5): shows that, there were statistically significance difference between both study and control groups in the 1 st, 2nd
rd
and 3 observation of successfully weaning regarding to their smoking habits and duration of mechanical ventilator connection and
successful weaning (P – value ≤ .001, .05 .001, .0001, 05 and .0001) respectively
Discussion exposure to occupational hazards, stresses and frequent use of

Institute for Healthcare Improvement developed the cigarettes and hookahs.
concept of "ventilator care bundles" to help health care The study finding was consistent with Ghiani. et al.,
providers more reliably deliver the best possible care for (2020), they studied "Variables predicting weaning outcome
patients undergoing particular treatments with inherent risks. in prolonged mechanically ventilated tracheotomized patients"
The modified ventilator bundle is considered as a "package" the study showed that, male represent more than two-thirds in
of evidence-based guidelines, designed to reduce in VAP cases with both weaning success and weaning failure groups.
rates, improvement of weaning strategies and promote In contrary with the current study finding the study done by
adherence to evidence-based protocols and guidelines in order Alkotami, .et al., (2019); who studied "Prognostic factors of
to improve clinical outcomes (Alsoda. et al., 2020). patients were requiring ventilatory support in the neuro-
intensive care unit" the study found that, more than half of the
Therefore, the current study was conducted aimed studied patients were females.
to apply a modified ventilator bundle and evaluate its Regarding to smoking habits, the current study
effect on weaning among mechanically ventilated patients. illustrated that, nearly half of the study and control groups
Regarding demographic characteristics of the studied were smoker with no statistically differences between both
samples, the current study showed that, nearly two third of the studied groups. Finding of the current study explain by the
study and control groups their mean age ± SD between (48.1 ± researcher points of view that; smoking increases the risk for
11.3) and (51.1 ± 9.8) years respectively. Finding of the developing more serious health problems as lung
current study explain by the researcher points of view that, failure/cancer, heart disease and stroke and may increase the
most people above forty year, they are more risk to expose of risk of developing pneumonitis, also smoking causes oxidant
many health problems such as cardiac / respiratory/ kidney/ stress, inflammation, and protease-anti-protease imbalance of
hepatic and neurological disease due to ageing process and the lung tissue Therefore, they need to use a ventilation
physiological changes. support for life saving intervention.
This finding is consistent with Kasem, .et al., (2019), This result was conformity with the study conducted
they studied about the "Recent predictive parameters for by Fortaleza, et al. (2020), who studied the "Sustained
successful weaning from mechanical ventilation in critically reduction of healthcare-associated infections after the
ill patients" the study showed that, there was no statistically introduction of a bundle for prevention of ventilator-
significance difference between the study and control groups associated pneumonia in medical-surgical intensive care units"
according to their age, mean age ± SD between (47.86 ± who said that smoking are one of most risk factors associated
15.94) and (47.41 ± 15 64) years respectively. In contrasting with developed of VAP among mechanical ventilated patient.
with the current study finding the study done by Faramarzi, Also study finding opposite with Liu, .et al. (2020), who
(2020), who evaluate the "Effect of gastric residual volume studied "Evaluation of the effects of applying the ventricular
monitoring on incidence of ventilator-associated pneumonia in care bundle (VCB) method for reducing ventilator-associated
mechanically ventilated patients admitted to intensive care pneumonia (VAP) in the intensive care unit of general
unit" the study found that, the majority of the studied patients Chinese hospital" illustrated that, there highly statistically
more than 60 years old with mean age ± SD between (59.72± differences between the intervention and control groups
19.01) years. related to smoking habits.
As regards gender, the current study found that, more On comparing the study and control groups by their
than two-thirds of the study and control groups were males. reason of ICU admission, nearly half of study and control
Finding of the current study explain by the researcher points groups the main reason were cardiorespiratory disease
of view that; males have greater risk than females due to high .Finding of the current study explain by the researcher points
levels of calcification in their arteries in addition highly of view that; respiratory and cardiac problems are the leading
causes for compromising normal ventilation process,
pulmonary circulation, and lunge compliance of the human Regarding the comparison between the study and
body and hence they are the most common diagnosis among control groups by their duration of mechanical ventilator in
the mechanical ventilated patients. days, the current study finding illustrated that, more than two
This result was conformity with the study conducted third of the study group, while only less than half of the
by Karagozoğlu, et al., (2018), who studied "The Effect of control group were staying on MV for shorter duration (4- 6
bundle adaptation control on VAP speed and length of days), and nearly one third of the study group compared with
hospital stay in avoiding the ventilator associated pneumonia more than half of control group were staying on ventilation
(VAP) at anesthesia intensive care unit" they found, the most support for longer duration (7- 9) days with statistical
of the controlled and uncontrolled groups the main reason of significant difference between both studied groups (P – value
ICU admission were internal medical diseases. One the other .005), mean length of stay ± SD between (6.1 ± 1.6) and (7.3 ±
hand the present study finding was disagreement with Lee, et 1.9) respectively. Finding of the current study explain by the
al., (2016), who studied "The importance of tracheostomy to researcher points of view: implementation of modified
the weaning success in patients with conscious disturbance in ventilator bundle practices may reduce the incidence of such
the respiratory care center" they showed that, less than half of complication, improve the quality of patient care, improve the
the first and second groups the most reasons for patient's prognosis of patient condition and this in turn would decrease
admission were neurological disease. the average length of ventilation support and hospital length of
On comparing the study and control groups by their stays.
baseline neurological assessment according grades of GCS, The current study agreement by Alsoda, et al.,
the current study illustrated that, two thirds of the study group (2020), they studied "Implementation of ventilator bundle for
compared with almost three quarters of the control group were prevention of ventilator-associated pneumonia in intensive
semi coma and more than one thirds of the study group while care unit" they found, significant reduction the length of MV
only quarters of the control group had oriented with statistical after implementation of ventilator bundle the whole mean
significant difference with (P - value .027). Finding of the ventilation duration was (10 ± 89 days) for both groups. Also
current study explain by the researcher points of view that; current study consistent with Wolfensberger, et al., (2020),
patients had higher GCS scores indicating that patients who they studied "Implementation and evaluation of a care bundle
had a stable condition were more likely to achieve favorable for prevention of non-ventilator associated hospital-acquired
weaning outcomes and short duration of MV connection than pneumonia - a mixed-methods study protocol for a hybrid type
those who did not. 2 effectiveness implementation trial" they found that, most of
The current study consistent with Cinotti, et al., the test group has got a shorter length of MV connection after
(2018), they studied "Management and weaning from application of VAP bundle with statistical significant
mechanical ventilation in neurologic patients" they found that, difference.
the majority of patients which predictors of successful In relation to weaning scores the current study
extubated had semi coma GCS >10. The current study finding showed that, the study group that utilized the full
finding was contrasting with the study conducted by Okabe, individual components of modified ventilator bundle obtained
(2018), who studied "Risk factors for prolonged mechanical higher weaning scores compared with the control group who
ventilation in patients with multiple injuries and blunt chest did not utilize all individual elements together with the
trauma " who showed, nearly one third of both SMV and statistical significant difference was detected between both
PMV groups were higher rate of severe GCS (≤ 8) with groups in the 1st, 2nd, 3rd and 4th observation (P–value ≤ .001,
significantly difference (P- value 0.047). 002, 05 and .025).
According to their baseline physical assessment of The current study finding was supported by Jeong &
respiratory system, as regards initial ventilated mode, the Lee, (2018), they studied "Clinical application of modified
result showed that, the majority of both study and control burns wean assessment program scores at first spontaneous
groups were connected with SIMV mode. Finding of the breathing trial in weaning patients from mechanical
current study explain by the researcher points of view that; ventilation" they found, study group were significantly higher
because SIMV mod the patients are partial dependent on MV, rate of successful weaning scores compared with the control
the ventilator breath are synchronized with patient inspiratory group after applying of VAP bundles. On the same line, the
effort and has been described as the most effective and current study was agreement with Lavallée, et al. (2019),
efficient mode of ventilation especially in the ICU .This will studied "The effects of care bundles on patient outcomes: a
encourage use of patients’ respiratory muscles, facilitate systematic review and Meta -analysis" they found, application
spontaneous breathing trials and this in turn would and of ventilator bundles practices in the study group associated
enhance early weaning". with positive effect on patients outcomes include higher rate
The current study finding was consistent with Abd- of successful weaning scores, reduction in mortality rate and
Elbaky, Mohammed, (2020), they studied " Effect of various length of stay.
body positions on the measurement of endotracheal tube cuff Regarding the relationship between study and control
pressure among critical patients" they found, all of the studied groups according to their weaned successfully and their
patients, remained attached to the mechanical ventilator on smoking habits, duration of MV at the different observations,
SIMV mode during the MV connection. On the other hand, the study represented that, there were statistically significance
the present study finding was opposite with Al-Banna, et al., difference between both study and control groups in the 1st,
(2016), who studied "Mechanical ventilation relationship 2nd and 3rd observation of successfully weaning regarding to
between body mass index and selected patients outcomes at a their smoking habits and duration of mechanical ventilator
university hospital in Cairo" they stated that, more than three connection and successful weaning (P – value ≤ .001, .05
quarters of the studied groups were received continuous .001, .0001, 05 and .0001) respectively . Finding of the current
mandatory ventilation (CMV) mode. study explain that: the study group of patient was received the
modified ventilator bundle practices can significantly attribute

in successful patients weaning from MV, and this in turn (1) Designing in-service training educational program
reduction the duration of ventilation support than the control for critical care nurses to improve nurses' knowledge
group. and practice regarding modified ventilator bundle.
Current study was consistent with Al-Thaqafy, et al, (2) Strict supervision and follow up of nurses'
(2018), who studied "Association of compliance of ventilator compliance with modified ventilator bundle
bundle with incidence of ventilator-associated pneumonia and application with their patients.
ventilator utilization among critical patients over 4 years" they (3) Developing a simplified and comprehensive booklet
found, significant correlation between both studied groups as including basic information about VAP as; definition,
regards successfully weaning regarding to their smoking risk factor and nursing role towards VAP prevention,
habits and duration of MV connection. components of modified ventilator bundle and its
importance.
Conclusion
Based on current study results and research Recommendations related to patients
hypothesis, the following can be concluded that: The study (1) Applying the grouped ventilator bundle practices
group of patients who received the complete modified together in a full compliance for the mechanically
ventilator bundle had higher weaning scores and shorter ventilated patients.
duration of mechanical ventilator compared with the other (2) Modified ventilator bundle should be replicated on
control group of patients who received routine hospital multiple types of diagnosis among mechanically
nursing care. ventilated patient.
Recommendations Recommendations for furthers researches

Recommendations related to nurses (1) Replication of the study on a larger probability
sample from different geographical locations in
Egypt to ensures the generalizability of the study.
References
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critical patients. International Journal of Novel Research in Healthcare and Stay in Avoiding the Ventilator Associated Pneumonia (VAP) at Anesthesia
Nursing, 7, (3), (42-50). Intensive Care Unit. Int J Nurs Clin Pract 5: 295.:
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Effect of Preoperative Nursing Protocol on Pain and Daily Activities for Post Inguinal Hernia
Repair Patients
Eman Abdelmobdy Ali 1, Islam Ibrahim Ragab 2, Mohammed Abdel Shafy Mohammed3, Rokaia Fathi Mohamed 4
(1) Clinical instructor of Medical Surgical Nursing-Faculty of Nursing - South Valley University
(2) Assistant Professor of Medical Surgical Nursing - Faculty of Nursing - South Valley University
(3) Assistant Professor of General Surgery Department- Faculty of Medicine – South Valley University
(4) Lecturer of Medical Surgical Nursing - Faculty of Nursing- Minia University
*Email of the corresponding author: eman_mobdy92@yahoo.com
Abstract
Background: Pain is the most serious long-term complication occurring after inguinal hernia repair with negative
effects on all daily activities. As teaching is considered an important part of nursing care, interventions aimed to
reduce pain and improving daily activities following surgical inguinal hernia repair are critically needed. Aim of the
study: To investigate the effect of Preoperative nursing protocol on reducing pain and improving daily activities post
inguinal hernia repair. Methodology: Research design: Quasi-experimental research design was utilized in the
present study. Sample: A purposive sample of (60) male patients undergoing inguinal hernia repair surgery. Setting:
The study was carried out at the general surgical unit of Qena University Hospital, Qena governorate, Egypt. Tools of
data collection: Three tools were utilized to collect data, First Tool: Structured questionnaire covered 3 parts: First
part: Demographic data of the patients. Second part: Medical profile of the patients. Third part: Included
knowledge assessment sheet about inguinal hernia disease, pain-relieving strategies and, how to prevent inguinal
hernia recurrence. Second Tool: Pain numerical rating scale. Third Tool: Physical self-maintenance scale (Activities
of daily living). Study Duration: Data collection of this study was carried out through six months, from the
beginning of December 2019 till the end of May 2020. Results: our results revealed that ages among the study and the
control groups ranged between (51 to 60 years), with a mean age (51.7±9.42 years and 55.4±6.21 years) respectively.
Also, the study group demonstrated low level of pain as compared to control group after application of nursing
interventions with a statistical significant difference between the mean score of pain level among the study and the
control groups whereas the 1st follow-up was (2.03±0.66 & 0.16±0.37) respectively, at the 2nd follow-up was
(5.83±0.46 & 3.57±0.50) respectively, and at the 3rd follow-up was (5.97±0.183 & 5.53±0.507) respectively,
moreover the mean score of daily living activities of the study group improved versus the control group with a
statistical significant difference in which the 1st follow-up was (1.93+.691 & 0.23+0.43) respectively, at the 2nd
follow-up was (5.33+0.661 & 3.6+0.563) respectively, and at the 3rd follow-up was (5.93+0.2454 & 5.53+0.507)
respectively. Conclusion: application of preoperative nursing protocol reflected a significant effect on patient's
outcomes among the study group as postoperative pain level declined and level of activities increased as compared to
the control group. Recommendations: Educational classes with a guide booklet should be provided at regular
intervals for patients undergoing hernia repair, and replication of the current study on a larger probability sample from
different geographical areas to achieve generalizable results are recommended.
Key Words: Preoperative, Nursing protocol, Pain, Activities of Daily Living (ADLs), Inguinal hernia.
Introduction: working, sleeping, personal relationships, mood and general

