Tanta Scientific Nursing Journal

Prof.Dr /Latifa Fouda Boarder Director

Assist. Prof. Dr: Afaf Abdelaziz Basal Editor in Chief

Prof Dr. Ikbal Elshafie Managing editor

Assist. Prof. Dr. Safaa Zahran Editor Secretary

Dr. Zainab Adel Editor Secretary

Volume Number May

Tanta Scientific Nursing Journal

Editorial Advisory Board

Community Health Nursing

Prof. Dr. Nazek Ebrahim Abd Elghany: Community Health Nursing, Alexandria University. Prof. Dr. Ikbal Elshafie : Community Health Nursing, Tanta University. Prof. Dr. Latifa Fouda : Community Health Nursing, Tanta University. Assist. Prof. Dr. Entisar Abo Elghit : Community Health Nursing, Tanta University.

Nursing Administrative

Prof. Dr. Fouada Shaban : Nursing Administration, Tanta University. Prof. Dr. Seham Hamoda : Nursing Administration, Tanta University. Assist.Prof. dr. Safaa Zahran : Nursing Administration, Tanta University Assist.Prof. Dr.Karima Ahamad : Nursing Administration, Tanta University. Assist.Prof Dr. Samar Ghadiry : Nursing Administration, Tanta University.

Pediatric Nursing

Prof. Dr. Yomn Yousef : Pediatric Nursing, Alexandria University. Prof. Dr. Rahma Soliman : Pediatric Nursing, Tanta University. Prof. Dr. Ebtisam Mohamad : Pediatric Nursing, Tanta University.

Psychiatric and Mental Health Nursing

Prof. Dr. Sanaa Abdal Aziz : Psychiatric and Mental Health Nursing , Alexandria University. Prof. Dr. Sanaa Habashy : Psychiatric and Mental Health Nursing ,Alexandria University. Prof. Dr. Essmat Gemeay : Psychiatric and Mental Health Nursing ,Tanta University. Assist.Prof. Dr. Mervat Shalby : Psychiatric and Mental Health Nursing, Tanta University.

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Obstetric and gynecological Nursing

Prof. Dr. Nefertiti Zaki : Obstetric and gynecological Nursing, Zagazig University. Prof. Dr. Manal Hassan: Obstetric and gynecological Nursing, Tanta University. Assist.Prof Dr.Azza Eladahm: Obstetric and gynecological Nursing, Tanta University.

Medical Surgical Nursing

Prof. Dr. Kowthar Mohamad Tolba: Medical Surgical Nursing ,Alexandria University. Prof. Dr. Nagwa Ragb Attia: Medical Surgical Nursing, Tanta University. Prof. Dr. Om Ebrahiem Ali: Medical Surgical Nursing, Tanta University. Assist.Prof Dr. Afaf Abd Elaziz Basal: Medical Surgical Nursing, Tanta University.

Critical Care Nursing

Prof. Dr. Nadia Mohamad Taha :.Critical Care Nursing , Alexandria University. Prof. Dr. Warda Yousef :.Critical Care Nursing ,Cairo University. Prof. D. Amaal Kadry: Critical Care Nursing, Alexandria University. Assist.Prof Dr. Gehan Younis: Medical Surgical Nursing, Tanta University.

External Editorial Advisory

Prof. Dr. Marcia Leigh Van Riper : Professor and Chair, Family Health Division University of North Carolina, School of Nursing/ Carolina Center

Assist.Prof. Dr. Dalal Bashir : President of the Arab Scientific Association for Nursing and the Assistant Professor of Maternal Health, Faculty of Nursing Elzaitona University, Jordon

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Information to Authors General policies

The Bulletin of Tanta Scientific Nursing Journal publishes concise, original articles and contributions in the board field of nursing sciences. The Editor is responsible for the view and statements of authors expressed in their articles. The authors must transfer all copyright townships of the published manuscripts to the Bulletin of Tanta Scientific Nursing Journal. Table and figures are permitted to be used by authors. Provide the proper reference is made to the original published manuscripts and the journal.

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Title of manuscripts: It should be concise not more than 15 words and include the name of the authors(s) professional title and institution affiliation.

Abstract: It should not exceeding 200 words, it should state the aim of the study , subjects and methods and important findings and conclusion. Below the abstract provide and identify 3 to 10 key words or short phrases for indexing according to the contemporary subject headings. A list of all used abbreviations should be provided after the abstract. Abbreviations are not placed in parentheses at first use in the text.

Introduction: It should include relevant literature related to the problem. Abbreviations should be spelled out the first time they are used. Symbols, others than standard statistical symbols, should be identified the first time used.

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Results: Tables, figures or graphs should be typed or drawn on one page and relative placement should be noted in the text.

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Discussion: It should illustrate the findings with other relevant studies in the field of studies in the field of study.

Conclusion Summaries the key findings, outcomes or information in your report. Recommendations

Are the actions you are suggesting should take place bearing in mind your conclusion.

References: They are numbered according to order of appearance in the text and should follow the style of the uniform requirements for manuscripts submitted to the journals. The Vancouver style should be followed .

Procedures All papers will be reviewed by three .The final decision to publish or reject the manuscript remains in the hand of the editor. All manuscripts will be sent to a statistical reviewer. Proof reading of manuscripts for linguistic and typographic sounds will be done by the editors will be returned .The initial review process is expected to take 2 weeks. Accepted manuscripts become the property of the Tanta nursing scientific journal. The journal reserves the rights to edit all manuscripts for its style and space requirements and for the purpose of the clarity of Tanta journal of nursing will determine in which volume and issue accepted manuscripts will appear.

Faculty of Nursing, Tanta University Address: Email: Tanta nursing [email protected] Email: [email protected] or [email protected] Three copies of the manuscripts and CD that should be sent to Tanta Scientific Nursing Journal

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Contents

Subjects Page Effect of Educational Program about Dental Problèmes on Heath related Quality of Life for Children.

Amany Mosad Abd Elgphar , Ebtisam Mohamed El Sayed , Nagwa Abd

Elhady Ghoname , Nagafa Hafez Farag - MSC Pediatric Nursing, Faculty of Nursing, Tanta University. Pediatric Nursing , Faculty of nursing, Tanta University Pediatric Dentistry, Faculty of Dentistry, Tanta University.

Quality of El-Menshawy General Hospital Infrastructure among Nursing Staff

Hanan Mahmoud Elbadry , Samar Hosny Ghadiry , Karima Ahmed El-sayed - Nursing Administration, Faculty of Nursing

Assist.Prof. of Nursing Services Administration, Faculty of Nursing , Tanta University

Effect of Training Program on the Nurses’ Attitude and Perception of Caring Behavior toward Substance Use Disorder Patients

Marwa Abdel-fatah Zewiel , Amal Ebrahim Sabra ). Hala Ahmed El Sayes .

Mai Abdel-Raouf Essa - Psychiatric and Mental Health Nursing , Faculty of Nursing , Tanta University

Neuro – Psychiatry , Faculty of Medicine , Tanta University

Effect of Psycho- Educational Program about Violence

on Nurses' Knowledge and Practice Amina Ahmed Wahba El-Salamony , Zebeda Abd-Elgwad Elsherif , Mervat Hosny Shalaby , Prof. Adel Abd El Kareem Badawy

.Assistant lecture of Psychiatric & Mental Health Nursing Dept. Faculty of Nursing - kafr Elshiekh University. [email protected]

. Assistant Prof. of Psychiatric & Mental Health Nursing Dept. Faculty of Nursing Tanta University.

. Professor of Neuropsychiatry Department Faculty of Medicine Tanta University

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The Effect of Internal Disaster Management Intervention Program on Nursing Staff Knowledge and Skills

Eman Mohamed Ali Hassan , Reda Abd El-Fatah Abo Gad , Safaa Mohamed El Demerdash - Nursing Administration, Faculty of Nursing

Assist.Prof. of Nursing Services Administration, Faculty of Nursing , Tanta University

Effect of Implementation of a Teaching Program about Immediate Postpartum Care on Nurses’ Knowledge and Practice.

