Journal Pre-proofs

Knowledge related to Chronic Kidney Disease (CKD) and perceptions on in‐

patient management practices among nurses at selected referral hospitals in
Rwanda: A non-experimental descriptive correlational study

B. Emmanuel Gapira, Geldine Chironda, Didace Ndahayo, Theos Mbambazi,

Marie Jeanne Tuyisenge, Lakshmi Rajeswaran

PII: S2214-1391(20)30080-9
DOI: https://doi.org/10.1016/j.ijans.2020.100203
Reference: IJANS 100203

To appear in: International Journal of Africa Nursing Sciences

Received Date: 28 August 2019

Revised Date: 15 April 2020
Accepted Date: 16 April 2020

Please cite this article as: B. Emmanuel Gapira, G. Chironda, D. Ndahayo, T. Mbambazi, M. Jeanne Tuyisenge,
L. Rajeswaran, Knowledge related to Chronic Kidney Disease (CKD) and perceptions on inpatient management
practices among nurses at selected referral hospitals in Rwanda: A non-experimental descriptive correlational
study, International Journal of Africa Nursing Sciences (2020), doi: https://doi.org/10.1016/j.ijans.2020.100203

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ABSTRACT

Introduction

Chronic Kidney Disease (CKD) is a serious condition to manage and requires multidisciplinary
team involvement. Nurse’s knowledge and perceptions regarding management of CKD is
paramount as this decrease the morbidity and mortality among the population.

Purpose of the study

The purpose of this study was to assess the knowledge related to CKD and perceived inpatient
management among nurses at selected referral hospital in Rwanda.
Methodology

This study used a non-experimental descriptive correlation design. A purposive sampling strategy
was used in selection of 120 nurses working in internal medicine, emergency and renal units. Data
was collected using a self-administered questionnaire. Descriptive statistics and inferential of Chi
-square and Pearson’s correlation coefficient were used to analyze the data.

Results: Eighty four percent (84%) had moderate level of knowledge related to CKD and 51% of
nurses had moderate level of perceptions regarding of inpatient management of CKD. The factors
associated with knowledge were institution type (p=.024), department (p=.000), level of education
(p=.010) and type of specialty (p=.000). The factor associated perceived inpatient management of
CKD was department type (p=.015). A very weak non-significant positive relationship (r = .115,
N = 120, p = .21) between knowledge and practice was observed.
Conclusion: The level of knowledge related to CKD and perceived inpatient management was
moderate among nurses. Therefore, in-service training for registered nurses working in the internal
medicine and emergency is called for and further research is needed to elicit the major contributory
factors to improper inpatient management.

Key-words: Chronic Kidney Disease, nurses, knowledge, perceptions, inpatient management.

1.Introduction

Chronic kidney disease is now known as a major medical problem worldwide. In 2015, the global
burden of disease study emphasizes chronic kidney disease as 17th among the causes of death
worldwide and among the five causes of death in many countries (Jai & Modi ,2017) with an
estimated prevalence of 15.8% (Kaze et al, 2018). It is defined as an estimated glomerular filtration
rate less than 60ml/min/1,73m2 and persistent albuminuria (Jadoul et al., 2018) and from stage 3
to stage 5, 50% of kidney function has been lost with significant increased risk of morbidity and
premature deaths (Hoerger et al. ,2015). End stage renal disease or stage five is the worst stage of
chronic kidney disease where death is an inevitable consequence unless the renal replacement
therapy is introduced (Etheredge & Fabian, 2017). A recent systematic review for Africa revealed
a pooled prevalence of 10, 1% (95CI 9.8% to 10.5%) among the population suffering from chronic
kidney disease (ElHafeez et al, 2018). The severity in sub-Saharan Africa seems to be higher as
evidenced by an estimated pooled prevalence of more than 14% (ElHafeez et al, 2018 & Kaze et
al, 2018).

Regarding east African region where Rwanda is situated, the prevalence is approximately 14.4%
(Kaze et al, 2018). In Rwanda little is known about prevalence of chronic kidney disease but the
expected prevalence is approximately 10% with the main causes as hypertension, diabetes mellitus
and Human Immunodeficiency Virus (Kalyesubula et al., 2017). Proper medication management
of comorbidities like diabetes mellitus, hypertension in chronic kidney disease patients can reduce
the complications of chronic kidney disease, prolong the lives of chronic kidney disease patients
so that they will probable get a kidney transplantation and improve their quality of life (Geldine et
al.,2017). CKD management with dialysis, nutrition, and fluid restriction improve quality of life
and minimizing complications related to CKD (Wouters et al, 2015). Hence the need for nurses to
have knowledge and positive practice behaviors towards the management of CKD patients.