Hernia occurs when a viscus or a part of a viscus is enjoyment of life (Reinpold, 2017).
abnormally pushed out as a result of a defect either weak There is a strong correlation between pain and
muscles or a tear in the wall of the cavity containing the limited daily living activities (ADLs), it was founded that 30%
viscus. According to the location, a hernia can be classified to 50% of people with chronic pain suffered from limitations
into inguinal, femoral, umbilical, incisional and hiatus hernia. to walk, to participate in social activities and to maintain an
An inguinal hernia is the most common type estimated at independent lifestyle. The level of limitation affected by some
about 75% of all types and occurs when bowel or fatty tissue factors e.g. severity, location, and duration of pain.
protrudes into the groin area, about 80–90% of inguinal (Duenas, et al., 2020)
hernias usually occur in males (Townsend, et al., 2017). Unrelieved acute postoperative pain has been found
Surgical Inguinal hernia repair is the choice of to be a contributing factor to the development of chronic pain.
treatment in most cases and is considered one of the most Therefore, interventions aimed at reducing pain following
common surgeries performed worldwide. Annually, more inguinal hernia surgery are critical. Pre-operative teaching
than 20 million surgical inguinal hernia repairs are conducted provides patients undergoing surgery with information about
worldwide (Kockerling and Simons, 2018). While in Egypt; the surgical procedure as well as information about post-
surgical inguinal hernia repair was estimated at about 240000 operative sensations, including pain and other adverse
patients in 2015 (Fawzy, et al., 2016). symptoms. (Sawhney, et al., 2017).
Pain is the most serious long-term complication As teaching considered an important part of nursing
occurring after inguinal hernia repair, it was founded that care, preoperatively the nurse should prepare the patient with
more than 38 % of patients suffering from moderate to severe written and verbal explanations including teach the patient
pain for 6 months after groin hernia repair with negative pain relieving strategies such as; (breathing exercise, cold
consequences on all daily activities including walking, applications to reduce scrotal swelling, positioning as
recumbent position or flexion of the hip and thigh, supporting
P a g e | 130 Eman A., et al
the site, applying gentle pressure on operation site while Exclusion criteria:
coughing, sneezing and moving between sitting and standing,  Patients receiving long-term analgesics.
avoidance of heavy activity, and straining in toilet) as well as  Patients have a recurrent inguinal hernia.
counseling educations about actions and life style
modifications that preventing its recurrence all are considered The setting of the study:
helpful measures to relief painful symptoms This study was conducted at the general surgical unit
(Sawhney, et al., 2017) . in Qena University Hospital, Qena governorate, Egypt.
Significance of the study: Study Duration:

Surgical inguinal hernia is considered one of the most Data collection for this study was carried out through
common surgical interventions, according to the last six months, from the beginning of December 2019 till the end
registration records of Qena University Hospital from of May 2020.
(January 2017 to December 2017) in which the number of
inguinal hernia repair patients was (288) cases. Tools of data collection:
Related literature illustrated that pain following Three tools were utilized in order to fulfill this study:
inguinal herniorrhaphy is most relevant and an ignored 1. First Tool: Structured questionnaire sheet:
problem associated with negative consequences on a It was used for both groups before the surgery. It
functional level and the quality of life, with incidence rates consisted of two parts collected by the researcher as the
varies between (0.7–48.3%) and high follow-up rates following:
(Reinpold, 2017 and Fawzy, et al., 2016).
Furthermore, from the clinical experience as a Part (1): Demographic characteristics:
supervisor for faculty of nursing students at the clinical area in (e.g. name, age, residence, marital status, occupation
Qena university hospital, the researcher found that no previous and level of education).
studies in our geographical area had addressed this problem, Part (2): Medical data profile: included (past medical and
and there was a lack of assessing the functional consequences surgical history, date of admission, and date of surgery).
of groin pain after herniorrhaphy and effectiveness of patient Part (3): knowledge assessment sheet:
education on improving the level of pain and level of activity. It used to assess patient`s knowledge about inguinal
hernia (definition, potential postoperative complications, pain-
Aim of the study: relieving strategies post inguinal hernia repair including
The aim of the current study was to investigate the {relaxation techniques as breathing exercise and distraction
effect of a nursing protocol on reducing pain and improving also cold applications for reducing scrotal swelling and
daily activities post inguinal hernia repair. positioning like recumbent position or flexion hip and thigh
adding to supporting techniques as applying gentle pressure
Research Hypotheses: on operation site during coughing, sneezing, and moving,
 Patients of the study group will exhibit reduced pain finally, avoidance of heavy activity or straining}, in addition,
level rather than patients of the control group after actions to prevent the recurrence of inguinal hernia after
application of the preoperative nursing protocol. surgery).
 Patients of the study group will have improved level It included (32) multiple-choice questions collected
of daily activities than patients of the control group by the researcher and used pre- surgery for the control group
after application of the preoperative nursing protocol. without giving the nursing protocol while used for the study
group before and after giving and explaining the nursing
Research Design: protocol.
A quasi-experimental research design was utilized to
fulfill the purpose of this study. Scoring system:
If patients have a score of 60 % and more it was
Subjects: considered ''satisfactory level of knowledge'' and if less than a
A purposive sample of (60) male patients undergoing score of 60% it was considered ''unsatisfactory level of
inguinal hernia repair surgery. knowledge'' (Fawzy, et al., 2016)
Sampling size: 2. Second Tool: Pain numerical rating scale adopted from
According to the following formula (McCaffery & Beebe, 1989)
(Nagy, et al., 2019): It was applied for both groups (study and control) on
t2 x p (1-p) the second day postoperatively, then during follow-up after
N =
m2 one and three months by telephone. The rating scale scored as
the following; from (0 to 10) (11point scale) with the
(1.96)2 x 0.04(1- 0.04) understanding that (0) is equal to no pain and 10 is equal to
N =
0.052 worst possible pain.
 N = 60 patients
Scoring system
Inclusion criteria: (Zero) score indicated absence of pain, (1-3) scores
 Adult male (21-60) years. indicated mild pain, (4-6) scores indicated moderate pain, and
 Conscious and oriented. (7-10) scores indicated severe pain.
 Patients without other causative conditions of pains
(e.g. arthritis).
3. Third tool: Physical self-maintenance scale (Activities of
daily living, or ADLs) Developed by (Lawton & Brody, Data Collection Procedure:
1969) Phase I: Preparatory and administrative phase:
It was applied on the second day postoperatively, Official letter was issued from the dean of the faculty of
then during follow-up after one, and three months by nursing Minia University to the head of the Qena University
telephone for both groups. Hospital soliciting the necessary approval to conduct the
Its categories are: (Toilet, feeding, dressing, present research and then official permission to conduct the
grooming, physical ambulation and bathing). proposed study was obtained by the researcher from the
manager of Qena University Hospital.
Scoring system: Phase II: Implementation phase: Once the
The total score ranges from (0 to 6), only the highest permission was obtained to conduct the study, the researcher
level of function receives a (1) because each describes initiated data collection. Collection of data was started from
competence that represents some minimal level of function. the beginning of December 2019 to the end of May 2020,
through 2 days weekly during morning and afternoon shifts.
Educational booklet the content of nursing protocol was As well as official permission from the patients was
developed by the researcher based on reviewing the current granted, patients were divided into both control and study
national and international literature to improve patient`s groups randomly (30 patients for each group) according to
knowledge about the disease (as a definition of the disease, their admission to the surgical department. Those (30 patients)
risk factors, potential post-operative complications, pain- who admitted first constituted the control group subjects and
relieving strategies post inguinal hernia repair, and methods of other (30 patients) who came after constituted the study group
preventing its recurrence) and improve patient's performance ones.
through educated the patient how to practice pain-relieving The study and control groups were visited by the
strategies that include (Deep breathing exercise, distraction, investigator to initiate line of communication, explain the
cold application, positioning, supporting the site, avoidance of nature and purpose of the study and fill out the first tool (part
straining and heavy activities) and how to use pain numerical I, II, and III) as a pre-test. This tool was filled by the
scale. researcher within (15-30) min.
The control group was exposed to routine nursing
Tools Validity: care, while the developed nursing protocol was applied for the
The tools were tested for content validity by a jury of study group with demonstration and return demonstration
five experts in the field of the study and necessary included methods to reduce pain after inguinal hernia repair,
modifications were done. The tools were tested for internal actions that prevent inguinal hernia recurrence and how to use
consistency. pain numerical scale, this educational session took about 30-
40 minutes, then immediate posttest was done for patients in
Tools Reliability: the study group using the third part (knowledge assessment
It was established by the Alpha Cronbach`s test sheet) which filled by the researcher within (15-20 min)
which is used to measure the internal consistency (reliability before the surgery.
of the used tool or instrument). The reliability scores of the Phase III: Evaluation phase: The second day
tools are (0.95 and 0.94) for pain scale and Daily living postoperatively for each patient on both study and control
activities scale respectively, which indicates the high tool groups, the researcher used tool II (pain numerical rating
internal consistency of the used tool. scale) and tool III (Activities of daily living scale), then
during follow-up after one and three months by telephone.
Pilot study:
A pilot study was conducted on 6 subjects (10% of Limitations/difficulties of the study:
the total sample) to ensure the clarity and utility of designed (1) Interruptions during interviewing by staff members.
study tools and to identify any difficulties or problems that (2) Some patients were missed during the follow up (2
needed to be handled before receiving it. They were included patients from the control group and 1 from the study
in our actual sample because no modifications needed to be group) and the researcher replaced them with other
performed. cases.
Ethical Considerations: Statistical Analysis of Data:

Official permission to conduct the study was Data entry was done using a compatible personal
obtained by the researcher from the responsible hospital computer. Data entry and statistical analysis were done using
authorities of the general surgical department at Qena SPSS 23.0 statistical software package. Data were presented
university hospital. At the initial interview, each patient was using descriptive statistics in the form of frequencies and
informed of the purpose of the study. The investigator percentages for qualitative variables, means and standard
emphasized that the participation is voluntary and deviations for quantitative variables. T-test was used to
confidentially and anonymity of subjects will be assured compare means. Qualitative variables categorical were
through coding of all data. Confidentiality of the data was comparing using chi-square or Fisher exact test as appropriate.
asserted. The aim of the study was explained to patients by the ANOVA test and Pearson correlation were used to detect the
researcher. The right to refuse to participate in the study was relation between variables. Statistical significance was at p-
emphasized to the patients. This study was approved by the value < .05.
research ethical committee of the faculty of nursing at Minia
University.