Doaa Samir Abou El-Yazeed El-Khawaga , Manal Hassan Ahmed , Manar Zaki Elwelely .

Demonstrator of Maternity and Gynecological Nursing, Faculty of Nursing, Tanta - University, Tanta, Egypt. Prof. of Maternity and Gynecological Nursing, Faculty of Nursing, Tanta University, Tanta, Egypt. Lecturer of Maternity and Gynecological Nursing, Faculty of Nursing, Tanta University, Tanta, Egypt.

Effect of Nurse's Therapeutic Communication and Protecting Patient's Rights on Patient's Satisfaction

Dr . Amal Sayed Mohamed , Dr. Asmaa Mohammed Ahmed , - 1) Lecturer of Nursing Administration, Faculty of Nursing, Assiut University, Egypt. 2) Lecturer of Nursing Administration, Faculty of Nursing, South Valley University, Egypt.

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Effect of Educational Program about Dental Problems on Health Related Quality of Life for Children.

Amany mosad. Abd Elgphar , Ebtisam Mohamed El Sayed , Nagwa Abd Elhady Ghoname , Nagafa Hafez Farag

MSC Pediatric Nursing, Faculty of Nursing, Tanta University. Pediatric Nursing , Faculty of nursing, Tanta University Pediatric Dentistry, Faculty of Dentistry, Tanta University.

Abstract: Back ground: Oral health related quality of life OHRQOL reflects people‟s comfort when eating, sleeping, and engaging in social interaction. Poor oral health affects social activities and child quality of life, such as attending school and inter acting with other people. Aim of this study was to determine the effect of educational program about dental problems on health related quality of life for children. Subjects and Method: A Quasi experimental research design was used at pedodontic clinic, Faculty of Dentistry, Tanta University. A convenient sample of 60 school age children with dental problems. Tools: Three tools were used to collect the required data Structured interview schedule (Tool I): to assess child knowledge and practice regarding to oral health and dental problems. Oral Assessment Scale (OAS) (Tool II): to assess oral health of school age children. Oral health related to quality of life scale (Tool III): to assess the effect of oral health on children quality of life . Results showed that, before program 56% had poor knowledge and practice about oral health and dental problems while after program 66.7% had good knowledge and practice. Regarding child quality of life, nearly two third ( %) of children had poor quality of life pre- program while as half of them ( 51.6 %) had good quality of life after three months of program implementation. Conclusion: The educational program has a positive effect on improving childrens knowledge, practice and their quality of life. Recommendations: Establish continous educational programs for mothers and their children as well as nurses working in dental clinic to improve their information. School curriculum should be containing information about oral health and dental problems to improve awareness of school age child about it .

Key words: Educational Program, Dental problems, Quality of Life

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Introduction The impact of oral diseases on the quality Oral Health is the standard of oral and of life is very obvious. The psychological related tissue health that enables and social impact of such diseases on daily individuals to eat, speak, and socialize life is easily comprehensible which makes without active disease, discomfort, or them of considerable importance. Any embarrassment and contributes to general disease that could interfere with the wellbeing. their self-esteem; and activities of daily life may have an adverse satisfaction with respect to oral health. OH effect on the general quality of life. is the result of interaction among oral Therefore the notion of oral health related health conditions, social and contextual quality of life (OHRQOL) is the product of factors, as well as the rest of the body . many observations and research . Oral health related quality of life has no The nurse has historically been the one to strict definition. However, there is general receive a child in pain, determines the agreement that it is a multidimensional source of the discomfort, renders care as concept . appropriate and makes the necessary School age children have 20 primary teeth referral. The nurse can enhance dental and sometimes called “baby” or “milk” teeth oral health by increasing parental that begin erupting around 6 months of age information about the importance of sound and continue to erupt through about 2 years of nutrition practices, regular dental check of age. Primary teeth are essential for good up, proper oral hygiene at varying age . nutrition, language development, self- The aim of this study was to: determine esteem, and as placeholders for permanent the effect of educational program about teeth . dental problems on health related quality Inadequate dental care results in the most of life for school age children. common dental problems such as dental Subjects and Method caries, malocclusion, gingivitis and Research Design: Trauma, especially tooth avulsion . A quasi experimental research design was Good oral and dental hygiene help prevent used in this study bad breath, tooth decay ,gum disease and Setting: tooth loss. It can keep the teeth as the The study was conducted at pedodontic clinic, child gets older . Faculty of Dentistry, Tanta University.

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Subjects: Scoring system for children knowledge A convenient sample of 60 school age for each question: children with dental problems and their - Correct and complete answers were mothers were included from the previously scored 2. mentioned setting. They were attended for - Correct and incomplete answers were dental management. scored 1 . Tools of data collection: - Incorrect or no answers were scored 0 . Three tools were used to collect the Total scores for children knowledge: necessary data. - Less than 50% were considered poor Tool (I): Structured interview schedule: knowledge. It was developed by the researcher after - From 50% to less than 70% were reviewing the related literature to assess considered fair knowledge. child knowledge and practice regarding to - 70% and more were considered good oral health . It includes three parts: knowledge. Part (1): Demographic characteristic of: Part (3): children reporting practice a- Children such as: age, sex, birth related to oral health hygiene includes: order and educational level. frequency and importance of tooth b- Mothers such as: educational level, brushing, periodical dental checkup and occupation, monthly income and dietary habits . family size. Scoring system for children reporting Part (2): childrens' knowledge about : practice: a- Dental health: definition of oral health, -Reporting done correctly and types, numbers and importance of completely were scored 2 . healthy teeth and harmful behaviors -Reporting done correctly but incomplete related to child teeth. were scored 1 . b- Dental problems such as: dental caries, - Incorrect or not done were scored 0 . gingivitis, bad breath, teeth bleeding, Total scores for children reporting dental injury and discoloration of practice: teeth. - Less than 50% were considered poor c- Preventive measures to avoid dental practice. problems .

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- From 50% to less than 70% were embarrassed, to be irritable with other considered fair practice. people, has difficulty in school - 70% and more were considered good achievement, feel that life in general was practice. less satisfactory, and to be totally unable to Tool II: Oral Assessment Scale (OAS) : function). This scale was adopted by Ullman - Responses was done on 3 point Likert and used twice by the researcher scale . Each item was given three before and after three months of program different scores ranging from never (1) implementation to assess oral health of to often (3).The total scores range from school age children .It includes five items 14 to 42. scores of 21 or more has been (lips, tongue, saliva, oral mucosa and associated with oral impact on quality teeth). It was done on three point Likert of life. scale (3-2-1) and analyzed as continuous Method rang from (5-to 15). It was categorized as -The study was carried out after getting an following: official permission from the responsible - mild dysfunction if it was 5- authorities. - Moderate dysfunction if it was 8- - Ethical considerations:- - sever dysfunction if it was 12 - Children and their mothers were informed Tool III: Oral health related to quality about the purpose of the study .consent of life scale (OHRQoL): was obtained for the participation. It was adopted by Slade, 1997 and privacy and confidentiality were modified by the researcher .it was used considered. mothers reassured that, the twice before and after three months of collected information were used only for program implementation to assess the the purpose of the study and they have the effect of oral health on children quality of right to withdraw at any time. life. It consists of fourteen items (has - A pilot study was carried out on 10% of problem pronouncing words, feel the sense the study sample. It was done before of taste worsened, has painful aching in the starting data collection to verify the mouth, find uncomfortable to eat any food applicability, feasibility, and clarity of the to be self-confidence, feel tense, has an study tools. unsatisfactory diet, has to interrupt meals, -Tools of the study were tested for content find difficult to relax to be a bit validity by 5 jury experts in the field of

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pediatric nursing, Faculty of Nursing, and collect the required data using tool I part 1 Pedodentists, Faculty of dentist, Tanta and 2. The time required for each university. interview was about 30- 45 minutes. -Three tools were used for data - Children reporting practice related to oral collection. hygiene were assessed twice Before and A structured interview schedule (Tool I) after Three months of program to collect: implementation using tool I part 3.