Clinical experiences revealed altered knowledge and improper inpatient management of CKD and
their limited literature in Rwanda to ascertain this. However, a study done in Nepal revealed 44%
of nurses having low level of practice regarding patient’s care during hemodialysis (Al-mawsheki
I et al, 2016). In Tanzania, 59.4% of nurse revealed low knowledge of CKD with 72.4% not
knowledgeable about nutrition of chronic kidney disease patients (Munuo et al.,2016). Moreover,
moderate knowledge to majority [70.6%], with only 17.6% good knowledge and 11.8% low
knowledge was highlighted among nurses (Younis et al, 2018). A study conducted by Munuo et
al (2016) among health care workers highlighted a significant association between age group
(p=0.01), work experience(p<0.01) and nutrition knowledge of participants(p≤0.001) in relation
to management of CKD. However, some studies reveal non-significant associations between
knowledge and age (p = .31) as well as knowledge and years of nursing experience (p =.488)
(Adejumo et al, 2018 & Al-mawsheki et al, 2016). Furthermore, Parvez et al (2016) identified a
significant difference in knowledge between the groups, with primary care providers reporting
more uncertainty about relative survival rates with conservative management compared with
different patient groups(p≤0.04). Of the aforementioned studies, Al-mawsheki et al (2016)
identified no relationship between knowledge and practice though it was on only considering
patients on hemodialysis.

The knowledge and proper inpatient management of CKD for health care providers is crucial in
reducing mortality and morbidity among CKD patients (Sinclair et al., 2017). Mismanagement of
CKD patients tend to increase mortality and morbidity, quick progression to end stage renal disease
(ESRD), decreased quality of life, recurrent infections of patients with catheters who are on
hemodialysis, malnutrition among CKD patients and fluid overload (Sadeghpour et al.,2019). In
Rwandan context, the management of CKD patients is done at tertiary hospitals and encompasses
dialysis (hemodialysis and CAPD), medication compounded with dietary and fluid restriction.
Hence the present study is focusing on assessing knowledge related to CKD and inpatient
management perceptions among nurses at selected referral hospitals in Rwanda.

2.Purpose of the study

The purpose of this study was to assess the knowledge related to CKD and perceived inpatient
management among nurses at selected referral hospital in Rwanda.

3.Specific objectives

To describe the level of knowledge related to Chronic Kidney Disease (CKD) among nurses at
selected public referral hospitals in Rwanda.
To determine the perceptions regarding inpatient management of CKD among nurses at selected
public referral hospitals in Rwanda.

To establish factors associated with nurses knowledge and perceptions regarding inpatient
management of CKD at selected referral hospital in Rwanda.

To examine the relationship between knowledge and perceptions regarding inpatient management
of CKD of nurses at selected referral hospital in Rwanda.

Definition of key words

Knowledge: Is the extent to which a person has theoretical and practical information required to
perform a task including the ability to apply again in the work (Tran, 2014). In the present study,
the level of knowledge refers to extent to nurse’s knowledge about CKD definition, causes, risk
factors and complications.
Perceptions: Is the act or faculty of perceiving, or apprehending by means of the senses or of the
mind; cognition; understanding. (The American Heritage® Stedman's Medical Dictionary ,2019).
In this study, perceptions refer to how nurses apprehend and understand the management of
admitted CKD patients in terms of their dialysis, medications, fluid restriction and nutrition.
In patient Management: refers to treatment provided in a hospital or other facility and this
requires at least one overnight stay (Santiago, 2019). In this study inpatient management refer to
the treatment of admitted CKD patients using medication, fluid restriction, dialysis and nutrition
in emergency, internal medicine and renal unit.
Chronic kidney disease (CKD): is an abnormalities of kidney structure or renal function as
defined by markers of kidney disease or decrease in GFR below 60ml/min/1.73m2 for more than
3 months (Delanaye et al, 2019). In this study, CKD is operationalized as the disease of focus.
Nurse: is a healthcare professional who is focused on serving of individuals, families and
communities, ensuring that achieve, maintain and recover optimal health and functioning.
(Henderson, 2006). In this study, nurses are members of registered health care practioners with
Nursing council of Rwanda. They work in internal medicine, emergency as well as renal unit with
the expectations of identifying and treating patients with CKD according to prescribed regimen.
4. Methodology

4.1. Study Design

A non-experimental descriptive correlational study to assess knowledge on CKD and perceptions

regarding inpatient management among nurses at selected public hospitals in Rwanda.

4.2. Study setting

The study setting was carried out at 2 public referral hospitals in Kigali/ Rwanda. The two
hospitals were considered because they are both referral public hospitals with same practice
regulation on CKD management. They are located in Kigali city and cover almost 85 percent of
the country in terms of receiving referred patients from district hospitals.