Results:
Table (1): Frequency distribution of the study & control groups according to their demographic data (N=60).
Demographic data N (30) N (30) Fisher / x 2 P – value
(N) (%) (N) (%)
(1) Age:
 21-30yrs 3 10 1 3.3
.469
 31-40yrs 3 10 1 3.3
2.36 (NS)
 41-50yrs 9 30 9 30
 51-60yrs 15 50 19 63.3
Mean+SD 51.7+9.42 55.4+6.21 1.77 .081(NS)
(2) Residence :
 Urban 10 33.3 9 30 1.00
.077
 Rural 20 73.3 21 70 (NS)
(3) Marital statues:
 Single 7 23.3 1 3.3
 Married 22 73.3 28 93.3 5.35 .052*
 Widow 1 3.3 1 3.3
(4) Occupation:
 Manual 14 46.7 14 46.7
 Office 15 50 11 36.7 3.11 .192(NS)
 Other 1 3.3 5 16.7
(5) Educational level:
 Illiterate 8 26.7 10 33.3
 Reads and write 6 20 9 30
.485
 Secondary- 2.67
(NS)
12 40 10 33.3
education
 High education 4 13.3 1 3.3
NS= Not significant * p ≤.05 (statistical significance) (Chi square and fisher exact test)
Table (1): Illustrated the frequency distribution of the study and control groups according to their demographic data.
It was found that their ages ranged between (51 to 60 years), with a mean age among study and control groups (51.7+9.42 years and
55.4+6.21 years) respectively, most of them were lived in rural areas, most of them were married, while highest percentage were
manual workers, and the highest percentage in the study group were secondary educated.
Table (2): Comparison between the study and the control groups according to mean score of pain level through three times of
follow up. (N=60)
Mean score of pain level
Times of follow up
(N=30) (N=30) T-test P
Mean +SD Mean+ SD
Pain after 2 days .16±0.371 2.03±0.66 13.3 .000**
Pain after 1 month 3.83±0.46 5.57±0.50 18.2 .000**
Pain after 3 months 2.97±0.183 5.53±0.507 4.176 .000**
* p≤0.05 (significant) ** p ≤.01 (highly statistical significance) (student T-test)
Table (2): Shows the comparison between the study and the control groups according to the mean score of pain level,
through three times of follow up. It revealed that there was a significant improvement of pain level for the study group versus the
control group at the three times of follow-up with highly statistically significant differences reflected by P-Value (.000**).
Table (3): Comparison between the study and control groups according to mean score of daily living activities and T-test
difference through the three times of follow up (N=60)
Mean score of daily living activities
Times of Study group Control group
follow up (N=30) (N=30) T-test P
Mean +SD Mean+ SD
ADLs after 2 days 1.93+.691 0.23+0.43 12.420 .000**
ADLs after 1 month 5.33+0.661 3.6+0.563 12.095 .000**
ADLs after 3 months 5.93+0.2454 3.53+0.507 3.890 .000**
* p≤0.05 (significant) ** p ≤.01 (highly statistical significance) (student T-test)
Table (3): Clarifies the comparison between the study and the control groups according to mean score of daily living
activities through the three times of follow up. It was found that there was a significant increase in the mean score of daily physical
activities for the study group versus the control group at the three times of follow up with a highly statistical significant difference
reflected by P-Value (.000**).

Table (4): Relation between demographic data and the mean score of pain level for the study and the control groups at the
three times of follow-up ( N=60)
Study group (N=30)
Pain after Pain after Pain after
2 days 1 month 3 months
Demographic data Test of
Test of Test of
Mean Mean Significanc Mean
Significance Significance
±SD ±SD e ±SD
F(P-Value) F(P-Value)
F(P-Value)
(1)Age :-
1.00±1.0
1-30 5.67±1.528 1.67±1.155
2.813 1.041 0 1.264
1-40 4.67±1.155 1.67±.1.155
(.059)* (.391)NS .33±.577 (.307) NS
1-50 4.11±.333 1.33±.707
.22±.667
1-60 4.8±.862 2.13±1.246
.73±.799
(2) Residence:-
2.029 .121 1.382
Rban 5±1.054 1.9±.1.287 .8±.919
(.165) NS ) (.730)NS (.250) NS )
ural 4.5±.827 1.75±1.020 .45±.686
(3) Marital status:- 4.71 ±
1.57±.976 .43±.787
Single 1.254 1.139 2.383 1.956
1.77±1.066 .55±.739
married 4.59±.796 (.335) NS (.111) NS (.161) NS
4±.000 2±.000
widow 6 ±.000
(4) Occupation:
.83±.835
manual 4.83±0.835 .432 2.08±1.165 1.581 1.578
.35±.702
office 4.53±1.007 (.654)NS 1.53±1.007 (.224)NS (.225)NS
1.00±.00
other 5±.000 3±.000
0
1.33±.70
illiterate 5.56±.726 3.00±1.00
6.397 11.481 7 7.618
reads and write 4.33±.816 1.67±.816
(.002)** (.000)** .33±.516 (.001)**
secondary education 4.18±.603 1.018±.603
.09±.302
high education 4.5±1.00 1±.000
.50±1.00
Control group (N=30)

Pain after Pain after Pain after
2 days 1 month 3 months
Test of Test of
Demographic data Test of
Significan Significan
Mean Mean Significanc Mean
ce ce
±SD ±SD e ±SD
F(P- F(P-
F(P-Value)
Value) Value)
(1)Age :-
1-30 9±.000 5±.000 2±.000
3.931 .269 1.001
1-40 9±.000 4±.000 3±.000
(.019) * (.847) NS (.408)NS
1-50 7.89±.601 4.33±1.000 2.78±.441
1-60 7.68±.478 4.32±.749 2.63±.496
(2) Residence:-
.110 .986 .683
Rban 7.89±.601 4.56±.726 2.78±.441
(.743) NS ) (.329) NS (.416) NS
ural 7.81±.602 4.24±.831 2.62±.498
(3) Marital status:-
9±.000 4±.000 3±.000
Single 2.250 .417 .500
7.79±.568 4.32±.819 2.64±.488
married (.125) NS (.663) NS (.612) NS
8±.000 5±.000 3±.000
widow
(4) Occupation:
7.79±0.57
manual .861 4.43±.852 .297 .46917.1± .597
9
office (.434)NS 4.18±.751 ) (.745) NS .522±517.2 (.558) NS
8 ±.632
other 4.4±.894 .8±.447
7.60±.548
illiterate 7.8±.632 4.8±.632 17.4±.483
1.699 2.49 .875
reads and write 7.67±.5 4±.866 17.8±.441
(.192)NS (.082) NS (.76.) NS
secondary education 7.9±.568 4.1±.738 1764±.516
high education 9±.000 5±.000 1.00±.000
* p≤0.05 (Statistical significant) ** p≤0.01 (highly significant)

(ANOVA test)
Table (4) Displays the relation between demographic data and the mean score of pain level for the study and control groups
at the three times of follow-up. It was found that there was a statistical significant relation between age and the mean score of pain
level at the 1st follow-up among both study and control groups, also, there was highly statistically significant relation between
educational level and mean score of pain level at the three times of follow up (2 days, 1 month and 3 months) among the study group
revealed by P-Value (002**, .000** and .001**) respectively
Table (5): Relation between demographic data and mean score of daily living activities for the study and control groups at the
three times of follow-up ( N=60)
Study group (N=30)

ADLs after 2 days ADLs after 1 month ADLs after 3 months
Demographic data Test of Test of Test of
Mean±SD Significance Mean±SD Significance Mean±SD Significance
F(P-Value) F(P-Value) F(P-Value)
(1)Age :-
1-30 2.67±.577 5.67±.577 6±.000
9.481 3.683 1.444
1-40 2.67±.577 6±.000 5.67±.577
(.000)* (.025)* ) (.253) NS
1-50 2.22±.441 5.56±.527 6±.000
1-60 1.47±.516 5±.655 5.93±.258
(2) Residence:-
1.9±.738 .034 5.3±.675 .037 5.9±.316 .252
Rban
1.95±.686 (.856) NS 5.35±.671
) (.849)NS 5.95±.224 (.619) NS )
ural
2.29 ± .488 5.17±.753 6±.000
Single 2.075 2.808 .300
1.86±.710 5.43±.590 5.91±.288
married (.145) NS ) (.078) NS ) ( (.743) NS
1 ±.000 4.00±.000 6±.000
widow
(4) Occupation:
manual 1.75±0.622 2.081 5.08±.641 2.245 5.92±.277 .044
office 2.12±.697 (.144) NS 5.56±.629 (.125)NS 5.94±.250)( (.957)NS
( )
other 1±.000 5±.000 6±.000
illiterate
1.33±.500 12.261 5±.707 3.912 5.89±.333 .331
reads and write
1.83±.408 (.000)** 5±.632 (.020)** 6±.000 ) (.803) NS
secondary education
2.09±.539 5.55±.522 5.91±.302
high education
3±.000 6±.000 6±.000
Control group (N=30)

ADLs after 2 days ADLs after 1 month ADLs after 3 months
Demographic data Test of Test of Test of
Mean±SD Significance Mean±SD Significance Mean±SD Significance
F(P-Value) F(P-Value) F(P-Value)
(1)Age :-
1-30 1±.000 4±.000 4±.000
6.008 3.357 3.751
1-40 1±.000 4±.000 4±.000
(.003) ** (.034) * (.023) *
1-50 .44±.527 3.89±.333 4±.500
1-60 .05±.229 3.37±.496 3.37±.496
(2) Residence:-
.33±.500 .687 3.44±.527 .750 3.33±.500 3.090
Rban
.19±.402 (.414) NS 3.62±.498 (.394) NS 3.71±.561 (.090) NS
ural
1±.000 4±.000 4±.000
Single 1.868 1.003 .811
.21±.418 3.57±.504 3.61±.567
married (.174) NS (.380) NS (.455) NS
0±.000 3±.000 3±.000
widow
(4) Occupation:
manual .14±0.363 .819 3.64±.497 .426 .514±3.57 .038
office .36±.505 (.452)NS 3.55 ±.522
) (.658) NS .674±3.64
) ( (.963) NS
other .20±.474 3.4±.548 3.60±.548
illiterate
.20±.422 1.469 3.5±.527 .454 2.7 ±..16 .8.6
reads and write
.11±.333 (.246)NS 3.67±.5 (.717) NS 27.8±.771
) ( (.466) NS ) (
secondary education
.30±.483 3.5±.527 2764±.6..
high education
1±.000 4±.000 7±.000
* p≤0.05 (Statistical significant) ** p≤0.01 (highly significant) (ANOVA test)
Table (5): Illustrates the relation between demographic data and mean score of daily living activities for the study and
control groups at the three times of follow-up. It was found that that there was a statistical significant relation between age and the
mean score of daily living activities at the three times of follow-up among both groups. Also, there was a significant relation between
educational level and mean score of daily living activities at 1st and 2nd times of follow-up among the study group