- Demographic characteristics of children - Oral assessment scale (Tool II) was used and their mothers, children knowledge twice by the researcher before and after related to oral health, and dental Three months of program implementation problems and children reporting to assess five item of oral health (lips, practice related to oral hygiene. tongue, saliva, oral mucosa and teeth) . - Oral Assessment Scale (OAS) (Tool II). - The effect of oral health on children It was used twice by the researcher before quality of life was assessed twice by the and after three months of program researcher before and Three months after implementation to assess oral health of program implementation using school age children related to their lips, OHRQoLscale (tool III). It contain 14 togue, saliva, oral mucosa and teeth. using item. lickert scale. - Three point lickert scale was used Oral Health Related to Quality of Life never (1) ,occasionally (2), and often Scale (OHRQOL)(Tool III). It was used (3). The total score was calculated from two times by the researcher. Each child 14-42 .The total scores of 21 or more it was asked about the frequency that he or had been affect quality of child life. she experienced an impact on 14 daily - program constriction activities. Responses were done on a 3- Based on children needs the program was point Likert scale ranging from never (1) to developed. Five sessions were conducted often (3) . in the pediatric dental clinic using different -total score from 14 to 4 teaching strategies such as lecture, group -scores of 21 or more has been associated discussion, pictures, posters, role play and with oral impact on quality of life. demonstration . - Each child interviewed individually or with care giver in the dental clinic to

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Session I : was calculated. For comparison between Definition of dental health, structure of the more than two means of non-parametric oral cavity. data, Kruskal-Wallis (X value) was Session II : calculated. Correlation between variables Focused on: definition of dental caries, was evaluated using Pearson‟s correlation stages, clinical manifestation, and how to coefficient (r). prevent this problem. Results Session III : Table (1) shows percentage distribution of About: definition and clinical studied children regarding to socio manifestation of gingivitis and how to demographic characteristics. It was found avoid this problem. that, more than half of the studied children Session IV : (55 % )their age 9 years, about one quarter Concentrated on: definition, causes, and (23 %) 7 year and 22 % from 11 to 12 prevention of dental injury and trauma. years. Regarding to their sex , it was Session V : noticed that, more than half of them (53,3 Includes oral hygiene using tooth brush %) were females and 46,7% were male . correctly, and how to use msiwak. It was found that, 40 % of studied - The program was evaluated immediately children were the second children in the and after three months of program family , 20% were first one and 25 % were implementation using the same tools of pre the third one .All of them in primary test. education . It was observed that, nearly two Statistical analysis: third (65%) of children from rural area , The collected data were organized, while the rest 35% from urban area. tabulated and analyzed using SPSS Figure(1) presents total scores of children software. For quantitative data, mean and knowledge about oral health and dental standard deviation were calculated. For problems pre , immediate and after three qualitative data, using Chi-square test ( ). months of program implementation .It was For comparison between means of two noticed that, there was an improvement in groups of parametric data Z value of total scores of children knowledge Mann-Whitney test was used. F or immediately and after three months of comparison between more than two means program implementation as (85%) and of parametric data, F value of ANOVA test (81,67%) respectively had good scores

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while as pre program most of them Figure (5) presents total scores of children (88,33%) had poor scores. with statistical quality of life before, and after three significant difference.( P< 0,05) months of program implementation. It was Figure ( 2) illustrates total scores of clear that, pre program nearly two third children reporting practices before and (65,00%) of children had poor quality of after three months of program life compared by half of them (51,6 %) implementation. it was found that pre had good quality of life after three months program nearly two third of children of program implementation. %) had poor practice while as two Figure (6) Correlation between total scores third (66,7%) had good practice after three of children knowledge , practice and oral months of program implementation with health related to their quality of life before statistical significant difference.( p= 0,05) . and three months after program Figure (3) shows Correlation between implementation. It was observed that, there total scores of children knowledge and were an improvement in children practice before and after three months of knowledge and practice and their quality of program implementation. It was noticed life, no statistical significant difference that, before program slightly more than between children knowledge , practice, half (55% ) had poor knowledge and oral health and child quality of life. practice about oral health and dental problems while after program two third (66,7%) had good knowledge and practice. Table (2) and figure(4 )demonstrates Total scores of oral health assessment using oral assessment scale. it was observed that , nearly same percentage of children pre and post program had mild dysfunction 41,67% and 40% respectively . while as, 56,67% and 58,33 respectively had moderate dysfunction and the same percentage had sever dysfunction 1,67% . No statistical significant .

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Table 1: Percentage distribution of studied children regarding to their socio demographic characteristics.

Socio Demographic Studied children (60) characteristic Number (No) Percentage (%) Age in years - - -

Mean±SD 10.42±1.40 Sex -Male -Female Birth order -First -Second -Third -Fourth -Fifth and more Educational level -Primary

Residence -Urban -Rural

Figure 1:Total scores of children knowledge pre , immediate and after three months of program implementation .

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Figure 2: Total scores of children reporting practice before and after three months of program implementation.

Figure 3 : Correlation between total scores of children knowledge and reporting practice before and after three months of program implementation.

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Table 2: Total scores of oral health assessment for studied children using oral assessment scale before and after three months of program implementation.

After 3 months Items Pre-program (N=60) P (N=60) χ of assessment value No % No %

-Mild dysfunction )5-7( -Moderate dysfunction )8-11( -Severe dysfunction )12-15( Mean +SD 7.82±1.21 7.88±1.26 0P value = t = -

Figure (4 ) Total scores of oral health assessment before and after three months of program implementation.

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Figure (5) Total scores of children quality of life before, and after 3 months of program implementation

figure (6): Correlation between total scores of children knowledge , practice and oral health related to their quality of life before and three months after program implementation.

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Discussion children from rural and urban areas. From OHRQoL is defined as a multidimensional my point of view it could be explained construct that reflects children‟s comfort that, children in rural areas had more when eating, sleeping, and engaging in untreated dental problems reflecting social interaction; their selfesteem; and difficulty accessing dental care in these their satisfaction with respect to their oral places. health. Regarding child knowledge about oral Regarding child age affected by dental health and dental problems, the findings of problems, the present study revealed that, the present study revealed that, pre more than half of the studied children with program the majority of studied children dental problems their age range from 9 to had poor knowledge in all items of oral 11 years and it was more among female health . while as after program children than male and rural areas more implementation their knowledge were than urban area. This result was improved. This may be attributed to the contradicted with sudha 2005 who effect of good education, communication found that, dental problems were higher at and interaction of children during session 5 to 6 years compared by 8 to 10 years and in addition child during this stage had the 11 to 13 years age group and Abd Elaziz curiosity to learn and welling to who reported that, more than communicate and interact with others . it half of children with dental problems came was observed that after three months of from urban areas and the most common program implementation children affected age were from 8 to 9 years . It knowledge improved but slightly reduced. could be due to increase awareness of oral This retention of knowledge might be hygiene among those children at this age or explained by the fact that knowledge it may be explained that the permanent retention is usually affected by time. teeth which were erupted during this stage Concerning total scores of children more resistant to caries process and other knowledge about dental problems and oral dental problems than the primary teeth. health, the majority of children had poor on the other hand it was in harmony with scores pre program meanwhil children had Sanic & Hasangie (2008) who reported fair and good scores after program. This that, dental state of permanent teeth in could be attributed that the content of children aged from 7 to 9 years show a program was developed based on child significant differences between the needs, the clarity and simplicity of the