4.3. Study population:

The population was composed of registered nurses working at 2 hospitals in emergency, internal
medicine and renal units. Because when CKD patients came to these referral hospital, diagnosis
is made at emergency, patients with CKD at stage 1 to 4 are transferred to internal medicine where
medication, fluid restriction and diet is managed whereas patients who are at ESRD who need to
start hemodialysis, they are transferred to renal unit for renal replacement therapy and thereafter
send back to internal medicine when are not stable.
Inclusion and exclusion criteria
Inclusion criteria in the study were registered nurses working in emergency, internal medicine and
renal unit for at least 3months. Those available at the time of the study and signed consent form
were included in the study. Excluded were nurse aides, registered nurses not working in
emergency, internal medicine and renal unit as well as those on maternal leave, annual and sick
leave. Moreover, newly qualified registered nurses were excluded because they were not going to
give realistic perceived knowledge and comprehend inpatient management of CKD.
4.4. Sample size
Sample size defined as a subset of the population that is selected for a particular study (Burns and
Grove,2012). Initially, the targeted sample size for registered nurses was 146. After applying the
exclusion criteria, the sample size for the study was 120 registered nurses working in emergency,
internal medicine and renal units at selected study sites. The sample size was obtained using the
concept of census population where the entire population was included in the study (Polit and
Beck, 2012). In this study, all available nurses who meet the selection criteria were included in the
sample. A census sample was used because the entire population was small, so the data was
gathered from every member of the population. Moreover, the authors have selected two hospitals
to maximise the sample size.
Sampling strategy
Convenience sampling strategy was used to select the study participants. This type of non-
probability sampling method is based on the ease and efficiency (Grove, Burns and Gray, 2013).
The researchers selected a group of registered nurses who were conveniently available to
participate in study.

4.5. Data collection instruments

With given permission, knowledge questions for the data collection tool were adopted from the
instrument developed by Choukem et al (2016). The researchers only adopted the knowledge
questions from Choukem et al (2016) as the tool was measuring Knowledge and attitudes.
Although the knowledge questions were used on physicians, nurses are also part of the health care
team who are supposed to have same knowledge related to CKD as physicians hence the
applicability of knowledge question to the scope of nurses. The authors gave permission to use
and modify the tool to suit the context of Rwanda. All the questions for inpatients management of
CKD were derived from further in-depth literature (Al-Mawsheki et al, 2016 & Parvez et al. 2016).

The tool was composed of 3 sections. Section A was made of demographic data questions namely
Institution type, department type, Age, Gender, years of experience, level of education and type of
specialty. Section B was made of Knowledge questions on definition of CKD, risk factors of CKD,
marker of kidney function, classification of CKD, complications of CKD, forms of renal
replacement therapy (RRT), medication administration in CKD patients, management of nutrition
in CKD patients, fluid management in CKD patients and hemodialysis in CKD patients. Section
C was made of practice questions about management with medications, fluid, nutrition,
hemodialysis and peritoneal dialysis. Practice questions were formulated by giving a scenario on
inpatient management and participants response was agreeing or disagree with this management.

The minimum possible total score of knowledge was zero (0) and the maximum possible score,
signifying level of knowledge of inpatient management of CKD among nurses was twenty-four
(24). Dividing the attained score on this section by the maximum possible attainable score (24)
and multiplying by a hundred to come up with a percentage calculated level of knowledge of 80%
to 100% was classified as high, 79% to 50% was classified as moderate and level of below 50%
was considered as low.

The minimum possible total score of perceptions was zero (0) and the maximum possible score,
signifying high level of perceptions regarding inpatient management of CKD among nurses was
seven (7). Dividing the attained score on this section by the maximum possible attainable score (7)
and multiplying by a hundred to come up with a percentage calculated level of 80% to 100% was
classified as high, 79% to 50% was classified as moderate and level of below 50% was considered
as low level of perceptions. The investigators developed the scale because no scale was found in
literature. The development of the scale was based on the pass mark for knowledge and practice
in clinical area used by the nursing council and academic institutions in Rwanda.

4.6. Validity and reliability of the data collection instrument

The researcher has evaluated the validity of this instrument in terms of face and content validity.
In this study face validity has been observed in 3 sections of questions in questionnaire. However,
since face validity is the weakest measure, the researcher considered content validity of the
instrument. In this study the content validity was enhanced by the use of adopted instrument on
knowledge questions and other components of in-depth literature for formulating questions
relating to inpatient management of CKD among nurses. After that, the instrument was given to
experts in clinical and academics for reviews and comments. Further, the content validity ratio was
calculated for each item on a scale by rating 0 (not necessary),1(useful), or 3(necessary).
Measurement of content validity index for the instrument by giving the instrument to 6 experts for
rating each item in instrument using a 4 point. content validity ratio obtained was 0.7. The closer
the CVR is to 1.0, the more essential the items in the instrument are considered to be. For this
study, CVR was close to one meaning the experts considered all items in the instrument to be
essential.

In this study reliability was considered to identify any inconsistencies seen in the research tool.
Nurses were administered questionnaire to evaluate its level of consistency; each nurse of these 15
responded to questionnaire two times in interval of 2 weeks. 15/15 of nurses answered to the
questionnaire in the same manner and the consistent of the tool has been observed. The instrument
was translated to French and Kinyarwanda, and backtranslation for evaluating the consistency of
instrument. During data collection, the same instrument was used for all participants. Furthermore,
internal consistency of the instrument was generated and the Cronbach alpha was found to be 0.75.
This means that the instrument was a reliable measure of the all the variables under study.