Table (6): Correlation between pain level score and daily living activities score among the study group (N=30).
Pain
Correlation r (p)
After 2 days After 1 month After 3 months
-.472
After 2 days
(.008)**
Daily living
-.386
activities After 1 month
(.035)*
r (p)
-.229
After 3 months
(.223) NS
* p≤0.05 (significant) **p≤0.01 (highly significant) (Pearson correlation test)
Table (6): Shows the correlation between pain level score and daily living activities score among the study. It reflects that
there was a negative correlation between pain level score and daily living activities score at the three times of follow-up, with
statistical significance at 1st follow-up (.008)** and 2nd follow-up ( .035)*.
Discussion:
An inguinal hernia occurs when bowel or fatty tissue 2. Discussion of the comparisons between the study and
protrudes into the groin area. It is the most common type of control groups according to the mean score of pain level
hernias estimated at about 75% of all types. Nursing plays an and mean score of daily living activities after application
important role preoperatively by providing teaching which of the nursing interventions:
helping patients on faster recovery and reducing complications As regards the comparison between the study and
as possible that may occur after surgery. Therefore, this control groups according to the mean score of pain level at the
research was conducted to investigate the effect of a nursing three times of follow-up, our results revealed that the study
protocol on reducing pain and improving daily activities post group demonstrated a low level of pain as compared to the
inguinal hernia repair . control group after application of nursing interventions with a
highly statistically significant difference revealed by P-Value
1. Discussion of the demographic characteristics of the (.000**) at the three times of follow up. These findings were
studied sample: in accordance with a study carried out in Canada by
The present study revealed that more than half of the (Sawhney, et al., 2017) who demonstrated that pain intensity
sample their ages ranged between (51 to 60 years), with a and its interference with general activity after hernia repair
mean age among study and control groups (51.7±9.42 years was found to be decreased by providing education
and 55.4±6.21 years) respectively. This explained as; with interventions. Also, these results were in the same line with
aging, there is a degradation induced of the elastic fibers in the (Vaan Dijk, et al., 2015) which showed that the intervention
deep inguinal ring. This result was supported by the study of group had higher knowledge scores and lower pain scores
(Sawhney, et al., 2017) who reported that the ages of the compared with the control group.
studied groups were between (50 to 60 years). Also, further Concerning the comparison between the study and
validation by (Ainapure & Singaraddi, 2018) who revealed control groups according to the mean score of daily living
that the majority of patients undergoing inguinal hernia repair activities at the three times of follow-up, results displayed that
their mean age (49.1 years). the mean score of daily living activities of the study group was
As regard residence, it was found that most of the improved at the three times of follow-up versus the control
study and control groups were lived in rural areas. This may group with highly statistical significant differences revealed
be attributed to the main profession of rural population is by P-Value (.000**, .000** &.001**) at the three times of
agriculture which required heavy work leading. That result follow-up respectively. The study results agreed with
was in the same line with (Fawzy, et al., 2016) which (Rolving, et al., 2016) who showed an important finding of his
reported that the majority of both study and control groups study which was the mobility of the study group and the
were from the rural areas. performance of activities were better than the control group
Concerning marital status, most of both groups were and low analgesics were needed. (Zhang, et al., 2019) health
married. This result was in agreement with (Fawzy, et al., education improved the daily living activities (ADLs) of
2016), who demonstrated in her study that the married patients patients and improved their quality of life (QoL). Another
were more than three-quarters of the total studied sample. validation by (Abdel Rahman, et al., 2017) showed that there
As regard occupation, half of the patients in the study was a significant positive correlation between total patients'
group were manual workers, while the highest percentage in knowledge and postoperative total quality of recovery. On
control group was manual workers also. This fact can be other hand; (Sawhney, et al., 2017) evaluated the effectiveness
explained by repeated lifting heavy materials for a long period of an individualized Hernia Repair Education Intervention
or activities requiring high efforts, suddenly increased intra- (HREI) for patients following inguinal hernia repair and
abdominal pressure leading to a higher risk of inguinal hernia founded that the HREI improved patients' outcomes following
incidence. This finding was supported by (Oberg, et al., ambulatory inguinal hernia repair.
2017) which revealed that works required cumulative
continual heavy lifting activities and elongated standing or 3. Discussion of relationships between demographic data
walking, increased risk of inguinal hernia. and mean score of pain level and mean score of daily living
(Mitura, et al., 2018) revealed that more than half of activities for both groups after nursing intervention:
inguinal hernia patients of the studied sample were high As regard relation between demographic data and
school educated. This agrees with our results which reported mean score of pain at the three times of follow up among the
that secondary education had the highest percentage in the study and control groups, the results clarified that there was a
study group. statistical significant relation between age and 1st follow-up
among both study and control groups, as patients between (25- 4. Discussion of correlation between pain level score and
30) age group had higher mean score of pain. Explanations for daily living activities score for the study group:
the increases in pain sensitivity under different experimental
conditions have been suggested to include age-related As regard correlation between pain level score and
anatomical, physiological, and biochemical changes as well as daily living activities score at the three times of follow-up
compensatory changes in homeostatic mechanisms and among the study group, the results displayed that there was a
intrinsic plasticity of somatosensory pathways involved in the negative correlation between pain level score and daily living
processing and perception of pain. Other potential activities score at the three times of follow-up with statistical
contributing factors related to the impact of age on pain significance at 1st follow-up (.008)**, and 2nd follow-up (
sensitivity include dysregulation of the hypothalamic- .035)*. This may be due to the bad feeling of pain with or
pituitary-axis and changes in autonomic function along with without movement which leading to decreased ability and
an increased prevalence of auto-immune disorders that occur desire to do daily activities normally. This result was in the
with advancing age. This finding was in agreement with same line with (Altug, et al., 2017) who revealed that there
(Reddy & Srinivas, 2016) found in the study titled " Study of were positive correlations between pain intensity and its
postoperative pain in patients with inguinal hernioplasty" who interference with daily activities; similarly, negative
showed that there was a significant relation between the correlations were found between the pain threshold and these
patient’s age and pain, as the severity of pain decreased with activities.
age advanced. (Mitura, et al., 2018) revealed that younger
patients` pain experience and its intensity were significantly Conclusion:
higher than in the middle-aged and the oldest group. Another Preoperative application of preoperative nursing
study for (Donati, et al., 2013) was in the same line, who protocol reflected a significant effect on patients' outcomes
demonstrated that there was no statistical significance in the among the study group as postoperative pain level declined
difference between (younger and older patients) except for and level of activities increased compared to the control group
early postoperative pain. But, these results were in and this achieved the research hypothesis.
disagreement with (Erdogan & Ozenc, 2018) who mentioned
that their study showed there was no significant correlation Recommendations:
between age and postoperative pain however some studies Based on the results of the present study it can be
showed that as the age increased, the need for analgesia and recommended that:
risk of chronic pain decreased.
Regarding the relation between the educational level Recommendations for nurses:
and the mean score of pain, there was a highly significant  Application of this preoperative nursing protocol for
relation between educational level and mean score of pain at nurses in order to improve the quality of provided
the three times of follow-up among the patients of the study nursing care and to be able to provide sufficient
group revealed by P-Value (.002**,.000 **, and .001**) education for patients undergoing inguinal hernia.
respectively. Illiterate patients had a higher mean score of
pain. This may be related to the lower mean score of Recommendations for Patients:
knowledge for illiterate patients. These results returned to the  Planning educational classes supported with a guide
relationship between educational level and post knowledge booklet should be provided at regular intervals for
among study group patients and accordingly improving pain patients undergoing hernia repair about methods to
level of the patients. This result agreed with (Wong & Yu, reduce pain, improve activity, and prevent inguinal
2016) who found that a great improvement in the knowledge hernia recurrence post-inguinal hernia repair.
obtained by patients who have a high level of education after  Written Arabic booklets or brochure and posters
the implementation of an educational program. Other including post inguinal hernia repair instructions
supplementation by (Sawhney, et al., 2017) who should be available at health care settings and given
demonstrated that pain intensity and its interference with to patients and their caregivers.
general activities was found to be decreased effectively after
hernia repair education intervention (HREI). Recommendations for further researches:
Concerning to relation between the demographic data  Replication of the current study on a larger
and the mean score of daily living activities at the three times probability sample from different geographical areas
of follow-up among the study and control groups, the results to achieve generalizable results.
clarified that there was a statistical significant relation
between age and the mean score of daily living activities at the
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Minia University. Med Sci Monti, 25:4602-4608

Correlation between the patients with Hepatitis C Virus and their Health-Related Quality of Life
Ola Omer Abd ElHamied 1; Hala Ibrahem Mohamed 2; Hend Elham Mohamed 3; Eman Fadl Abd Elkhalik 4
(1) Bachalor of nursing Minia University - Egypt

(2) Professor of Tropical Medicine Department- Faculty of Medicine- Minia University, Egypt
(3) Assist. Professor of Medical Surgical Nursing - Faculty of Nursing - Minia University, Egypt
(4) Lecturer of Medical Surgical Nursing - Faculty of Nursing - Minia University, Egypt
Abstract
Background: Hepatitis C virus (HCV) infection is a global health problem and a major cause of morbidity and
mortality. The current study aimed to assess the correlation between the patients with the hepatitis C virus and their
health-related quality of life. Descriptive design was used. Setting: Carried out at liver virology outpatient. Subject:
A convenient sample of two hundred adult patients with HCV newly received Sofosbuvir and Daclatasvir. Tools:
Interview questioner and medical data sheet and Short-Form health survey (SF-36) questionnaire. Results: An
improvement in the total quality of life this appear through 51.0% of hepatitis patients were poor in quality of life
before treatment with Sofosbuvir and Daclatasvir medication while (62.0%) of them become excellent in quality of
life after 3 months from treatment with highly statistically significant differences. Also, there was a fair negative
association between the duration of disease of the studied patients with their total quality of life measured by short-
form of health before administration of treatment with Sofosbuvir and Daclatasvir. Conclusion: The study concluded
that the administration of Sofosbuvir and Daclatasvir for patients had positive effect on their quality of life especially
for newly diagnosed patients. Recommendation: The study recommended that early screening for hepatitis C to begin
early suitable treatment.
Keywords: Correlation, Hepatitis C Virus, Quality of Life
Introduction the central nervous system. The replicating virus has been
Hepatitis C virus (HCV) infection is a global health found in central nervous tissues, and changes in
problem and a major cause of morbidity and mortality neurotransmitter levels in the frontal white matter of patients
(Faddan, et al., 2019), Egypt has the highest prevalence of with chronic hepatitis C are correlated with impaired attention
Hepatitis C in the world. Overall, estimates of the HCV rate in and concentration (Youssef, et al., 2017).
the general population have ranged between 10 and 20 Although treatment-related adverse effects may
percent. Geographically, the Hepatitis C prevalence is higher dissuade people from starting therapy and reduce compliance
in Lower Egypt (Nile Delta) than in Upper Egypt and lower in with associated reductions in sustained viral response, for the
urban compared to rural areas. The economic burden is majority of patients' viral clearance produces improvements in
multiplied by the impact of HCV on health-related quality of both HRQoL and long-term prognosis. Novel agents, with
life (HRQoL), appreciable at any stage of severity improved adverse effect profiles, may allow more patients to
(Omran et al., 2018). achieve a sustained viral response (Zainulabid, 2019).
In Egypt, a cross-sectional survey of 21 governorates The nurse must participate in educating individuals
was done by El-Ghitany and Farghaly, (2019) to determine with HCV infection to improve HRQL through lifestyle
geospatial epidemiology of hepatitis C infection in Egypt changes initiated through behavioral modification. For
found that the participant's age ranged from 14-90 years, the example, education on the monitoring of symptoms such as
darkest spot of HCV infection in Menoufeya (37.8%) fatigue, body pain, depression, and lack of ability to function
followed by Beni Suef (29.2%) and Minia (28.6%), and anti- effectively. Previous research has shown that individuals
HCV prevalence was higher among males. chronically infected with HCV respond to interventions
Quality of Life (QOL) is a popular term that conveys focused on increasing knowledge and this, improves
an overall sense of well-being, including aspects of happiness functional status and HRQL of individuals with chronic HCV
and satisfaction with life as a whole. It is broad and subjective (Youssef et al., 2017).
rather than specific and objective. The Complications of
advanced liver disease such as encephalopathy, variceal Significance of the Study:
hemorrhage, and ascites have been reported to negatively According to a recent survey done in Egypt, 2015
affect HRQoL. Extra-hepatic manifestations related to HCV found the prevalence rate among the population aged from 1-
as fatigue, irritability, depression, muscle pain, joint pain, and 59 years (sample size 1,466) in Minia governorate was 9.0%
cognitive impairment may also influence the patient’s of them have positive HCV antibody and 6.1% have positive
psychological well-being and self-perceived health HCV RNA test. HCV has a major impact on the quality of life
(Jain, et al., 2019). and can cause patients significant distress. So, this study will
Chronic infection with HCV has a profound effect on be carried out to investigate the effect of HCV infection on
health-related quality of life (HRQoL) – with fatigue, HRQOL among patients. Multiple studies worldwide have
depression, and neurocognitive deficits among the most shown that chronic hepatitis C is associated with considerable
common complaints. Neuropsychiatric symptoms have impairment of HRQoL (Ministry of Health and Population
prompted research to determine whether the HCV acts within et al., 2015).
P a g e | 139 Ola O., et al
physical role problems (four items from Q 13 to Q 16) and
Aim of the study: due to emotional problems (three items from Q 17 to Q 19),
Assess the correlation between the patients with energy or fatigue (four items: Q 23, 27, 29, 31), emotional
Hepatitis C Virus and their Health-Related Quality of Life. wellbeing (five items Q 24- 26, Q 28, Q 30), social
functioning (two items, Q 20, Q 32), Bodily Pain (two items,
Research question: Q 21 & Q 22), and general health perceptions (five items: Q 1
Is there a correlation between the patients with and from Q33 to Q 36), which Q 2 refer to current patient
Hepatitis C Virus and their Health-Related Quality of Life health compared to one year ago.
impairment?
Scoring system
Research Design: Each subscale is scored from (0 to 100) when patient
A Descriptive research design was utilized assessment indicates score 0 this means the worst score for
quality of life but when have 100 mean they have the best
Subjects score for quality of life. While the total scores were less than
A convenient sample of two hundred adult patients 50% considered as poor quality of life. If the total scores
with HCV newly received Sofosbuvir and Daclatasvir. ranged from 50 % – 75% considered as good quality of life,
and when the total scores were 75% or more considered as
Inclusion criteria : excellent quality of life.
 Adult patient from18- 60 years
 Conscious and oriented Tool Validity and Reliability:
 The patient has early stage of chronic hepatitis C A panel of five experts in the field of medical
 Newly received Sofosbuvir and Daclatasvir surgicalnursing staff to examine validity of the content. No
medication. alterations of the content were be done allowing to the panel
judgment on the clearness of sentences, suitability of the
Exclusion criteria: content, and categorization of items. Reliability was done by
 Musculoskeletal problems. using the alpha Cronbach’s test was .81 and it examined by
 Pregnant women. many studies was 0.80 by McHorney et al. (1994)
 Other hepatitis viruses
Pilot Study :
 Immunocompromised diseases.
Was conducted for 10 % (20 patients) of the total
 Obesity (overweight 25 kg) and underweight
sample to test the study process and to evaluate the efficiency
patients.
of tools.
 Patients with speech and mental disorders.
. Procedure:
The researcher met the patients during a time of
Setting : outpatient clinics, introducing herself, and explained the
The study was conducted in liver virology purpose and nature of the study. oral consent was obtained to
outpatients' clinic at Minia University Hospital and Fever participate in this study. The researcher started a collection of
Hospital related to ministry of health. data in 12 months by using Bio-socio-demographic
characteristics for 15- 20 minutes for each patient. The
Study duration: researcher distributed the data collection sheets to respondents
The total data collections were collected over period individually in the reception in the liver virology outpatient
of 12 months starting from December 2018 to December patient clinics at Minia university hospital and fever hospital.
2019. Collection of the study data was done on daily basis (2 to 3
days /week) during the morning shift. The researcher checked
Data Collection Tools : the completeness of each filled form after the participant filled
The current study data were collected by Two tools it. Health-related quality of life was measured for every
were designed, prepared, tested, and used for collecting data patient before and after 3 months from finishing the treatment.
in this study after extensive reading in the literature review by
the investigator (Rand Corporation, 2013). Statistical data
Statistical analysis was done by using Statistical
Tool Ӏ: Bio-socio-demographic characteristics were included Package for the Social Science (SPSS IBM 25.0). Quality
in two parts (Appendix B) control was done at the stages of coding and data entry. Data
1st part: sociodemographic data : sex, age, marital were presented by using descriptive statistics in the form of
status, education level, occupation, and residence frequencies and percentages for qualitative variables and mean
2nd part: Medical information include: past and & standard deviation (SD) for quantitative variables. Chi-
present medical history, including medical diagnosis, square ( ) was used to test the association between two
smoking, medication qualitative variables. T-test was used to measure mean
differences of quality of life measured by short-form
Tool ӀӀ: A Short-Form health survey (SF-36) questionnaire questionnaire (SF-36) between before and after treatment
arabic version adopted by Ware and Sherbourne, (1992) & Graphs were done for data visualization using Microsoft
McHorney et al. (1994) to measure the quality of life for Excel. The P-value of ≤ 0.05 indicates a significant result
patients with hepatitis C virus which include eight health while the P-value of > 0.05 indicates a non-significant result.
domains: physical functioning (ten items from Q 3 to Q 12),