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content using attractive audio visual aids, problems reported with physical, mental, availability of the researcher for more and social functioning. clarification, using simple language. All WHO 2005 reported, oral health affects these factors play important role in general health caused by pain and facilitating child understanding changing what people eat, taste food, look, scLina et al (2010) studied children speech, enjoying life and their social knowledge about oral health and reported interaction with others. On the same line that, children knowledge still need to be Cunnion stated that , toothache is improved, thus the present study suggested usually caused by dental problems, that the awareness about the importance of moreover Biazevic et al 2008 reported oral health needs to be enhanced among that prevalence of oral disease, physical school age children through continuous and psychological influence of these implementing regular program with aggravating circumstances of children life, follow up . concerning the joy of living, possibility of The present study emphasized that, speaking and social interaction. Children children with dental problems who who had good knowledge had good received the instructions of designed practice and gain good quality of life program had significantly improvement of .Contenious educational program to child their health related to quality of life and their mothers and continuous regular compared by pre program. The follow up play an important role in improvement includes, child had less improving child quality of life. toothache, abilities to eat also sleep and Conclusion: daily function were improved. In addition Based upon the finding of the present their school function and attendance were study, it can be concluded that: improved. The educational program had a positive On the same line some studies reported effect on improving children knowledge; that oral clinical indicator should be reporting practice as well as their quality associated with oral health related quality of life. of life out come. Koposova et al and Recommandations Malden et al reported , dental problems based upon the finding of the present study affects children's oral health related their the following recommendations were quality of life with a significant reduction suggested;

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- Establish continous educational promotion. Bull World Health Organ. programs for mothers and their - children as well as nurses working in Wong D. Essential of Pediatric dental clinic to improve their Nursing. 2nd edddition Philadelphia: informations . Mosby Co., 2009; 960- - School curriculum should be contained Carll J . oral health policy development iformation about oral health and dental since the surgeon general's report on problems to improve school age child oral health. Acad pediatr .2009;9 awareness about it. - References: Liu Z , Grath C, Hagg U. The impact US Department of Health and Human of malocclusion/orthodontic treatment Services, National Institute of Dental need on quality of life. Asystematic and Craniofacial Research. National review. Angle orthod. - Institutes of Health.2000. http://www. Abd Elaziz A. Predisposing factors of nidcr.nih.gov/DataStatistics/SurgeonGener dental problems among school age al/sgr/chap1.htm. Accessed 21 July 2013. children. Master thesis, faculty of Petersen P, Alekes J,Christen L, Eriksen nursing. Benha University,2008;1. H, Kalo I, Oral health behavior and Ullman A. Oral health of critically ill attitudes of adults in Lithuania. Journal children. Master thesis, School of Acta Odontal Scand - Nursing and Midwifery. Queensland Taji S, Seow W. A literature review of University of Technology,2009. dental erosion in children. Aust Dent J Slade G. Derivation and validation of a - short form oral health impact profile. Wright J. anatomy and development of Community Dent Oral the teeth .up to date,2009.Available Epidemiol.1997;25 (7):284- from: www.Uptodate.com(accessed Sudha p , Bhasin S,Anegundi R. March,2010). Prevalence of dental caries among 5-13 Wong, L. Maternal and Child Nursing years old children of Mangalore city. J rd Care.3 ed, Philadelphia: Mosby Co., India Soc Pedod Prev Dent - - Watt R. Strategies and approaches in Abd Elaziz A. effect of educational oral disease prevention and health intervention on quality of life of school age children with dental problems. Ph

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thesis, faculty of nursing. Benha young children following dental University,2011. treatment under general anaesthetic Sanic B, Hasangie M. Risk factors for Community Dent Oral Epidemiol caries control and prevention. Medicin - Ski Glasnik. 2008; 5(2):1- WHO. Oral health, general health and Rai B, Jain R, Duhan J, Anand S. quality of life .2005; 83(9):641- Relation ship between dental caries and Cunnion D, Spiro A, Jones J,et al. oral hygiene status of 8-12 years old pediatric oral health related quality of school age children. The Internet life improvement after treatment of Journal of Epidemiology. - early childhood caries: A prospective Do L, Spencer A. Oral health related multisite study. Jdent child. quality of life of children by dental - caries and fluorosis experience. J Biazevic M, Rissotto, Michel Crosato Public Health Dent - E,et al. Relationship between oral Schroth R, Smith P, Whalen J, et al. health and its impact on quality of life prevalence of caries among preschool among adolescents.Braz Oral Res. aged children in Norther M anitoba - Community. Jcan Dent Assoc - Lina C, Phing T, Chat C, Shin B. Oral

health knowledge , attitude and

practice among secondary school

student in Kuching Sarawak. Archives

of Orofacial Sciences. 2010;5(1):9-

Koposova N, Widstrom E, Eisemann M, et al. oral health and quality of life in Norwegian and Russian school children: Apilot study. Stomatolog

Baltic Dent Maxillofac J .2010; 12(8) 10- Malden P, Thomson W, Jokovic A,et al. Changes in parent assessed oral health related quality of life among

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Quality of El-Menshawy General Hospital Infrastructure among Nursing Staff

Hanan Mahmoud Elbadry , Samar Hosny Ghadiry , Karima Ahmed El-sayed

Nursing Administration, Faculty of Nursing

Assist.Prof. of Nursing Services Administration, Faculty of Nursing , Tanta University

Abstract

Background: According to the World Health Organization, every citizen of the world has the right to healthy and safe work; a right to a work environment that enables him or her to live a socially and economically productive life. The hospital infrastructure is the total of all physical, technical and organizational components or assets that are prerequisites for the delivery of health care services. Aim of the study: Assess quality of El-Menshawy General Hospital infrastructure among nursing staff. Research design: Descriptive research design was used in this study. Setting: The study was conducted at El- Menshawy General Hospital departments. Subject: All (530) available nursing staff at the time of data collection .Tools: Tool 1: Nursing staff perception regarding quality of El Menshawy General Hospital infrastructure questionnaire, Tool П:Quality of El-Menshawy General Hospital infrastructure observational checklist. Results: According to them the majority of Nursing staff showed high level of perception regarding neonatal intensive care unit. Also, above fifty percent of nursing staff showed high level of perception regarding emergency room infrastructure, intensive care unit, the facilities and its management, operative room infrastructure, dialysis infrastructure, respectively . According to researcher observation the actual level of quality is high in information technology , neonatal intensive care unit and dialysis infrastructure. Moderate level of quality in technical medical equipment, operative room and facility and its management. While low level of quality in supply facility system. Conclusion: There was significant positive correlation between facility and its management and information technology . Also there was significant positive correlation between disposal system and outreach services. Recommendations: Activation of hospital committee role ( quality committee, health and occupational safety committee, infection control committee and continuous training committee), Provide continuous training program for all nursing staff that improve their performance , increase their knowledge and skills , and motivate them to perform quality patient care.

Key wards: Quality, Infrastructure, Nursing Perception, Nursing staff

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Introduction communication technology, and the Quality was defined as the extent to which outreach services . health services provided to individuals, Facility management covers a wide field of patients, and population to improve desired activities related to workplace, facility, health outcomes. Quality health care is support services, property, corporate real “the right care for the right person at the estate and infrastructures. There are right time the first time ” The Institute of different classifications proposed by the Medicine has identified six aspects of academic researchers. One classification of high-quality care. Health care should be facility management scope is premises, safe, timely, effective, efficient, equitable, support services and information and patient-centered. Improved quality technology. The classification seems to outcomes are not, however, delivered by emphasize the facility management health-service providers alone . Healthy function to physical infrastructures rather work environments have both direct and than to cover all the facility management indirect impacts on patient safety. Healthy activities .. work environments have been linked to Physical Infrastructure refers to structures, increased nurse and health care worker systems, and facilities serving the economy retention, recruitment, job satisfaction and of a business, industry, country, city, town, have decreased stress and burnout, which or area, including the services and facilities subsequently leads to safer patient necessary for its economy to function. It is practices . typically a term to characterize the The term „infrastructure‟ is used in existence or condition of costly 'technical manifold ways to describe the structural structures' such as storage chambers, elements of systems. In the context of a electrical capacity, fuel tanks, cranes, health care system and in reference to overhead clearances, or components health care facilities. The seven major of water supplies, sewers, electrical components of the infrastructure of a grids, telecommunications and so forth . health care facility include: the facility and Health care waste is defined as the total its management, the physical waste stream from a healthcare infrastructure, the supply facility system, establishment, research facilities, the disposal system, technical medical laboratories, and emergency relief equipment, information and donations. Health care waste includes