4.7. Data collection process

After getting information of Institutional Review Board (IRB), RMH and CHUK authorities, the
researcher proceeded to emergency, internal medicine and renal units of the selected sites to start
data collection. On arrival to this service, the in charge of the unit was informed. The purpose of
the study was explained through the information sheet where the participants were instructed to
read it carefully. The components of the participants information sheet included introduction of
data collector, purpose of the study, study site, duration of the completing the questionnaire, type
of questions to be completed, possible risks involved, benefits of the study, maintenance of
confidentiality and contact information of the researchers and ethical boards in case the
participants need to report on the study. Thereafter, those who were willing to participate signed
the consent form before filling the questionnaire. The participants were informed of returning the
completed questionnaires in a sealed envelope and deposit them at ward in-charge office for
collection by researcher.

4.8. Data analysis

Data analysis was done using the statistical package of social science (SPSS) version 21. Before
entering into SPSS software, the data was cleaned, number coded and there was no missing data
in all the completed questionnaires. Descriptive statistics were used to describe the demographic
variables, nurse’s knowledge related to CKD and perceptions regarding inpatient management.
Inferential statistics of chi-square test was used to establish association between demographic
characteristics and nurse’s knowledge on CKD and perceptions regarding inpatient chronic kidney
disease management. The level of significance used was p at .05. Knowledge and inpatient
management of CKD were two continuous variables which were normally distributed, hence the
use of the Pearson correlation coefficient was calculated to identify relationship between the
aforementioned two variables. Regarding the strength of the relationship, 0.10 to 0.29 considered
as weak correlation/relationship, 0.30 to 0.49 considered as moderate relationship/medium
correlation and 0.50 and above considered as high correlation (Hall, 2015). Weak correlation
would imply lower likelihood of the existence of a relationship between knowledge and
perceptions of nurses on inpatient management of CKD, meaning the variables are hardly related.
Moderate correlation mean that a substantial relationship exists between the two aforementioned
variables under study. High correlation would mean strong relationship between the nurses’
knowledge related to CKD and perceptions on inpatient management.

4.9. Ethical considerations

Before data collection ethical clearance was obtained from University of Rwanda College of
Medicine and Health Sciences institutional review board (Ref: CMHS/IRB/033/2019) and Ethical
Committee of Hospital 1 (Ref: RMH/IRB/010/2019) and Hospital 2 (Ref: EC/CHUK/038/2019)
was obtained. Participants right to confidentiality, to privacy, to self-determination, to fair
treatment were observed. Written informed consent was obtained from participants after full
explanation of the interest of the study to the participants.

5. Results
5.1. Demographics

Table1 displays results on Institution type, department type, gender, age, year of experience, level
of education and type of specialty of the participants. The sample of 120 nurses revealed 69
(57.5%) of participants to be working in hospital 2. In terms of department type, 53(42.5%) of
participants were taken from emergency ,57 (47.5%) in internal medicine and 10 (8.3%) from renal
unit. In terms of gender, the majority [77(64.2%)] were females. Majority of participants
[81(67.5%)] were in the age group of between 31 -40 years old. A substantial number [67(55.8%)]
had 1-5 years of nursing experience. In terms of level of education, most 72(60%) had advanced
diploma with only 2(1.7%) participants trained at masters level. There were only 3(2.5%)
nephrology trained nurses with majority being [117(97.5%)] registered general nurse without any
specialty.

5.2. Nurses Knowledge related to CKD

Table 2 below displays knowledge related to CKD of the selected participants. There were
73(60.8%) who failed the definition of CKD whilst 110(91.7%) of participants correctly responded
to the question of diabetes as a risk factor of CKD. Approximately 105(87.5%) correctly identified
drugs as a risk factor of CKD and 112(93.3%) confirming hypertension as a risk factor of CKD.
Most [100(83.3%)] answered correctly to the question of glomerulonephritis as a risk factor and
83(69.2%) failed to identify HIV as a risk factor of CKD. Seventy (58.3%) correctly identified
hepatitis as a risk factor of CKD.

There were 106(88.3%) who correctly identified glomerular filtration rate and creatinine clearance
as appropriate marker of kidney function whilst the majority [85(70.8%)] of participants failed to
the question of classification of CKD. Three quarters [90(75%)], 110(91.7%) and 111(92.5%)
correctly agreed to anemia, hyperkalemia and uremia as complications of CKD respectively.
Moreover, 100(83.3%) of participants correctly answered hypertension whilst more than half
[67(55.8%)] failed to identify osteodystrophy as a complication of CKD. The participants correctly
answered edema [99(82.5%)] nausea and vomiting [88(73.3%)] and coma [98(81.7%)] as
complications of CKD.
Whilst 71(59.2%) failed to identify peritoneal dialysis as form of renal replacement therapy,
117(97.5) and 79(65.8%) correctly agreed to kidney transplantation and hemodialysis as forms of
renal replacement therapy. Approximately 71% participants correctly agreed to nephrotoxic drug
dose reduction in cases where eGFR<60ml/min/1.73m2 and 91(75.8%) correctly answered to
consider nutrition in CKD patients due to the risk of electrolytes imbalance. Further, 78(65%)
failed the question of fluid intake of output +1.5liter in CKD stage 4 & 5 who are not on
hemodialysis and 101(84.2%) incorrectly identified hemodialysis as management of stage 3 CKD.