Results:
Table (1): Percentage distribution of Bio-socio-demographic characteristics of the studied Sample (n = 200)
Items NO. %
Age
20- 30 34 17.0
31- 40 58 29.0
41 – 50 52 26.0
51 – 60 56 28.0
Sex
Man 124 62.0
Woman 76 38.0
Marital Status
Single 24 12.0
Married 160 80.0
Widow 16 8.0
Educational level
Illiterate 28 14.0
Basic 38 19.0
Diplom 82 41.0
Bachelor 52 26.0
Residence
Urban 32 16.0
Rural 168 84.0
Occupation
Jobless 136 68.0
Work 64 32.0
Table (1): presents that 29.0% of the studied patient their age ranged between 31- 40 years with mean 33.4 ± 8.1 years,
62.0% of them was man. The highest percentage of the study sample were married and lived in rural areas constituted (80.0% &
84.0% respectively). Related to occupation status found that two-third (68.0%) of the study sample were jobless.
.
Duration of disease
3.0% 25.0%
72.00%
One Week Month One Year

Figure (1): Percentage distribution of studied Sample regarding the duration of disease (n = 200)
Figure (1): illustrates that near to three quarters (72.0%) of the studied sample have duration of their disease from one year
ago, while 25.0% of them from one month, and a minority of them from one week.
Figure (2): Percentage distribution of studied Sample regarding smoking habit (n = 200)

Figure (2): demonstrates that near to three quarters (72.0%) of the studied patient was not smokers and more than one-quarter
(28.0%) of them was smoker.
Table (2): Mean scores of quality of life domain of the studied sample before and after 3 months from the administration of
treatment
Quality of life domains Before treatment Three months after t-test P-value
treatment
Physical functioning 47.1 ± 28.9 89.4 ± 12.7 13.401 .0001**
Role limitations due to physical health 42.8 ± 44.4 70.8 ± 41.4 4.609 .0001**
Role limitations due to emotional problems 57.0 ± 59.2 94.3 ± 55.3 4.609 .0001**
Energy 59.0 ± 30.7 77.6 ± 22.4 4.899 .0001**
Fatigue 44.7 ± 33.0 25.4 ± 28.2 4.446 .0001**
Emotional wellbeing 44.4 ± 25.4 64.7 ± 22.5 5.997 .0001**
Social functioning 53.5 ± 29.9 75.8 ± 25.7 5.647 .0001**
Pain 59.8 ± 35.5 81.2 ± 26.1 4.841 .0001**
General health 45.7 ± 19.2 58.4 ± 18.4 4.769 .0001**
Total SF-36 47.6 ± 24.9 75.6 ± 19.2 8.888 .0001**
Independent t test **Highly statistical significant difference at ≤ 0.01
Table (2): reveals that the total mean score of quality of life domain after 3 months of treatment with Sofosbuvir and
Daclatasvir medication was higher than before treatment constitute (75.6 ± 19.2 & 47.6 ± 24.9) respectively with highly statistically
significant (0.001).
Table (3 Relation between total Quality of life of the studied sample and their bio-socio-demographic characteristics before
administration of Sofosbuvir and Daclatasvir (n= 200).
Quality of life Before treatment
Bio-socio-demographic Good Excellent
Poor (n= 102) X2 P-value
characteristics (n= 66) (n = 32)
NO. No. % No. % No. %
Age/ Years
20- 30 34 12 35.3 10 29.4 12 35.3
31- 40 58 40 69.0 8 13.8 10 17.2 18.438 .005**
41 - 50 52 28 53.8 16 30.8 8 15.4
51 - 60 56 22 39.3 32 57.1 2 3.6
Gender
Male 124 54 43.5 50 40.3 20 16.2 4.429 .109
Female 76 48 63.2 16 21.0 12 15.8 NS
Marital Status
Single 24 10 41.7 6 25.0 8 33.3
Married 160 80 50.0 56 35.0 24 15.0 5.192 .268
Widow 16 12 75.0 4 25.0 0 .0 NS
Educational level
Illiterate 28 6 21.4 20 71.4 2 7.2
Basic 38 24 63.1 6 15.8 8 21.1
Diplom 82 34 41.5 32 39.0 16 19.5 18.662 .005**
Bachelor 52 38 73.1 8 15.4 6 11.5
Residence
Urban 32 18 56.3 4 25.0 3 18.7 .562 .755
Rural 168 84 50.0 29 34.5 13 15.5
Occupation
Jobless 136 70 51.5 20 29.4 13 19.1
Worker 6 6 100. 0 .0 0 .0
Nursing 12 4 33.3 6 50.0 2 16.7 17.957 .06
Security 6 0 .0 6 100 0 .0 NS
Teacher 22 16 72.7 4 18.2 2 9.1
Office worker 14 4 28.6 10 71.4 0 .0
Driver 4 2 50.0 0 .0 2 50.0
Chi-test for qualitative variables NS = not statistically significant differences ** Highly statistically significant differences
Table (3): shows that, 69.0% of studied patient who aged between 31- 40 years and 53.8% of the studied patient who aged
between 41- 50 years had a poor total quality of life before administration of treatment with Sofosbuvir and Daclatasvir medication,
and 73.1% of them who had bachelor degree and 63.1% of them who had basic education had poor quality of life before treatment
with statistically significant differences ( 0.005 and 0.005) respectively.
Table (4): Relation between total Quality of life of the studied sample and their bio-socio-demographic characteristics 3
months after the administration of Sofosbuvir and Daclatasvir (n= 200).
Quality of life 3 months after-treatment X2 P-value
Items Poor (n= 26) Good Excellent
(n= 50) (n = 124)
NO. No. % No. % No. %
Age/ Years
20- 30 17 2 1.0 6 3.0 26 13.0 7.522 .275
31- 40 19 8 4.0 14 7.0 36 18.0 NS

Quality of life 3 months after-treatment X2 P-value
Items Poor (n= 26) Good Excellent
(n= 50) (n = 124)
NO. No. % No. % No. %
41 - 50 26 4 2.0 10 5.0 38 19.0
51 - 60 28 12 6.0 20 10.0 24 12.0
Gender
Male 124 12 6.0 26 13.0 86 43.0 3.870 .144
Female 66 14 7.0 24 12.0 38 19.0 NS
Marital Status
Single 24 2 1.0 8 4.0 14 7.0 1.737 .784
Married 160 20 10.0 38 19.0 102 51.0 NS
Widow 16 4 2.0 4 2.0 8 4.0
Educational level
Illiterate 28 4 2.0 14 7.0 10 5.0
Basic 38 4 2.0 12 6.0 22 11.0 11.277 .080
Diplom 82 6 3.0 14 7.0 62 31.0 NS
Bachelor 52 12 6.0 10 5.0 30 15.0
Residence
Urban 32 8 4.0 10 5.0 14 7.0 3.431 .180
Rural 168 18 9.0 40 20.0 110 55.0 NS
Chi-test for qualitative variables NS = not statistically significant differences
Table (4): reveals that there were no statistically significant total Quality of life of the studied sample and their socio-
demographic characteristics 3 months after the administration of treatment.
59.70%
60.00%
Week One month One year
50.00%
45.00%
40.00%
33.30% 33.30% 33.30%
30.60%
30.00%
20.00%
15.00% 15.00%
9.70%12.00%
10.00% 9.00%
10.00% 7.00% 8.00%
1.00% 1.00% 2.00%

0.00%
0.00%
Quality of life Before treatment Quality of life 3 months after treatment

Figure (3): Comparison between total Quality of life of the studied sample and their duration of disease before and after 3
months administration of Sofosbuvir and Daclasvir (n= 200).
Figure (3): illustrates that 59.7% of the studied patient with hepatitis from one year had poor quality of life before
administration of treatment with Sofosbuvir and Daclatasvir medication decreased to 12.0% of them after 3 months of treatment

80.00%
Yes No
71.40%
70.00%
60.00%
50.00%
43.10%
41.00%
40.00% 36.10%
30.00% 25.00%
20.80% 21.00% 21.00%
20.00%
10.00%
10.00%
3.60% 3.00% 4.00%
0.00%
Quality of life Before treatment

Quality of life 3 months after treatment
Figure (4): Comparison between total Quality of life of the studied sample and their smoking habits before and after 3 months
administration of Sofosbuvir and Daclasvir (n= 200).
Figure (4): illustrates that 71.4% of the smoker patient had poor quality of life before administration of treatment with
Sofosbuvir and Daclatasvir medication decreased to 3.0% of them after 3 months of treatment
Table (5): Correlation between bio-socio-demographic characteristics and their total quality of life measured by short-form of
health before and after 3 months of Sofosbuvir and Daclatasvir administration
Items Quality of life before treatment Quality of life 3 months after treatment
r P - value r P - value
Age .183 .068 -.201 .045
Educational level .077 .449 .143 .155
Occupation .025 .806 .113 .262
Duration of disease -.329 .001** .075 .459
Pearson and spearman correlation test**Correlation is significant at the 0.01 level
Table (5): reveals that there was a fair negative association between duration of disease of the studied sample with their total
quality of life measured by short-form of health before administration of treatment with Sofosbuvir and Daclatasvir (r= -.329& P –
value < .001).
Discussion married, about two-fifth of them had diploma degree and the
Infection with the hepatitis C virus (HCV) remains a most of them had lived in the rural area.
major health problem, and the patients with hepatitis C virus This result comes in the line with El Niwehy et al.,
necessitate to change their lifestyle and adopt healthy (2018) reported that more than half of patients aged 51-60
behaviors through an adjustment to a chronic medical years with (35.23±11.58) years; more than two-thirds were
condition, managing of symptoms and treatment health males; while the most of them were married and more than
consequences, and making and maintain lifestyle changes two-thirds were living in rural areas
(El-Maksoud et al., 2015). As regarding education this result confirmed by
Regarding the hepatitis patient characteristic, the Abdellatef & Mohamed (2019) reported that more than two-
present study showed their age mean 33.4 ± 8.1 years, less third of the studied group was living in rural areas.
than two-third of them was male, the most of them was