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several different waste streams, some of possess an important and obvious role in which require more stringent care and quality of care and that it is one of the disposal including sharps (e.g. needles, highest priorities of healthcare managers . razors, scalpels), pathological waste, other Nursing staff perceive that they are potentially infectious waste, providing high quality nursing care and pharmaceutical waste, biological waste, would recommend that family and friends and hazardous chemical waste . use the hospital for their health care. To Medical technology is a broad field where establish this atmosphere there must innovation plays a crucial role in be assess the quality of infrastructure sustaining health. Areas like within hospital ( ) . biotechnology, pharmaceuticals, Aim _of the study information technology, the development The aim of the study is to:- of medical devices and equipment, and Assess quality of El-Menshawy General more they have all made significant Hospital infrastructure among nursing contributions to improving the health of staff. people all around the world .Outreach Research question:- services are used to describe any type of -What are the levels of nursing staff health service that mobilizes health perception regarding quality of el- workers to provide services to the Menshawy General Hospital population or to other health workers, infrastructure? away from the location where they usually 2-What are the actual levels of quality of work and live. Outreach services are one of el-Menshawy General Hospital? the possibilities to enhance access to health Materials workers and to improve overall retention at Research design: country level( ) . Descriptive research design was used in Significance of the study this study. Nursing staff in healthcare have a legal Setting: and moral obligation to ensure a high The study was carried out at El- Menshawy quality of patient care and to strive to General Hospital at Gharbia Governorate improve care. They are in a prime position that is affiliated to Ministry of Health and to mandate policy, systems, procedures Population. El Menshawy General Hospital and organizational climates. Accordingly, consists of three building and contains 20 it is evident that healthcare nursing staff units with 258 beds.

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Tools: Tool 1: Nursing staff perception needed to complete the questionnaire regarding quality of El Menshawy General items from nursing staff were 10-15 Hospital infrastructure questionnaire. minutes . It was carried out on a sample Tool П:Quality of El-Menshawy General 10% (n=53) of nursing staff .These Hospital infrastructure observational sample was excluded from the main checklist. study sample during the actual Methods collection of data. Necessary Official permission was obtained from modification was done. El Menshawy General Hospital to Data collection phase: The data was obtain the approval and assistance to collected from the identified subject by collect the data. the researcher . The researcher met the Ethical consideration: Nursing staff nursing staff in small groups during consent was obtained from the their work shifts to distribute the participation after exploration of the questionnaire. The nursing staff nature and purpose of the study recorded the answers in presence of the confidentiality of the information‟s researcher to ascertain that all questions obtained from and the right to were answered. withdrawal is preserved. The questionnaire sheets were submitted to five experts for testing the content and face validity. Reliability of tool was tested using Crombachs Alpha Coefficient Test, its value= 0.899. Pilot study was carried out after the expert‟s opinion and before starting the actual data collection. The aim of pilot study was to test the sequence of items, clarity, applicability, and relevance of questions. Pilot study also served to estimate the time required for filling the questionnaire sheet. The estimated time

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Results

Table (1)Personal characteristics of nursing staff (n=530)

Variables N % Age > 30 years . 30 - > 40 years . <40 years . Range - Mean ±SD 31.928±5.757 Level of education Nursing diploma . Nursing technical . Bachelor of nursing . Years of experiences >5 years . 5 - >10 years . <10 years . Range - Mean ±SD 11.253±6.044 Unit of work ICU Infrastructure(intensive care unit) . ER Infrastructure(emergency room) . Dialysis Infrastructure . NICU Infrastructure(neonatal intensive care unit) . OR Infrastructure(operative room) . Training courses related to quality Yes . No . Graduation title Supervisor nurse . Staff nurse .

Table (1): illustrates personal characteristics of nursing staff such as : age, educational level ,years of experiences, , unit of work , previous training courses and job title. The age of nurses ranged from 22- 46 years old with mean age 31.94+5.77 . More than half (57,17%) of nursing staff had Bacalerote in nursing, while 7,9% of nursing staff had Nursing Diploma in the nursing profession. About 43,58% of nursing staff had an experience between 5-10 years in nursing profession . While (13,21%) of them had an experience less than 5 years in the working area respectively. Nearly one quarter (22,6%) of nursing staff are working at neonatal Intensive Care Unit and (21,1%) of them are working at intensive care unit. About (39,4%) of all nurses had previously course on quality. About (62,1%) of nursing staff are supervisor nurse according to graduation title, while (37,9%) are staff nurse, respectively.

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Figure (1): Levels of nursing staff perception regarding hospital infrastructure quality (n=530)

Figure (1)reveals levels of nursing staff perception regarding hospital infrastructure quality. Above fifty percent (58,11% , 56,04% , 52,64%) of nursing staff had moderate level of perception regarding supply facility system, information technology and technical medical equipment, respectively. About 59,81% , 35,85% of the nursing staff had high level of perception regarding the facility and its management and outreach services, respectively .About 33,21% , 29,62% , 27,36% of the nursing staff had low level of perception regarding supply facility system , disposal system and technical medical equipment, respectively.

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% 84.15 90 80 70 60 50 40 30 12.45 20 3.40 10 0 Low Moderate High Total

Figure (2): Levels of nursing staff perception regarding hospital infrastructure quality (n=530)

Figure (2)reveals levels of nursing staff perception regarding hospital infrastructure quality. The majority (84,15%) of nursing staff had high level of perception. While (12,45%) of the nursing staff had moderate level of perception . On the other hand, (3,40%) of the nursing staff had low level of perception regarding hospital infrastructure quality.

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Figure (3): Actual level of quality of El Menshawy General Hospital according to researcher observation (n=530)

Figure (3): reveals actual level of quality of El Menshawy General Hospital according to researcher observation. The actual level of quality in information technology is high (58,87%) and above (50%) in technical medical equipment and the facilities and its management. The quality of supply facility system is (21%) , respectively.

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Figure (4): Actual level of quality of El menshawy general hospital according to researcher observation (n=530)

Figure (4): reveals actual level of quality of El menshawy general hospital according to researcher observation. The level of quality was high in about (84,72%). While moderate level of quality was about (10.19%). On the other hand low level of quality is about (5,09%) regarding the hospital infrastructure quality.

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Table (2) Correlation between nursing staff perception and researcher observation regarding hospital infrastructure quality related to quality dimensions (n=530)

The facilities Supply Technical Disposal Information Quality dimensions and its facilities medical system technology management system equipment

Supply facilities R . system P-value .

R . . Disposal system P-value . .

Technical R . . . medical equipment P-value . . .

Information R . . . . technology P-value . . . .

R . . . . . Outreach services P-value . . . . .

Table (2) illustrate correlation between nursing perception regarding hospital infrastructure quality related to quality dimensions .There was a significant positive correlation between the facility and its management and information technology( P=0.001). Also there was significant positive correlation between nursing staff perception and researcher observation regarding hospital infrastructure quality.