5.3. Perceptions of nurses regarding inpatient management of Chronic Kidney Disease

(CKD)
Table 3 displays results regarding nurses’ perceptions on inpatient management of CKD. More
than half [63(52.5%)] of participants agreed to accurately replace glipizide with prescribed
metformin 500mg twice a day for a 48 years old man with laboratory studies showing eGFR of
55ml/min/1.73m2. Sixty-six (55%) agreed to correctly administer prescribed oral cipro floxacillin
to 65-year-old woman with stage 4 CKD secondary to hypertension with signs of urinary tract
infection. Whilst 78(65%) of participants agree to give the required food intake of chicken, fish,
beef, eggs, soybeans and quinoa as protein requirement for a patient on hemodialysis with albumin
of 2.6g/dl, 72(60%) disagreed to achieve an energy requirement of 23 to 35 kcal/day for a 70 years
old patient with stage 3 C KD with poor appetite.

About 66(55%) of participants agreed to promptly administer 3% of normal saline intravenously

to a 56 years old man who comes to hospital with long history of alcohol use, decreased breath
sounds, hepatomegaly with blood chemistry of creatinine:0.8mg/dl, Na:108mEq/L and
urea:4mg/dL. There were 66(55%) of participants who agreed to correctly administer prescribed
Intraperitoneal antibiotics for a 67-year-old man with mild neurocognitive disorder (dementia),
abdominal pain for the past 48 hours and lab diagnoses of gram positive in peritoneal fluid. Almost
half [61(50.8%)] of participants disagreed to give prescribed sodium modeling to a 60-year-old
woman with ESRD on HD with cramping during hemodialysis, weakness after each treatment and
Post-treatment HR of 95/min and BP of 90/60 mmHg (Refer to Table 3).
5.4. Level of knowledge related to CKD and perceptions regarding inpatient management of
CKD
Referring to table 4, the minimum and maximum total scores on knowledge was 10 and 23 out of
possible score of 24 respectively. The mean, mode and median were 16.3, 17 and 16 respectively
showing that the data was normally distributed. Only 12% of the participants scored high level,
84% moderate and the minority [4%] low level of knowledge of related to CKD. The minimum
and maximum total scores on perceptions section was 0 and 6 respectively. The median, mode and
mean of perceptions were 4, 4 and 3.7 respectively showing evidence of normality for the data.
There were only 7.5% who exhibited high level, 51% moderate and 42.5% of participants have
low level of perceptions of inpatient management of CKD (Refer to Table 4).

5.5. Factors associated with knowledge related to CKD and perceptions on inpatient
management of CKD.
In table 5 below, the factors associated with knowledge related to CKD were institution type (mean
= 16.3; 95% CI (15.5–17); p=.024), department type (mean = 17.6; 95% CI (16.6–18.6); p=.000),
level of education (mean = 17.4; 95% CI (12.1–22.6); p=.010) and type of specialty (mean = 19.4;
95% CI (18.4–20.3); p=.000). The factor associated with perceptions regarding inpatient
management of CKD was work service (mean = 3.8; 95% CI (3.4–4.3); p=.015). Pearson
correlation coefficient revealed a non-significant weak positive relationship (r 0.115, p=.21)
between knowledge related to CKD and perceptions on inpatient management of CKD
6. Discussion

The results of the current study revealed the majority of nurses having moderate knowledge related
to CKD with only 12% showing high level of knowledge. This is in agreement with Al-mawsheki
et al (2016) study who showed 90% of nurses with satisfactory level of knowledge. Moreover,
moderate knowledge to majority [70.6%], with only 17.6% good knowledge and 11.8% low
knowledge was highlighted among nurses (Younis et al.,2018). Furthermore, Adejumo et al (2018)
observed 6% of the respondents with good knowledge, 55% fair knowledge, and 37% had poor
knowledge of CKD. Medical specialists had shown a higher mean knowledge on CKD score
(13.75) compared to medical doctors and nurses with mean scores 12.05 and 9.51 respectively
(Munuo et al, 2016) yet they spent most of the time with the patient. Basically, significant
deficiencies in the knowledge of CKD among nephrology and non-nephrology nurses who
participated in the study is alarming. This lack of adequate knowledge related to CKD among
nurses comes with negative implications on the patients.

Narva et al (2016) highlighted confusion related to knowledge of CKD among health care
providers as a limiting factor for provision of education to patients with CKD. A study by Lederer
et al (2015) highlighted patients reporting limited CKD knowledge and dissatisfaction with the
patient-provider relationship thus affecting effective communication between the two parties. This
mainly happens when the health care providers including nurses have limited knowledge regarding
the condition they are looking after in the ward as this compromises their ability to educate
patients. Knowledge of nurses in caring for CKD patient is paramount and needs to be improved
through using variety of educational interventions. The study of Kadium (2015) gave an evidence
of a statistically significant (t (55) = −4.46, p < .001) improvement in the registered dialysis nurses’
knowledge followed the educational intervention.