This result goes in line with Kandeel et al., (2017) characteristics before administration of Sofosbuvir and
revealed that more than two-thirds of HCV patients were Daclasvir treatment, the current study showed more than two-
living in a rural areas. Also this result partially come in the third of studied patient who aged between 31- 40 years and
line with Faddan, Soliman, & Hassan, (2019) reported that more than half of the studied patient who aged between 41- 50
the majority of those patients were males, less than two-third years had poor total quality of life before administration of
of them were from rural areas, more than three quarters were treatment with Sofosbuvir and Daclasvir medication, and
with basic education and about two-third had low about three-quarter of them who had bachelor degree and near
socioeconomic level. two-thirds of them who had basic education had poor quality
Regarding the duration of disease, the present study of life before treatment with statistically significant
illustrated that near to three quarters of the studied patient, the differences. Also, more than of the studied patient with
duration of their disease from one year ago, one-quarter of hepatitis from one year had poor quality of life before
them from one month, and a minority of them from one week. administration of treatment with Sofosbuvir and Daclasvir
This result differs from (Zhang et al., 2020a) who mentioned medication and more than two thirds of the studied smoking
that more than half of the patients had disease duration greater patient had poor quality of life before administration of
than 5 years. Also, this result comes away from Mapoure et treatment with a statistical significance.
al., (2018) reported that the median duration of HCV infection These results agree with Pereira & Fialho, (2016)
was 32 months. reported that there was a statistical significant association
As related to the smoking habit, the current study between patient age and their quality of life. Also, this result
demonstrated that less than three quarters of the studied was confirmed by Skevington, (2012) reported there
patient was not smokers. This result contradicted with astatically differences between patient age and quality of life.
Pericot-Valverde et al., (2020) reported that the majority of This result comes in accordance with Zhang et al.,
the patients were current cigarette smokers. This difference (2020b) who studied '' Health-Related Quality of Life among
due to more than one third of the studied patients was female Patients with Hepatitis C Virus Infection: A Cross-Sectional
and female in the upper Egypt the most female not smoke. Study in Jianping County of Liaoning Province, China '' and
As regarding the mean scores of quality of life and its mentioned that there were statistical significant differences
domain of the studied sample on before and after 3 months between the quality of life of a patient with HCV and the
from administration of Sofosbuvir and Daclasvir medication, disease years. This difference may be due studied patients not
the present study revealed that total mean score of quality of administered any therapeutic management for their disease so
life domain after 3 months of treatment with Sofosbuvir and their quality of life was poor.
Daclasvir medication were higher than before treatment This result comes in accordance with Lynch et al.,
constitute with highly statistically significant. (2018) reported that smoking had a significantly larger
This result comes in the line with Abd Elwahab association with moderate/severe pain (adjusted odds ratio
Elsayed & Abd El-Aal (2017) who mentioned that the quality [or] = 1.50, p < 0.001) than among veterans without HCV
of life of the patients was improved during the follow up (adjusted or = 1.26, p < 0.001).
phase than baseline before initiated the course of treatment Concerning the relation between total Quality of life
and during the treatment regimen. Also, these results came in of the studied sample and their bio-scio-demographic
accordance with Youssef et al., (2017) found a significant characteristics 3 months after administration of Sofosbuvir
change in HRQL across the three different periods among and Daclasvir medication, the present study revealed that there
patients receiving DAAs before, during and at the end of were no statistically significant total Quality of life of the
therapy. Moreover, Younossi et al., (2016) found that HRQL studied sample and their bio-socio-demographic
improvement was progressive overtime after the end of characteristics 3 months after administration of treatment.
treatment, with scores after 24 weeks greater than at 12 weeks. This result was come in the line with Kang et al., (2005)
Concerning the comparison between the studied reported that there was statistical significance difference
sample regarding their total quality of life levels before and 3 between demographic characteristics and quality of life after
months after the administration of Sofosbuvir and Daclasvir treatment with antiviral medication. These results may be due
medication, the present study showed that there was to the effective treatment with Sofosbuvir and Daclasvir.
improvement in total quality of life this appear through more Regarding the correlation between demographic
than half of hepatitis patients were poor in quality of life characteristics and their short-form of health before and after 3
before treatment with Sofosbuvir and Daclasvir medication months of administration of Sofosbuvir and Daclasvir
become about two-thirds of them become excellent in quality medication, the current study revealed that there was a fair
of life after 3 months from treatment with highly statistically negative association between duration of disease of the
significant differences. studied sample with their total quality of life measured by
This result confirmed with Younossi & Henry, short-form of health before administration of treatment with
(2015) revealed that interferon-free regimens containing Sofosbuvir and Daclasvir. This may be due to the length of the
sofosbuvir and ledipasvir have minimal negative effects on disease affect the deterioration of the patient's status that
health-related quality of life during treatment. Also, Younossi affects the outcome of the treatment and adversely affect the
et al., (2016) found that patients who achieved a sustained patient's quality of life.
virologic response at 12 weeks after treatment reported
significant improvement in their outcomes in interferon-free Conclusion
regimens. These results due to the patient received accurate Based on the results of the present study, it can be
dose of medication follow physician order, and they feel concluded that:
satisfaction toward medication action. Total mean score of quality of life domain after 3
As related the relation between total Quality of life months of treatment with Sofosbuvir and Daclatasvir
of the studied sample and their bio-scio-demographic

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Effectiveness of Teaching Program on Awareness Regarding the Minor Discomfort Problems among
Pregnant Women
1
Hager Abdalalla Hashem; 2Ekbal Abdel Reheem Emam; 3Amany Hassan Abd Elrahim
(1) B.Sc. in Nursing , Faculty of Nursing –Minia University

(2) Professor of Maternal Health and Obstetric Nursing, Faculty of Nursing –Minia University
(3) Lecturer of Maternal Health and Obstetric Nursing, Faculty of Nursing –Minia University
Abstract
Background: Most of the pregnant women experienced minor discomforts in their normal pregnancies. The current
study aimed to evaluate the effectiveness of planned teaching program on awareness regarding minor discomfort
problems among primigravida women. Design: Quasi-experimental research design was utilized to achieve the aim. A
convenient sample includes 66 primigravida women accordingly; this study was conducted in two maternal health
care centers in Minia city. a structured interview questionnaire was developed. The data collection tool consisted of 3
tools; the first tool: demographic data of the primigravida women; the second tool: knowledge assessment tool (pre –
posttest education): and the third tool: practice assessment tool. Results: Most of the primigravida women had poor
awareness about minor discomfort during pregnancy in the pre-teaching program which decreases to the minority
after post teaching program with a highly statistically significant difference. Also, more than three-quarters of them
had a poor level in total practice about minor discomforts in the pre-teaching program which decrease to the minority
in the post-teaching program with a highly statistically significant difference. In addition, there was a fair positive
association between the total knowledge score and the total practice score of primigravida women in the pre-teaching
program. Conclusion: The study concluded that the nursing teaching program was effective in improving awareness
of pregnant women regarding minor discomfort problems among primigravida women. Recommendation: The study
recommended the integration of the designed nursing instructions for primigravida in maternal health care centers.
Keywords: Awareness, Minor Discomfort Problems, Pregnant Women, Teaching Program
Introduction pregnancy to provide reliable information and compassionate