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Discussion specifically in perception regarding The concept of infrastructure is an indirect neonatal intensive care unit infrastructure measure quality of care . Infrastructure this may due to more experienced includes the tangible features of a service supervise nurse and continuous training delivery, which is related to equipment, and supervise the nursing staff about furniture, physical appearance of the neonatal intensive care unit standards and hospital, facilities, availability of making training courses for nursing staff. resources, and environment . It is also While, more than fifty percent in referred to as manmade organization‟s perception regarding emergency room, physical facility or services which include intensive care unit, operative room, interior attributes such as design, layout, dialysis Infrastructure and the facilities and and equipment - . its management and these from nursing According to personal characteristics the staff opinions, this could due to the more finding of the present study revealed that specialized departments require high the minority of total nursing staff (figure 5) qualified nursing staff and had more received training courses related to quality, training courses. But less than fifty percent this could be due to training initiatives are of the studied nurses in relation to not always prioritized by hospital perception regarding the disposal system, administration. Supervisor nurse more than technical medical equipment, information half of total nursing staff, and it is technology, and outreach services this generally believed that more experienced could be due to lack of specialized nurse provide higher quality , efficient care reviewing committee for these departments (Table, 1).Coyle et al.,(2012) and about following the quality standards in Buckley et al., (2010) suggested that introducing the patient care and lack of training courses related to quality is training courses according to quality associated with improvements in clinical standards . outcomes and direct benefits for service Actual level of quality of El- Menshawy users or care systems. General Hospital Levels of nursing perception regarding According to researcher observation hospital infrastructure quality According to researcher observation, The In the present study offer that more than level of quality is high in neonatal eighty percent of the nursing staff in intensive care unit infrastructure and this relation to quality of hospital infrastructure also may due to well trained supervise

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nurse which reflect on the nursing staff constructability; functionality; and skills about neonatal intensive care unit materials . standards and making training courses for In a comprehensive literature review nursing staff. The level of quality in conducted by Ulrich et al. , the dialysis infrastructure was high, this may authors found evidence that the quality of be due to more daily supervision and the aesthetic aspects of the physical design continuous on job training . Moderate (e.g. ward layout, window view, floor and level of quality is in information furniture coverings, ventilation and water technology. Regarding low level of quality supply systems) not only influences the infrastructure founded in disposal system quality of clinical spaces (e.g. air quality; and emergency room infrastructure , this cleanliness of floors, walls, furniture, etc.) may be due to lack of continuous but has also an impact on clinician's supervision and the nursing staff not aware behaviors, thus impacting on the clinical about quality standard implementation . quality of care provided and care outcomes Oliver S, Morse J ( show that (e.g. hospital-acquired infections, patient nurses often function as the „protector‟ in falls, length of stay). the NICU aiming to prevent additional Evidence based design is a current trend in stress to the infant and families. Neonatal facility infrastructure where relevant and nurses recognize the importance of quality proven design innovations that optimize standard in the NICU, which has allowed patient safety, quality of care and for successful advanced medical satisfaction as well as work place safety . interventions, including the use of Conclusion surfactant and continuous positive airway The majority of nursing staff showed high pressure. However, nurses are responsible level of perception regarding neonatal for many facets of care in the NICU . intensive care unit infrastructure. Also, Finally, the findings of the study suggest above fifty percent of the nursing staff that inadequacies in hospital infrastructure showed high level of perception regarding limit access to health care and contribute to emergency room infrastructure, Intensive poor quality of care outcomes. It can be Care Unit infrastructure, the facilities and seen as a major component of the structural its management, operative room quality of a health care system. The built infrastructure, dialysis infrastructure. environment dimension is determined by About less than fifty percent of nursing the interplay of four features: accessibility; staff showed moderate level of perception

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regarding supply facility system and environment of nurses. Washington, information technology . According to DC: National Academy Press. researcher observation the actual level of Spence Laschinger HK, Finegan quality is high in information technology , J, Wilk P( . Situational and neonatal intensive care unit and dialysis dispositional influences on nurses' infrastructure. Moderate level of quality in workplace well-being: the role of technical medical equipment, operative empowering unit leadership. Nurse room and facility and its management. Res. - While low level of quality in supply , Ngoli B .Rapid assessment of facility system and emergency room infrastructure of primary infrastructure. health care facilities a relevant Recommendations instrument for health At the nursing staff: care systems management.BMC Healt - Increase the nursing awareness about h Services Res. the importance of implementation of Stichler JF.(2012) Creating a healthy, quality standards that lead to quality positive work environment: A and low cost services. leadership imperative. Nursing for - Provide continuous training program Women's Health, 13(4): 341- for all nursing staff that improve their Das RC.(2017) Handbook of performance , increase their Research on Economic, Financial, and knowledge and skills , and motivate Industrial Impacts on Infrastructure them to perform quality patient care. Development. Advances in Finance, - Nursing supervisor need to be aware Accounting, and Economics IGI of infrastructure quality standards and Global. its impact on quality of patient care. Imdad S, Anwar S, Shoukat MS - Activation of hospital committee role ( Healthcare Waste: Evaluation quality committee, health and of its Generation Rate and occupational safety committee, Management Practices in Tertiary infection control committee and Care Hospitals of Lahore. Annals. 19 continuous training committee). - References Mitchell PH, Heinrich J, Moritz P, et Institute of Medicine (2015). Keeping al(2013). Outcome measures and care patients safe: transforming the work delivery systems: Introduction and

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purposes of the conference. Medical performance of HCPs during MNH Care. 35(1 l):NSl- services at district and sub-district National Quality Forum.(2014) level government hospitals, National consensus standards for Bangladesh. Health MED. - nursing- sensitive care: an initial Coyle YM, Mercer SQ, Murphy- performance measure set. Washington, Cullen CL et al(2012). Effectiveness DC: National Quality Forum; 2014. of a graduate medical education Parand A, Dopson S, Renz program for improving medical event A .The role of hospital reporting attitude and behaviour. managers in quality and patient safety: Quality and Safety in a systematic review. BMJ Open. HealthCare - 4(9):e005055. Buckley JD, Joyce B, Garcia AJ etal Purdy N, Laschinger HK,(2010) .Linking residency training .Olivera: Effects of work effectiveness to clinical outcomes: a environments on nurse and patient quality improvement approach. outcomes. Journal of Nursing - Management, 18, 901- Oliver S, Morse J(2015) Jooyeon H and Soocheong J. (2012): Developmental care and quality The effects of dining atmospherics on assessment program at Scott and behavioral intentions through quality White Memorial Hospital . perception", Journal of Service Enoch M.(2016) Sustainable Marketing 1(26): 262- transport, mobility management and Zeithaml A, Bitner J. &Gremler D. travel plans. Routledge . . Services marketing: Ulrich S, Zimring C, Zhu X, Du integrating customer focus across the Bose J(2013) A. A review of the firm. 5thed. New York. research literature on evidence-based Chassin M, LoebJ.(2011)The healthcare design. HERD: Health Ongoing Quality Improvement Environments Research & Design Journey: Next Stop, High Reliability. Journal. 61– Health Affairs. 30 (4): 559– Stantec Consulting Ltd. IslamF,Halim A, Rahman A, Dalal Advanced Hospital Design: Roadmap K(2015). Assessment of quality of for the Development of a Sustainable infrastructure and clinical care Hospital Complex.

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Effect of Training Program on the Nurses’ Attitude and Perception of Caring Behavior toward Substance Use Disorder Patients

Marwa Abdel-fatah Zewiel , Assist. prof . Amal Ebrahim Sabra Assist. prof. Hala Ahmed El Sayes , prof . Mai Abdel-Raouf Essa

Psychiatric and Mental Health Nursing , Faculty of Nursing , Tanta University Neuro – Psychiatry , Faculty of Medicine , Tanta University

Abstract Nurses are responsible for the holistic care of substance use disorder patients, which encompasses the psychosocial, developmental, cultural, and spiritual needs of the individual, and helped to manage physical needs, prevent illness, and treat health conditions, they consider the vital caregiver for SUD patients. To do this important role, they need to have good knowledge, positive attitude and caring behavior skills toward these patients. Aim of the study: This study was aimed to determine the effect of training program on the nurses‟ attitude and perception of caring behavior toward substance use disorder patients. Subjects of study: Sample consisted of 50 nurses who were chosen by convenient sampling. A quasi-experimental design was utilized. Tools of the study: Two tools were used for data collection; Substance Abuse Attitudes Survey (SAAS) designed to measure nurses' attitudes towards substance use disorder and Caring Behavior Assessment Tool (CBA) aims to assess nurse' perception regarding caring behavior toward substance use disorder patients. Result of the study: The results revealed that there was statistically significant improvement in nurses‟ attitude and perception of caring behavior skill regarding substance use disorder patients before and after implementing of the training program. Conclusion , recommendation: The study concluded that training program about substance use disorder enhancing the nurses‟ attitude and perception of caring behavior skills toward substance use disorder patients .According to these results, the study recommended that hospital policies must encourage nurses to attend in-service training program about attitude and caring behavior skills toward substance use disorder patients.