Satisfactory level on perceived inpatient management of CKD was revealed in half [51%] of the
participants. There were only 7.5% with high level and 42.5% exhibited low level of perceptions
of inpatient management of CKD. This is in agreement with Al-mawsheki, et al. (2016) who
revealed 44 % of studied nurses with low level of perceptions. Munuo et.al (2016) shared the same
sentiments as their study showed 92% of health care workers which include nurses did not see the
need to use any nutrition guidelines in management of CKD. Moreover, the study of Narva et al
(2016) concurred with the results of the current study as limited clinical confidence among health
care providers mimic their ability to positively provide proper inpatient management of CKD.
According to Donald et al (2018), interventions which facilitates self-management of CKD
patients are administered by a variety of providers with nursing professionals predominantly the
most common health professional group. Hence the need for nurses to be equipped with better
practice behaviors so that they will be able to effectively provide inpatient care to CKD population.

The present study highlighted knowledge related to CKD to be associated with institution type
(p=.024), department type (p=.000), level of education (p=.010) and type of specialty (p=.000).
The present study is reinforced by Munuo et al. (2016) were significant relationship between age
group (χ 2 = 16.69; p = 0.01), work experience (χ 2 = 18.61; p < 0.01) and nutrition knowledge of
participants was observed. According to Adejumo et al (2018), nurses who had nephrology posting
during their training had significantly higher mean knowledge score than others (14.38 ± 2.25 vs.
12.93 ± 3.10, P = 0.036). The present study showed a significant higher mean knowledge score
(22.6(21.2-24.1), p = .000) for specifically nephrology trained nurses than registered general
nurses. Moreover, nurses who were currently working in renal units had better knowledge of CKD
(21.2(19.5-22.9), p = .000) than those working in internal medicine and emergency department.

The only factor associated with perceived inpatient management in the present study was
department type (p=.015) and no documented literature could be found to attest this. Nurses
working in Renal unit had better perceptions of inpatient management of CKD patients than those
in other selected departments namely internal medicine and emergency department. In addition, a
non-significant weak positive correlation (r 0.115, p=0.210) between nurse’s knowledge related to
CKD and perceptions on inpatient management of CKD was highlighted by the present study. This
is supported by Al-Mawsheki, et al. (2016) who revealed a very weak non-significant correlation
(r = 0.147, p = .31) between knowledge related to CKD and the view of nurses on care for the
patients during hemodialysis.

7. Limitations to the study

The study was only conducted on nurses in 2 referral public hospitals, therefore generalizability
of the results to other public referral hospital was is possible. There was a possibility of information
bias because nurses might not have been able to comprehend the content of the questionnaire as
the researcher was not there during completion of the questionnaires. The researchers used
questions with yes / No answers to assess knowledge and this gives 50% probability of choosing
correct answers even if the nurses were ignorant. Moreover, the response of nurses on inpatient
management of CKD were based on their experience of caring for patients with CKD.

8. Conclusion

Moderate levels of knowledge related to CKD and perceptions of inpatient management was
evident among nurses working with CKD patients with significant associated factors
predominantly affecting knowledge. In-service training on CKD should be introduced to alter the
perceptions of nurses on inpatient management of chronic kidney disease. General nurses need to
be given adequate evidence-based knowledge at university level to enable them to appropriately
manage patients with CKD. Further research to elicit the major contributory factors affecting
inpatient management of CKD among nurses should be carried out.

9.Conflict of interest

The authors declare that they have no conflict of interests.

10.Funding

None
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ABSTRACT

Introduction

Chronic Kidney Disease (CKD) is a serious condition to manage and requires multidisciplinary
team involvement. Nurse’s knowledge and practice regarding management of CKD is paramount
as this decrease the morbidity and mortality among the population.

Aim

To assess knowledge related to CKD and perceptions regarding inpatient management of CKD
among nurses at selected referral hospital in Rwanda.

Methodology

This study used a non-experimental descriptive correlational design. A purposive sampling

strategy was used in selection of 120 nurses working in internal medicine, emergency and renal
units. Data was collected using a self-administered questionnaire. Descriptive statistics and
inferential of Chi-square and Pearson’s correlation coefficient were used to analyze the data.

Results: Eighty four percent (84%) had moderate level of knowledge related to CKD and 51% of
nurses had moderate level of perceptions regarding of inpatient management of CKD. The factors
associated with knowledge were institution type (p=.024), department (p=.000), level of education
(p=.010) and type of specialty (p=.000). The factor associated with perceptions was department
type (p=.015). A very weak non-significant positive relationship (r = .115, N = 120, p = .21)
between knowledge and practice was observed.
Conclusion: The level of knowledge related to CKD and inpatient management perceptions was
moderate among nurses. Therefore, in-service training for registered nurses working in the internal
medicine and emergency is called for and further research is needed to elicit the major contributory
factors to inpatient management perceptions among nurses.