Most pregnant women have experienced mild pain. guidance. To respond effectively, nurses need to consider not
Physiological, anatomical, endocrine/hormonal changes in only the minor discomforts but also the practice of self-care to
their usual pregnancies that may result in these minor mitigate them. In offering anticipatory advice to promote
discomforts. Hormonal changes during pregnancy can damage women's accountability for self-care activities, nurses may
the emotions of women, rendering them more susceptible to play a significant and critical role in clarifying misconceptions
anxiety. The gestational phase is also a possible stressor for and correcting any misinformation. It is necessary to educate
women with pre-existing psychological health issues that the pregnant mother to recognize safety threats posed by her
occur during or soon after pregnancy and a relatively high-risk lifestyle, cultural, social, behavioral, condition and
phase for women (Ayoub & Awed, 2018). environment and to recommend ways to improve them to
Pregnancy may be followed by radical changes in the prevent negative effects from the government (Pereira, et al.,
female body, leading to several discomforts called "minor 2020).
pregnancy disorders or ailments." Because of hormonal, Also, nurses must be mindful of the types of
accommodative, metabolic, and postural changes, these minor activities related to health in which pregnant mothers may be
disorders-occur. Most of these conditions are not hazardous; involved. If the nurses are adequately informed about self-care
they are just a natural part of pregnancy and can be handled at procedures, adequate referrals may be made to help pregnant
home. Nausea, vomiting, weakness, and frequency of mothers improve their recovery, deal with symptoms and
micturition are typical diseases of pregnancy during the first treatment-related adverse side effects, protect and encourage
trimester. Heart pain, constipation, vaginal discharge, and their health. Maternity nurses also play a vital role in
backache in the second trimester. Hemorrhoids, leg cramps, improving the standard of maternal care, providing
edema, and insomnia are present in the third trimester information and resources for pregnant mothers. At the same
(Vincent, et al., 2015). time, the nurse can provide evaluation, health education,
Minor discomforts linked to pregnancy can be therapy & appropriate referral for health promotion &
controlled by proper description, simple treatments, and psychosocial services (Homer, et al., 2019).
adjustment of lifestyle habits. Pregnant women should also
have a basic awareness of common minor discomforts. During Significance of the Study
pregnancy, they should also know how to conquer these Amasha and Heeba (2013) evaluated Jordanian
discomforts. To prevent the risks associated with their mild women's awareness of pregnancy normal and abnormal signs
pregnancy distress and to preserve their state of health. concluded that, lack of awareness about abnormal signs of
Providing information on pregnancy pain physiology, pregnancy regarding pregnant women attending antenatal
avoidance, and self-care will help to alleviate such maternity care. A recent study was done by AbdElhaliem, AbdElhady
care-related anxiety and fears is healthy pregnancy with a & Mohamed, (2018) in an outpatient clinic affiliated with the
physically safe and emotionally rewarding result for mother, obstetric department at Benha University reported that 45% of
child, and family (Khalil & Hamad, 2019). the studied sample had incorrect knowledge about minor
The birth of a healthy baby is the primary aim of any discomfort and utilization measures to relieve those so, it is
pregnancy. Many pregnant women rely on nurses during their important to evaluate the effectiveness of planned teaching
P a g e | 147 Hager A., et al
program on awareness regarding minor discomfort problems Knowledge about minor discomfort problems it includes:
among primigravida women in Minia city. MCQ questions regarding (types of minor discomfort
problems, causes, complications, and management). It was
Aim of the study: content 11 questions.
This study aimed to:
Evaluate the effectiveness of planned teaching Scoring System:
program on awareness regarding minor discomfort problems The women's answers related to awareness were
among primigravida women. scores and calculated. each complete correct answer was given
a score of two, the incomplete correct answer was given a
Research Hypothesis: score of one and the wrong answer a score of zero these scores
The utilization of teaching program will increase the converted into a percent score (poor knowledge scored
awareness of primigravida women regarding minor (<50%), average knowledge (50%- <75%) and good
discomfort. knowledge scored (75% or more).
The third tool: The practice assessment tool was
Subjects and Method used to assess the practice on the management of minor
Research Design discomfort. It was developed by the researcher after revising
A quasi-experimental research design was utilized in relevant literature and it concerned with how the women's
the current study. manage their minor discomfort during pregnancy which
includes (nausea, vomiting, heartburn, fatigue, and
Research Setting: constipation
This study was conducted in two maternal health care
centers in Minia city (East, and West). This center was Scoring System:
selected because has a high flow rate of pregnant women. Application of exercise by pregnant women was
classified as follows: Each correct practice was given a score
Sampling of ‘one’ and wrong practice a score of ‘zero’ respectively for
A convenient sample includes 66 primigravida every step of exercises. Poor practice scored (<50%); average
women accordingly; this study was conducted in two maternal practice (50%-75%); the good practice was considered if the
health care centers in Minia city (East, and West). This center percent score was (75% or more). the observational checklist
was selected because has a high flow rate of pregnant women. was graded as done and not done for every step of the
exercise.
The sample size determined according to:
 N=P *(1-p)* (Z α)/d) 2 Validity and Reliability
 N= (1.96)2 * (.04*(1-.04)*/(0.05)2 To establish validity, the questionnaire will be piloted
on a panel of 5 experts of Obstetrics and Gynecological staff,
Description: and Nursing professors who reviewed the instruments for
 (n) refer to sample size clarity, relevance, comprehensiveness, understanding,
 (P) refer to the prevalence of primigravida had minor applicability, and easiness, and will use alpha Cronbach’s way
discomfort in the first three months at maternal health to check the stability of the internal consistency of the
care centers in Minia city0.04. instrument.
 (d) Refer to tolerated error/margin of error = 0.05;
confidence interval (CI) =95%, the value for (Z α) = Administrative design
1.96. An official written approval letter clarifying the
purpose of the present study was obtained from the dean of the
Subjects Faculty of Nursing, as well as the Director of Minia university
Inclusion criteria hospital for maternity and child as approval for data collection
 Women during first trimester ≤ 5 weeks of gestation. to conduct this study also an oral informed consent was
obtained from included women in the study. It included a full
 Healthy pregnant women
explanation of the purpose of the present study, procedure,
 Read and write women
and rights for privacy and confidentiality.
Tools for Data Collection
Data Collection Procedure:
Tools of data collection were developed by the
I. Assessment phase:
researcher after an extensive review of the literature and
During the assessment phase demographic data such
similar studies conducted elsewhere. After that the developed
as age, residence, education level, family income, and source
questionnaire are revised by 5 panels of obstetrical and
of information about minor discomfort and Obstetric history
gynecological experts in nursing staffs, a structured interview
which include: gestational age, type of minor discomfort, time
questionnaire was developed. The data collection tool
of started and duration in addition to woman's awareness
consisted of 3 tools:
regarding minor discomfort were assessed.
The first tool: Demographic data such as age,
residence, education level, occupation, and source of
II. Implementation phase:
information.
First, the researcher has interviewed the women in
The second tool: Knowledge assessment tool (pre –
the antenatal clinic and introduced myself, briefly explained
posttest education):
the nature and the purpose of the study to women. They were
It was developed by the researcher after revising
informed that participation in this study is voluntary and they
relevant literature and it concerned with the women's
have the right to withdraw at any time. Oral approval of Operational design
women to share in this study was achieved. After obtaining Pilot Study:
the acceptance from the women to participate in the current A pilot study was conducted on 10% of primigravida
study, the researcher provided an overview and clarified the women at the previously mentioned setting to assess the
assessment tools questions to the woman. Then, the Self- current study tools for its clarity, validity, and time required to
Administered Questionnaire was distributed to each woman to be applied. According to the results of the pilot, all required
assess their awareness regarding minor discomfort (pre-test). and necessary modifications were done and the women who
The questionnaire took about 30-35 minutes to be were tested in the pilot study were included in the study
completed. After assessing the woman's awareness, the sample.
program was implemented. The session was conducted for one
hour started from 10 a.m. to 11 a.m. Health education sessions Ethical consideration:
were given to the women in the form of lectures and group  The research proposal was approved by the ethical
discussions by using audio-visual aids, it emphasized committee and the postgraduate committee in the
improving women's awareness regarding minor discomfort. faculty of nursing.
The lectures included information about minor discomfort.  Official permission was obtained from the dean of the
The researcher was discussed to the women how to manage Faculty of Nursing and requested from the Director of
their minor discomfort using a checklist. An additional 15 health affairs.
minutes was assigned at the end of the lecture for an open  Consent was obtained from primigravida women that
discussion with them about this topic. The booklet containing are willing to participate in the study, after explaining
information about the type of minor discomfort and the nature and purpose of the study.
management will be distributed to women at the end of the  The study subject had the right to refuse to participate
session. or withdraw from the study without any rationale at
any time.
III. Evaluation phase:  Study subject privacy was considered during the
For each woman two evaluations were being done, collection of data
the first one at the beginning of the study as a baseline data  Participants were assured that all their data are highly
(pre-test). The second evaluation was conducted after one confidential.
month of the educational program to detect the level of
women's awareness after health education regarding minor Statistical Design:
discomfort (posttest) for final evaluation. The collected data were organized, categorized, and
analyzed using the statistical package of social science (SPSS)
Supportive material (Health education guideline): IBM 25 and excel for figures. Data were presented using
It was designed to enhance women's awareness and descriptive statistics in the form of frequencies and
their health status regarding antenatal exercise. It was percentages for qualitative variables, and means and standard
designed by the researcher in the form of a handout (booklet) deviations for quantitative variables. The level of significance
using simple Arabic language and different illustrative was be accepted at P< 0.05 and was be considered highly
pictures to facilitate understanding its content. significant when P-value less than or equal to 0.01.
Results
Table (1): Distribution of the primigravida women according to their demographic data (n=66).
Demographic data No. %
Age / years
15 - < 20 3 4.5
20- < 25 21 31.8
25- < 30 26 39.4
30- < 35 12 18.2
>35 4 6.1
Mean ± SD 28.4 ± 4.30 year
Residence
Rural 37 56.1
Urban 29 43.9
Education level
Primary 7 10.6
Secondary 34 51.5
University 14 21.2
Occupation
Work 11 16.7
Housewife 55 83.3
Table (1): shows that more than third (39.4%) of the primigravida women aged between 25 – 30 years with mean age 28.4 ±
4.30 years, more than half (56.1%) of them live in the rural area, about half (51.5%) of them had secondary school and more than
two-thirds (83.3%) of them were housewives.

Table (2): Mean scores of the primigravida women awareness about minor discomforts problems in pre and post-teaching
programs (n = 66).
Knowledge Pre Post t- test P-value
General knowledge 3.1 ± .9 4.6 ± .6 11.157 .0001**
Nausea and vomiting 3.4 ± .9 7.5 ± 1.4 19.938 .0001**
Heartburn 2.3 ± .7 4.7 ± 1.5 11.605 .0001**
Constipation 3.2 ± 1.0 4.9 ± .8 11.451 .0001**
Fatigue 3.1 ± 1.0 4.9 ± .9 11.213 .0001**
Ptyalism 4.2 ± 1.4 7.6 ± 1.5 13.696 .0001**
Hemorrhoid 2.2 ± .5 4.1 ± 1.4 10.481 .0001**
Varicose vein 2.2 ± .5 4.4 ± 1.2 14.144 .0001**
Shortness of breath and dyspnea 2.3 ± .6 5.2 ± .8 23.625 .0001**
Urinary Frequency and Urgency 2.8 ± .6 5.1 ± .9 17.064 .0001**
Total awareness about minor discomforts problems 19.3 ± 7.7 52.7 ± 8.3 23.977 .0001**
Table (2): presents that there was an increase in mean scores of the primigravida women awareness post teaching program
about all items of minor discomforts problems during pregnancy than a pre-teaching program with highly statistically significant
differences.
Table (3): Mean scores of pre and post-self-care management about minor discomforts problems among the primigravida
women (n = 66).
Practices Pre Post t-test P-value
Nausea and vomiting 4.2 ± 2.1 8.9 ± 2.5 11.577 .0001**
Heartburn 4.9 ± 2.0 9.2 ± 1.1 15.131 .0001**
Constipation 2.8 ± 1.6 5.5 ± 1.0 11.033 .0001**
Fatigue 2.1 ± 1.2 4.3 ± .8 12.068 .0001**
Ptylism 1.0 ± .9 2.1 ± .8 6.837 .0001**
Hemorrhoids 1.7 ± 1.3 4.4 ± 1.2 12.557 .0001**
Varicose vein .1 ± .2 .6 ± .5 8.361 .0001**
Shortness of breath and dyspnea 3.5 ± 1.8 5.6 ± 1.2 8.038 .0001**
Urinary Frequency and Urgency 1.9 ± 1.1 3.9 ± 1.0 10.804 .0001**
Total practice 22.1 ± 9.5 44.5 ± 6.9 15.429 .0001**
Table (3): indicates that there was an increase in mean scores of self-care management post teaching program about minor
discomforts among the primigravida women than a pre-teaching program with highly statistically significant differences
Total Awareness level

95.50%
100.0% Pre
90.0%
80.0% Post
70.0% 51.50%
60.0% 42.40%
50.0%
40.0%
30.0% 6.10%
4.50%
20.0% 0.00%
10.0%
0.0%
Poor Average Good
Figure (1): Comparison between pre & post teaching program among the primigravida women regard their total awareness
level about minor discomfort (n = 66)
Figure (1): demonstrates that 95.5% of primigravida women had poor awareness level about minor discomfort problems
during pregnancy pre-teaching program decrease to 6.1% of them post teaching program, 4.5% of them had average level pre-
teaching program increased to 42.4% of them post teaching program and none of them had good level pre-teaching program increased
to 51.5% of them post teaching program with a highly statistically significant difference with P value < .0001.