Key wards: Attitude, Caring Behavior, Substance Use Disorder

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I-Introduction: world suffer from mental or neurological Substance use disorder is one of the major disorders and psychosocial problems that social, mental, legal, and public-health occur with substance use disorder challenges in the world; it is the major Also drug misuse accounts for 33.4% of burden in 21st century that impacts the burden of disease, 12.4% of all death families and society on multiple levels, globally and drug misuse was cited as directly or indirectly. Substance use constituting the third highest risk factor to disorder can result in wide range of health in the developed world. At the psychological and social problems and it is national level, the Minstery of Health a tremendous toll on society at many (2016) stated the percentage of substance levels it impacts the individual, family, and use disorder patient in Egypt reached to community, as it plays a role in many 6% from total population and percentage major social problems, such as violence, of substance users in Algharbia stress, child abuse, homelessness, crime, government reached to 6.9% from total and family disruption and missed work. population of government Productivity, relationship and physical Because of the nurses are responsible for health are also affected and are considered the holistic care of substance use disorder cause of preventable illnesses and patients, which encompasses the premature death in society. psychosocial, developmental, cultural, and It is a chronic pattern of behavior that is spiritual needs of the individual, and characterized by the repeated use of helped to manage physical needs, prevent substances or behaviors despite significant illness, and treat health conditions , they an ongoing harms associated with use, consider the vital caregiver for SUD where the harms over the benefits. It is patients. To do this important role, they difficult to control or cease the use of the need to have good knowledge and positive substances due to physical or psychological attitude, caring behavior skills toward dependence. Substance use disorder these patients. generally takes a- period of time to develop A positive attitude in nurses can impact on and follow a chronic and relapsing course nurses' actual job performance, in the form and therefore require ongoing support and of dealing with stressors of the job, treatment. At the International level, The crafting creative solutions to problems, World Health Organization (WHO, 2015) managing effective interpersonal estimated that 600 million people in the relationships with others and also

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enhancing nurse's ability to be more II Aim of the study productive. On the other hands negative The aim of this study was to: and pessimistic attitude of the nurse can Determine the effect of training program adversely adversely effect on the on the nurses‟ attitude and perception of therapeutic nurse-patient relationship, caring behavior toward substance use resulting in suboptimal patient care, so the disorder patients. nurses must have positive attitude toward Research hypothesis: those patients. The attitude and perception of caring A significant percentage of nurses have behaviors of the nurse who will attend the false ideas or gaps in their knowledge and training program toward substance use caring behaviors skills toward substance disorder patients expected to be changed use disorder, which causes them to behave positively.. toward SUD patients inappropriately, so III Subjects and Method that nurses must have knowledge and skills Research design: that enable them to behave in a manner A quasi -experimental research design was that meets patients need. - Nurses play used in the current study. a key role in many aspects of substance use Research setting: disorder management, planning and The study was conducted at Shopra implementation, so insufficient knowledge kas center for addiction, the center is and negative attitudes towards patients affiliated to the General Secretariat of with substance use disorder and its Mental Health. The capacity of the treatment can result in lack or improper center is 30 beds and it provides health implementation of management leading to care services to Gharbya, Menofia, poor patients' outcome. - Sharkia,Dakahelia and Kafr-ilsheikh In this regard it has been observed that governates. specific training of nurses in this field as Subjects: communication skill, humanistic skill, According to (Epi- Info program) the learning and teaching, supportive skill and subjects of this study consisted of stress management skills have positive nurses .The subjects were selected by consequences and enable them to work convenient sample and were fulfilling the effectively with those patients. - following inclusion criteria:-

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. Both sex. statement ''Cannabis should be . Nurses who provide direct care to legalized''. substance dependent person. . Treatment intervention subscale: . Agree to participate in the study. (from 9 to 13) 5 questions, this Tools of the study subgroup related to an individual's The data of this study was collected by orientation towards perceiving using the following two tools: substance use/misuse in the context of Tool I: Substance Abuse Attitudes treatment and intervention. Like Survey (SAAS); It was developed by statement ''Family involvement is a Chappel et al., 1985 . It divided into very important part of the treatment two parts:- drug dependence''. Part 1: Socio Demographic and . Non stereotypes subscale: (from 14 clinical characteristic of nurse: to 17) 4 questions relates to persons It was used to assess the socio non reliance on popular societal demographic data about nurses it will stereotypes of substance use and included 6 demographic data (age, substance users. Like statement gender, educational level, years of ''People who use cannabis usually do experience in nursing, years of not respect authority''. experience in care of substance use . Treatment optimism subscale: disorder patient, and having work shop (from 18 to 22) 5 questions related to related to substance use disorder. an optimistic perception of treatment Part 2: Substance Abuse Attitudes and the possibility of a successful Survey (SAAS); It consisted of 27 outcome. Like statement ''Drug items, designed to measure nurses' dependence is a treatable illness''. attitudes towards substance abuse and it . Non-moralism subscale: (from 23 composed of five subscales: to 27) 5 questions was linked to an permissiveness, treatment intervention, individual‟s absence or avoidance of non-stereotypes, treatment optimism, and moralistic perspective when non-moralism attitudes. considering substance use and' . Permissiveness subscale :( from 1 to substance users. Like statement ''Street 8) 8 questions implied accepting dealers are the initial source of drugs substance use within a continuum of for young people''. normal human behavior. Like

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Scoring system : Each item is scored on use disorder patients. like statement a 3-point Likert scale ranging from 1 ''Really listen to the patient when (strongly disagree) to 3(strongly agree). talk''. The minimum score is 27and maximum . Expression of positive /negative score is 81. Scoring system of these feelings from( 28 to 31) 4 questions, questionnaires was as followed: this subgroup related to help substance - < 50% = Poor attitude use disorder patients to express his - 50 – 75% = Neutral attitude feeling freely without fear. Like - Good attitude statement ''Encourage the patient to Tool II: Caring Behavior Assessment talk about how he feels''. Tool (CBA). The caring behavior . Teaching / learning from (32 to 39) 8 assessment tool was developed by Cronin questions, this subgroup related to and Harrison (1988) provide substance use disorder It adapted to assess nurse' perception patients some skills that help him to regarding caring behavior toward be independent person. Like statement substance abuse patients . The caring ''Help the patient set realistic goals for behavior assessment tool (CBA) is a 63 his health''. item questionnaire that used a 5 likert scale . Supportive, protective- corrective to reflect the degree to which each nursing environment from to 49) 10 behavior reflects caring. It was ascending questions, this subgroup related to scale from 1=little importance to 5= much provide substance use disorder importance. It ordered in seven subscales, patients support to prevent relapse. the subscales with their respective items Like statement ''Explain safety numbers precautions to the patient and his . Humanism / faith – hope/sensitivity family''. from (1 to16) 16 questions, this . Human needs assistance from (50 to subgroup related to human rights of 60) 11 questions, this subgroup related substance use disorder patients as a to assist substance use disorder human being .Like statement'' Treat patients in his need. Like statement the patient as an individual''. ''Check the patient condition very . Helping trust from( 17 to 27) 11 closely''. questions, this subgroup related to . Existential /phenomenological / provide trust from nurse to substance spiritual forces from ( 61 to 63) 3