Authors' contributions
Emmanuel Gapira. B and Geldine Chironda: primary investigators

Emmanuel Gapira. B and Geldine Chironda: Conceptualization and methodology

Emmanuel Gapira. B and Geldine Chironda, Lakshmi Lajeswaran, Didace Ndahayo, Marie Jeanne
T, Pierre Marie Theos M: Methodology.

Emmanuel Gapira. B and Geldine Chironda participated in responding to comments of reviewers

and developing the revised version.

Declarations:

 Ethics approval and consent to participate

The protocol for research has been approved by Institutional review board (IRB) of the College of
Medicine and Health Sciences (CMHS/IRB/033/2019), University of Rwanda after reviewing the
study protocol. Also, the institutional review board of Rwanda military hospital
(RMH/IRB/010/2019) and Centre hospitalier universitaire de Kigali (EC/CHUK/038/2019)
offered permission to collect data. Informed consent and participant authorization were sought
from the study participants.

Availability of data and material

The study materials and instruments used during the current study are available from the
corresponding author on reasonable request.

 Competing interests

The authors declare that they have no competing interests.

 Funding

None

 Authors' contributions
E.G.B and G.C developed the concept and study design. E.G.B, G.C, D.N, M.N, TM and M.J.T
participated in the conception, design, analysis and/or interpretation of data. E.G.B and G.C served
as primary investigators. G.C and E.G.B contributed to the development of the study instrument.
E.G.B, G.C, D.N, M.N, TM and J.T led participants recruitment, selection of study site, carried
out the data collection, transcribed and translated the data into English, and analyzed the results.
All authors participated in writing the manuscript by reviewing drafts and approving the final
version.

 Acknowledgements

We would like to thank the study site and participants.

Table 1. Demographic characteristics (N=120)

Variable Frequency Percentage (%)

Institution type
RMH 51 42.5
CHUK 69 57.5
Department type
Emergency 53 44.2
Internal medicine 57 47.5
Renal 10 8.3
Gender
Male 43 35.8
Female 77 64.2
Age
20-30 25 20.8
31-40 81 67.5
41 and above 14 11.7
Years of Experience
1-5 Years 67 55.8
5 years and above 53 44.2
Level of Education
Masters 2 1.7
Bachelor 46 38.3
Advanced diploma 72 60
Type of specialty
 Nephrology 3 2.5
Critical care and trauma 0 0
Registered general nurse 117 97.5

Table 2: Knowledge related to CKD among nurses (N=120)

Variable Correct Answer Wrong Answer
CKD is condition of chronically elevated serum Freq % Freq %
creatinine and urea which is usually reversible
with appropriate management 47 39.2 73 60.8

Diabetes is a risk factor of CKD 110 91.7 10 8.3

Drugs is a risk factor of CKD 105 87.5 15 12.5
Hypertension is a risk factor of CKD 112 93.3 8 6.7
Glomerulonephritis is a risk factor of CKD 100 83.3 20 16.7
HIV is a risk factor of CKD 37 30.8 83 69.2
Hepatitis is a risk factor of CKD 70 58.3 50 41.7
Glomerular filtration rate and creatinine clearance 106 88.3 14 11.7
are appropriate marker of kidney function
Classification of CKD into 4 stages by KDOQI 35 29.2 85 70.8
Anemia is a complication of CKD 90 75 30 25
Hyperkalemia is a complication of CKD 110 91.7 10 8.3
Uremia is a complication of CKD 111 92.5 9 7.5
Hypertension is a complication of CKD 100 83.3 20 16.7
Osteodystrophy is a complication of CKD 53 44.2 67 55.8
Edema is a complication of CKD 99 82.5 21 17.5
Nausea and vomiting are complication of CKD 88 73.3 32 26.7
Coma is a complication of CKD 98 81.7 22 18.3
Peritoneal dialysis is form of renal replacement 49 40.8 71 59.2
therapy
Kidney transplant is a form of renal replacement 117 97.5 3 2.5
therapy
 Hemodialysis as form of renal replacement therapy 79 65.8 41 34.2
while
Nephrotoxic drug dose reduction in 85 70.8 35 29.2
eGFR<60ml/min/1.73m2
Nutrition consideration of CKD patients due to the 91 75.8 29 24.2
risk of electrolytes imbalance
Fluid intake in CKD stage 4&5 who are not on 42 35 78 65
hemodialysis equal of output +1.5liter
Management of stage 3 CKD by Hemodialysis 19 15.8 101 84.2

Table 3: Nurses perceptions of inpatient management of CKD (N=120)