77.30%
Total practice level
80.0%
60.60%
70.0%
60.0%
50.0% 36.40%
40.0% 22.70%
30.0%
20.0% 3.00%
0.00%
10.0%
0.0%
Poor Average Good
Pre Post
Figure (2): Comparison between pre & post teaching program among the primigravida women regard total self-care practice
level for management of minor discomforts problems (n = 66)
Figure (2): demonstrates that 77.3% of primigravida women had a poor level in total practice about minor discomforts pre-
teaching program decrease to 3.0% of them post teaching program, 22.7% of them had an average level in total practice pre-teaching
program increased to 36.4% of them post teaching program and none of them had a good level in total practice pre-teaching program
increased to 60.6% of them post teaching program with a highly statistically significant difference with P value < .0001.
Table (4): Relation between total knowledge level pre-teaching program of the primigravida women and their demographic
characteristics (n = 66)
Total knowledge level (pre) Test of significance
Demographic characteristics Poor (n= 63) Average (n= 3) X2 P-value
No. % No. %
Age / years
15 - < 20 3 100.0 0 .0
20- < 25 21 100.0 0 .0 5.426 .246
25- < 30 25 96.2 1 3.8
30- < 35 10 83.3 2 16.7
>35 4 100.0 0 .0
Residence
Rural 37 100.0 0 .0 4.010 .045*
Urban 26 89.7 3 10.3
Education level
Read and write 11 100.0 0 .0
Primary 7 100.0 0 .0 1.215 .749
Secondary 32 94.1 2 5.9
Occupation
Work 10 90.9 1 9.1 .629 .428
Housewife 53 96.4 2 3.6
* = Statistical significance differences
Table (4): indicates that 10.3% of primigravida women live in urban areas had average knowledge levels with statistically
significant difference which P-value < .045 but there was no statistically significant difference between age, teaching level, and their
occupation and their total knowledge level pre-teaching program.
Table (5): Relation between total practice level pre-teaching program of the primigravida women and their demographic
characteristics (n = 66).
Total practice level (pre) Test of significance
Demographic characteristics Poor (n = 51) Average (n= 15) X2 P-value
No. % No. %
Age / years
15 - < 20 2 66.7 1 33.3
Total practice level (pre) Test of significance
Demographic characteristics Poor (n = 51) Average (n= 15) X2 P-value
No. % No. %
20- < 25 17 81.0 4 19.0 1.315 .859
25- < 30 21 80.8 5 19.2
30- < 35 8 66.7 4 33.3
>35 3 75.0 1 25.0
Residence
Rural 29 78.4 8 21.6 .059 .809
Urban 22 75.9 7 24.1
Education level
Read and write 8 72.7 3 27.3
Primary 6 85.7 1 14.3 2.258 .521
Secondary 28 82.4 6 17.6
Occupation
Work 7 63.6 4 36.4 6.395 .01*
Housewife 44 80.0 11 20.0
Table (5): presents that 36.4% of worked primigravida women had average practice levels than housewives' women with a
statistically significant difference which P-value < .01 but there were no statistically significant differences between age, residence,
teaching level of them and their total practice level pre-teaching program.
Table (6): Correlation matrix between total knowledge score and total self-reported practice score pre, and post-teaching
program among the primigravida women
Total knowledge Total knowledge score Total practice
score (pre) (post) score (pre)
r P – value r P – value r P-value
Total knowledge score (pre)
Total knowledge score (post) .128 .307
Total practice score (pre) .256 .038* .242 .050*
Total practice score (post) .098 .433 .663 .0001** .277 .024*
* Correlation is significant at the 0.05 level ** Correlation is significant at the 0.01 level
Table (6): presents that there was a fair positive association between the total knowledge score of primigravida women pre-
teaching program and their total practice scores pre-teaching program (r=.256 & P – value .038), there was a weak positive
association between total knowledge score of primigravida women post teaching program and their total practice scores pre-teaching
program (r=.242 & P – value .050), there was a strong positive association between total knowledge score of primigravida women
post teaching program and their total practice scores post teaching program (r=.663 & P – value .0001), and there was a fair positive
association between total practice score of primigravida women pre-teaching program and their total practice scores post teaching
program (r=.277 & P – value .024).
Discussion majority of the primi mothers had medium knowledge and the
The minor discomforts of pregnancy present most of them had good knowledge in pre-test. In post-test
difficulties for the health care provider as well as for the majority of primi mothers had reported excellent knowledge
pregnant woman herself. Management of the various and remaining primi antenatal mothers were reported good
symptoms requires astute observations and the ability to knowledge and also report the pre-test mean was 8.12±2.96
individualize therapy (El-Sharkawy & Araby, 2020). which was increased to 15.87 ±4.67 in post-test.
Regarding the demographic data of primigravida Regarding the mean scores of pre- and post-self-care
women, the current study showed that more than one third managements about minor discomforts problems among the
(39.4%) of the primigravida women aged between 25 – 30 primigravida women, the current study indicated that there
years with mean age 28.4 ± 4.30 years, more than half of them was an increase in mean scores of self-care management post
live in the rural area and had secondary school and (83.3%) of teaching program about minor discomforts among the
them were housewives. This result comes in the line with primigravida women than a pre-teaching program with highly
Hassan et al., (2020) to evaluate the impact of a tailored statistically significant differences.
educational program on primigravida anxiety and knowledge This result supported by Thomas, (2017) show that
regarding minor discomforts in Upper Egypt and reported the the mean posttest practices score (55.05) is more than the pre-
mean age of the study sample was (25.80 ± 7.48), near to half test practice e scores (25.72). in order to find the difference in
(38.0%) of them had secondary education, and 56.0% lives in significance. Hence it can be inferred that there is difference
a rural residence. in practices score after planned teaching program among
Regarding the mean scores of pre- and post-teaching sample Hence it can be inferred that there is a difference in
program, the current study showed that there was an increase practice score after planned teaching program among sample.
in mean scores of the primigravida women awareness post Also, Ahmed, (2016) who stated that the level of woman's
teaching program about all items of minor discomforts knowledge, health practices, and lifestyle increased after
problems during pregnancy than a pre-teaching program with application of the intervention as compared with before and
highly statistically significant differences. This result come in most women were satisfied after application of the
the line with (Hassan et al., 2020) who reported that the intervention and there was a highly significant difference
regarding knowledge, health practices, and lifestyle after post-teaching program among the primigravida women, the
application of the counseling intervention as compared with current study presented that there was a fair positive
pre-application of the counseling intervention (p<0.001). association between the total knowledge score of primigravida
Concerning the total awareness level about minor women pre-teaching program and their total practice scores
discomfort, the current study demonstrated that the majority of pre-teaching program (r=.256 & P – value .038), there was a
primigravida women had poor awareness level about minor weak positive association between total knowledge score of
discomfort problems during pregnancy pre-teaching program primigravida women post teaching program and their total
decrease to the minority of them post teaching program, and practice scores pre-teaching program (r=.242 & P – value
none of them had good level pre-teaching program increased .050), there was a strong positive association between total
to be more than half of them post teaching program with a knowledge score of primigravida women post teaching
highly statistically significant difference with P value < .0001. program and their total practice scores post teaching program
This result comes in the line with Abd Elhaliem, (r=.663 & P – value .0001), and there was a fair positive
AbdElhady, & Mohamed, (2018) demonstrated that most of association between total practice score of primigravida
the studied women had poor knowledge pre-intervention women pre-teaching program and their total practice scores
regarding minor discomforts compared to none them post- post teaching program (r=.277 & P – value .024).
intervention also, Vincent, et al., (2015) conducted a These results come in accordance with El-Sharkawy
descriptive study on knowledge of primi mothers on self- & Araby, (2020) who studied ''effectiveness of self-
management of minor discomfort of pregnancy intending to instructional module on knowledge and remedial practices
develop information' was carried out in Mangalore on 100 regarding selected minor ailments among primigravida'' and
primigravida mothers by using a purposive sampling reported that there was a non-significant positive correlation
technique. The findings revealed that more than half 59% of between total knowledge and total healthy practices regarding
the Primigravida mothers had poor knowledge, 29% had minor ailments at the pre-intervention phase (P > 0.05). While
average knowledge, and 12% had good knowledge regarding there was a highly positive statistical correlation between total
minor discomforts of pregnancy and its self-management. knowledge and total healthy practices regarding minor
This result might be due to the utilization of simple and clear ailments at the post-intervention phase (P ≤ 0.001).
language in the educational session and the appropriate
teaching method and audiovisual aids. Conclusion
Regarding total self-care practice level for Based on the results of the present study, it can be
management of minor discomforts problems, the current study concluded that:
demonstrated that the most of primigravida women had a poor The study concluded that most of primigravida
level in total practice about minor discomforts pre-teaching women had poor awareness level pre-teaching program
program decrease to the minority of them post teaching decrease to the minority of them post teaching program, and
program, more than one-fifth of them had an average level in none of them had good level pre-teaching program increased
total practice pre-teaching program increased to more than to half of them post teaching program, and more than three-
one-third of them post teaching program and none of them had quarters of them had a poor level in total practice about minor
a good level in total practice pre-teaching program increased discomforts pre-teaching program decrease to the minority of
to less than two-thirds of them post teaching program with a them post teaching program, and none of them had a good
highly statistically significant difference with P value < .0001. level in total practice pre-teaching program increased to near
This result supported by Ahmed, (2016) who stated to two-third of them post teaching program with a highly
that the level of woman' health practices and life style statistically significant difference with P value < .0001.
increased after application of the intervention as compared
with before and most of women were satisfied after Recommendations
application of the intervention and there was a high significant Based on the results of the present study and
difference regarding knowledge, health practices and life style research questions the following recommendations are
after application of the counseling intervention as compared suggested:
with pre application of the counseling intervention (p<0.001). Counseling and nursing intervention for newly
Regarding the relation between total pregnant women about:
knowledge level post teaching program of the primigravida a) Most common minor discomfort during pregnancy.
women and their demographic characteristics, the current b) Providing posters, booklets, and leaflets for newly
study presented that primigravida women aged between 20 – pregnant women, which describe care.
25 years had good knowledge post teaching program than c) Periodic antenatal care for pregnant women.
other ages with statistically significance difference which P- d) Providing practical guidance on every health issue
value < .005 but there were no statistically significant regarding minor discomfort.
differences between residence, teaching level, occupational of
them and their total knowledge level post teaching program. References
This result come consistent with Aldossary et al., (1) AbdElhaliem, S., AbdElhady, R., & Mohamed, A. (2018).
(2018) who reported that there was significance differences Utilization of Self-Care Practice Guideline on Relieving Mino
Discomfort (Ailments) Among New Pregnant Woman. IOSR
between mothers knowledge score with their age. But this Journal of Nursing and Health Science, 7(1), 07-15.
result differ with Hassan et al., (2020) who reported that a (2) Ahmed, A. (2016). Effect of Counseling Intervention on Women's
statistical significant relationship between the pregnant Knowledge, Practices and Lifestyle of Fetal Well-being among
women’s knowledge regarding minor disorders of pregnancy Primigravidae. International Journal of Nursing Science, 6(4), 87-
93.
and their residences, occupation status (Р<0.05). (3) Aldossary, A. D., Al Shamandy, S. A., & Haitham, A. A. (2018).
Regarding the correlation matrix between total A cross sectional study about knowledge and practice of
knowledge score and total self-reported practice score pre, and primigravida women: minor and common pregnancy discomforts.
J Nurs Health Sci, 4(1), 32-45.
(4) Amasha H., and Heeba M. (2013). Maternal Awareness of (9) Khalil, H. M., & Hamad, K. J. (2019). Knowledge of Minor
Pregnancy Normal and Abnormal Signs: An Exploratory Discomforts during Pregnancy among Pregnant Women Attending
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Minia Scientific Nursing Journal (Print - ISSN 2537-012X) (Online - ISSN 2785-9797) Vol. (8) No.

(1) December 2020

3. Effect of educational nursing guideline about paracentesis procedure care on nurses' 21

7. Assessment of Pain Intensity among Preschool-age Children during Venipuncture 56

8. Knowledge and Performance of Mothers Having Children with Cancer Undergoing 65

9. Effect of Kegel Exercise on Improving Manifestations of Uterine Prolapse among Pre 75

11.Early Identification of Risk Factors for Primary Postpartum Hemorrhage at Admission 90

13.Effect of Educational Program on Nurses Performance about Colostomy Care 103

Introduction Nurses play a vital role in the administration of

Subjects The nurses’ total practice score was classified as:

1. Infection control 3 10.3 8 27.6 11 19.0 2.831 .243

* Statistically significance differences **Highly statistical significance differences

* Statistically significance differences **Highly statistical significance differences

Discussion of nurses had good knowledge regarding care and peripheral

1. B.Sc. Nursing south valley university.

Introduction World Health Organization (WHO) motivates that

90.00% 76.00% 82.40%

Discussion clinical record review, there was no specific follow up or

1. Clinical instructor of Medical Surgical Nursing-Faculty of Nursing - South Valley University

Introduction care is beginning with (assessment for patient condition, vital

Aim of the study 2. Second Tool: Observational checklist adopted from

Tools of data collection Pilot study

Nurses level of practice regarding paracentesis procedure (n=40)

1-7yrs 22 55 7 17.5 .162 2 5 27 67.5 .055 4 10 25 62.5 .120 9 22.5 20 50 .661

Rural 18 45 7 17.5 1.15 1 2.5 24 60 1.17 3 7.5 22 55 .471 7 17.5 18 45 .008

Rural 19 47.5 6 15 1.95 2 5 23 57.5 .024 3 7.5 22 55 .471 8 20 17 42.5 .127

Discussion Discussion of the demographic characteristics of the

Introduction al., 2018).The role of the nurse is to contribute to the

* Statistical significant difference, Chi-squared test.

Discussion susceptibility to IA. Concerning the beliefs regarding the

1. B. Sc in Nursing, Minia University, Egypt.

Introduction A positive attitude among nursing students will bring

Part 1: Demographic Characteristics of the student, it

Discussion practice regarding blood donation among medical students of

1. B.Sc. Nursing Faculty of Nursing-Minia University;

Introduction As pregnancy progresses, the exercise program may

Immediate educational post education

Total awareness Total SF Total practice

Assessment of Pain Intensity among Preschool-age Children during Venipuncture

1. Master degree in Pediatric Nursing Faculty of Nursing, Minia University

Introduction &Danford, 2016). Uncontrolled pain also has a direct impact

Dorsal hand veins Forearm veins (cephalic or basilic vein )

- The child talks about positive things 0 0

Discussion Sadek (2017) and Ebrahem et al. (2019) to examine the

(1) Master degree in Pediatric Nursing Faculty of Nursing, Minia University

Introduction nervous system (CNS) tumors, and neuroblastoma. The

NS= Not statistically significant differences ** Highly statistically significant differences

Discussion mothers having children with leukemia undergoing

Effect of Kegel Exercise on Improving Manifestations of Uterine Prolapse among

(1) Clinical instructor- Technical Institute of Nursing - Minia University

Corresponding Author: Shaimaa Gamal Ramadan Hassan

Introduction require no treatment. Some women with a more advanced

Uterine Prolapse degree of Symptoms

Discussion manifestations of uterine prolapse than those who do not

Introduction: Robins, 2018). Parental neglect or lack of warmth is known to

Part (III): Hare Self-Esteem Scale (HSS, 1975). Ethical Consideration

Figure (1): Levels of aggressive behavior among foster children N=(51)

Figure (2): Levels of self-esteem among foster children N=(51)

Discussion (children enter foster care because of divorce) especially

Early Identification of Risk Factors for Primary Postpartum Hemorrhage at Admission

(1) Bachelor of Nursing, Faculty of Nursing, Minia University

Introduction Reexamination of the patient’s vital signs and vaginal

Effect of immediate pain management on oxygenation level among early extubation

Introduction As early weaning is accompanied by early pain management,