Variable Correct practice Incorrect practice

Nurses are supposed to correctly replace glipizide Freq % Freq %
with prescribed metformin 500mg twice a day for A 63 52.5 57 47.5
48 years old man who was hospitalized with 10 years
of DM and 5 years of HTN and recent laboratory
studies showed eGFR of 55ml/min/1.73m2
The nurse should correctly administer prescribed oral 66 55 54 45
Cipro floxacillin of A 65-year-old woman with stage
4 CKD secondary to hypertension with signs of
urinary tract infection
When nurses are feeding 70 years old patient with 48 40 72 60
stage 3 CKD with poor appetite, they should aim to
achieve 23 to 35 kcal/day of energy requirement.
Nurses should encourage a patient on hemodialysis 78 65 42 35
with albumin of 2.6g/dl to take chicken, fish, beef,
eggs, soybeans and quinoa to achieve required
prescribed protein requirement.
A 56 years old man who came at hospital with long 66 55 54 45
history of alcohol use with decreased breath sounds,
with hepatomegaly, creatinine:0.8mg/dl,
Na:108mEq/Land urea:4mg/Dl, therefore nurses are
supposed to promptly Administer the prescribed 3%
of normal saline intravenously
For a 67-year-old man with mild neurocognitive 66 55 54 45
disorder (dementia), in whom peritoneal dialysis with
abdominal pain for the past 48 hours, with gram
positive in peritoneal fluid, nurses should correctly
 administer prescribed Intraperitoneal antibiotics as
required.
A 60-year-old woman with ESRD on HD who has 59 49.2 61 50.8
cramping during hemodialysis as well as weakness
after each treatment. Post-treatment was HR:95/min
and BP:90/60 mmHg. Nurses should correctly give
sodium modeling as prescribed.

Table 4. Participants level of knowledge and perceptions regarding inpatient management

of CKD (n=120)

Perceived knowledge Knowledge score in Level of knowledge/ Frequency Measure of central

scores out of 24 percentage (%) tendencies.

10 42 Low:5(4%) Mean:16.3
11 46 Media:16
12 50 Mode:17
13 54 Moderate:101(84%) Minimum:10
14 58 Maximum:23
15 63
16 67
17 71
18 75
19 79
20 83
21 87
22 91
High:14(12%)
23 95
Perceived perceptions Perceptions score in Level of perceptions/Frequency Measure of central
score out 7 percentage tendencies.
0 0 Mean:3.7
1 14 Low: 50(42.5%) Media:4
2 28 Mode:4
3 43 Minimum:0
4 57 Maximum:6
5 71 Moderate:61(51%)
6 86
High:9(7.5%)
Table 5: Factors associated and multiple regression analysis of demographic, knowledge and
perceptions of inpatient management of CKD.
Factors associated with Factors Associated with perceptions
knowledge (Chi-square test) (Chi-square test)
Variables Mean (95% CI) p value Mean (95% CI) p value
Institution type
RMH 16.2(15.3-17.1) 3.4(3-3.8)
CHUK 16.7(15.7-16.9) .024 3.98(3.7-4.2) .272
Department type
Emergency 15.9(15.3-16.6) 3.3(2.9-3.7)
IM 15.7(15.1-16.3) .000 4(3.7-4.3) .015
Renal 21.2(19.5-22.9) 4.3(3.7-4.9)
Gender
Male 16.6(15.6-17.6) 3.6(3.2-4)
Female 16.1(15.5-16.7) .329 3.8(3.5-4.1) .499
Age
20-30 y-o 15.9(14.7-17.1) 3.4(2.8-4)
31-40 y-o 16.3(15.7-16.9) .312 3.8(3.5-4.1) .390
41 and above y-o 16.9(15.2-18.7) 3.6(3-4.3)
Years of experience
1-5 Years 16(15.3-16.7) 3.9(3.5-4.2)
5 years and above 16.6(15.9-17.4) .061 3.5(3.2-3.9 .404
Level of education
Masters 19.6(5.3-34) 4.7(3.2-6.1)
Bachelor 16.67(15.8-17.5) .010 3.7(3.3-4.1) .891
Diploma 15.9(15.3-16.6) 3.7(3.4-4)
 Type of specialty
Nephrology 22.6(21.2-24.1) 4.7(3.2-6.1)
Registered general 16.1(15.6-16.6) .000 3.7(3.5-4) .561
Nurse
Pearson correlation (r) analysis for knowledge and perceptions of nurses

r =.115 P value for the correlation = .21

Title

Knowledge related to Chronic Kidney Disease (CKD) and perceptions on inpatient management
practices among nurses at selected referral hospitals in Rwanda: A non-experimental descriptive
correlational study.

Authors

Emmanuel Gapira. B.1, Geldine Chironda1,2, 3, Didace Ndahayo1, Theos Mbambazi1, Marie Jeanne
Tuyisenge1, Lakshmi Rajeswaran1,2

Author Affiliations

1. University of Rwanda, College of Medicine and Health Sciences, School of Nursing and
Midwifery, Kigali, Rwanda.

2. New York University, Rory Meyers College of Nursing, New York, USA, Human Resources
for Health (HRH) Rwanda

3. University of KwaZulu-Natal, College of health sciences, School of Nursing and Public Health,
Durban, Republic of South Africa.

Corresponding Author

Emmanuel Bimenyimana Gapira

University of Rwanda, College of Medicine and Health Sciences,
School of Nursing and Midwifery
Kigali, Rwanda
Telephone: +250785614694
Email: begapira@gmail.com