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questions, this subgroup related to Tools of the study were translated into assist substance use disorder patients Arabic language by the researcher and to improve self-stem .Like statement were tested for content validity by a ''seem to know how the patient feel''. jury of five experts in the field of Scoring system, each nurse can receive psychiatric nursing to ascertain the score ranging from 63 to 315 grades. appropriateness of items for measuring Scoring system of this questionnaire was what they are supposed to measure as follow: and both tools were proved to be valid.  < 50% = Poor caring behavior skill A pilot study was carried out before  50 – 75% = Neutral caring behavior embarking in the field of work on 10% skill from total subjects to ascertain the  Good caring behavior skill clarity and applicability of the study Method tools. Also it served to estimate the An official letter was issued approximate time required for filling from faculty of nursing, Tanta study tools as well as to identify University to study setting to obtain obstacles that might be faced during his permission for data collection. data collection. After collecting pilot Ethical consideration: study, it was found that each nurse a. consent for voluntary participation took 25-30 minutes to fulfill tools of was obtained from all nurses the study and no modification was participating in the study. done on study tools. The pilot subjects b. The subjects were informed about the were excluded later from actual study aim of the study and reassured the sample. study subjects that the confidentiality Internal consistency of the study tools and privacy of any obtained were done by means of Cronbach's information were ensured and used Alpha coefficient which yielded only for the purpose of the study. values of r=0.924 – r=0.941 c. Respecting the right of the study respectively. subjects to refuse to participate or to 7- Actual study: The actual study was withdraw from the study at any phase divided into the four phases; was emphasized. d. The nature of study not produces harm for subject.

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I) Phase one: - Assessment phase negative attitude). Meanwhile the (pretest) objective of practical part of the  Tools of the study were distributed on program was providing study subjects the study subjects in individual basis with skills to improve their attitude and the subjects were asked to fill the and caring behavior skills like questionnaire in the presence of humanistic skills, teaching and researcher for any clarification and learning skills, supportive skills. filling of the questionnaire ranged  The prepared program was written into from 25 to 30 minutes, this phase a simplified Arabic language by the aimed to determine the study subject's researcher and revised by the needs as a base line of training supervisors to ascertain its content and program. appropriateness and applicability. II) Phase two: - Development of the Accordingly, the required training program modifications and corrections were  Training program was developed by carried out. the researcher based on reviewing of III) Phase three: - Implementation of the recent related literatures The training Program. - and the result of phase one. . The training program was  The general object of training program implemented on 16 sessions, the first was aimed to improve the nurses‟ one is introductory session and six of attitude and their perception of caring them were theoretical sessions, eight behavior toward substance use of them were practical sessions and disorder patients. The training the final session was summery for all program consisted of theoretical and previous sessions. practical parts in which each one of . The studied nurses classified into 8 them has set of specific objectives. subgroups. Each sub group composed The objective of theoretical part of of 5-7 nurses. Each sub group attended training program was providing sixteen sessions, these sessions were studied nurses with theoretical scheduled as 2 sessions per week for knowledge about substance use duration of 8 week. The time for each disorder like (definition, causes, types session was about (45-60 m). and treatment ) and attitude like . The training program was carried out (concept, type, impact of positive and in the training room of study setting on

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small group basis. This room was  Specifically prepared specifically by the hospital  The theoretical sessions was for continuing teaching and training implemented by using lecture nurses. interwoven with discussion and . Lecture, hand out, power point, role sometimes demonstration method. play were used as teaching method in Group discussion was used to enhance implementation of training program. interest and promote active . The data collection took about seven involvement of nurses. In addition to months from July 2017 to January the examples, and illustrations which provided by the researcher for assuring  In implementation of the program, understanding and the subjects also as a general, the researcher was the provided additional examples from initiator, provider and encourage of their professional experiences. Lecture exchange knowledge between studied was given in clear, simple manner nurses and researcher, and encouraged using attractive power point exploration of their responses, issues presentations which prepared by the or concepts and their attitude. The researcher in a simplified and researcher also acted as a group leader meaningful Arabic language for the who operated as a facilitator, teacher, study subjects and appropriate for and trainer. Clinical experiences of allocated time. nurses were taken into consideration  Lecture, group discussion were used as during teaching-training sessions. All method of teaching ,meanwhile the over the sessions, nurses were hand out , power point and posters motivated to share in the discussion were used as a media of teaching. with symbolic reward (by giving them  In the practical sessions, The paper notes, pens, and offering tea researcher used mainly role play, breaks), and emotionally reward by demonstration and re demonstrations as positive comments and appreciation. method of teaching also used lecture  At the end of the program for each and group discussion, visual aids, video subgroup, printed booklet of the .Role play was carried out between training program was given to all studied nurses themselves and studied studied nurses. nurses with researcher. Handout papers

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about simulated situations and scenario twice on all study subjects on an were distributed to all studied nurses at individual basis. the beginning of each session. In each - Immediately after implementation of practical session, simulated nurse, the training program. patient situations presented by the - Three months later after completion of researcher through data show and then the training program. discussed with the studied subjects. Statistical analysis  Firstly, the researcher allowed nurses The collected data were organized, to think critically and give wide range tabulated and statistically analyzed using of their own responses to the situations SPSS software statistical computer and analyze each one, after that the package version 16. For quantitative data, most therapeutic responses were the range, mean and standard deviation presented at the end of each situation‟s were calculated. For qualitative data, discussion in addition to giving comparison was done using Chi-square test rationale and analysis to each choice. χ For comparison between means,  In most of the sessions, nurses brought student t-test was used. For comparison clinical situations which also discussed between more than two means, the F-value with them. Also role playing for of analysis of variance (ANOVA) was simulated scenario was used as a calculated. Correlation between variables teaching method in showing was evaluated using Pearson‟s& Spearman therapeutic response to the clinical correlation coefficient r. A significance situations and such method help the was adopted at P<0.05 for interpretation of nurses to know how they convey the results of tests of significance.. appropriate response. Also after each IV Results. session, nurses were given a homework Table (1): illustrate the effect of training in which each nurse writes other program on the total mean score of studied situations with its therapeutic response nurses regard substance abuse attitude and this will be discussed in the survey pre, post and follow up the following session. implementation of training program .The IV phase four (Evaluation phase):- results revealed that there is highly  This concerned with the evaluation of statistically significant relation between the implemented training program. total mean score of studied nurses regard The tools of the study were reapplied substance abuse attitude survey before,

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immediately after, and after three month caring behavior skill before, immediately from implementation of the training after, and after three month from program in which (P-value=0.000*). This implementation of the training program in mean that studied nurses had total mean which (P-value=0.000*). Where studied score regard substance abuse attitude nurses had total mean score regard caring survey before program (32.180± 3.691), behavior skill before program (32.180 and then this level became high ± 3.691), while this level became high immediately and three months after immediately and three months after program (48.320±3.159& 46.280±3.540 program (48.320±3.159& 46.280±3.540 respectively). respectively). Table (2): clarifies distribution of the Table (4): show distribution of the studied studied nurses in relation to their mean nurses in relation to their mean score of score of non-stereotypes attitude subscale, caring behavior subscale (Humanism .faith The results revealed that there is highly -hope) skill, The results revealed that there statistically significant relation between is highly statistically significant relation nurses non-stereotypes attitude subscale between nurses caring behavior subscale before, immediately after implementation (Humanism .faith -hope) skill before, of the training program in which (P- immediately after, and after three month value=0.000*). Where there isn't from implementation of the training statistically significant relation between program in which (P-value=0.000*). nurses non-stereotypes attitude subscale Where studied nurses had mean score of post program and at follow (after caring behavior subscale (Humanism .faith implementation of the training program -hope) skill before program (20.620 three month ago) in which (P-value=0.159) ±3.613), while this level became high Table (3): illustrate the effect of training immediately and three months after program on the total mean score of program (27.900±3.512& 27.760±3.467 studied nurses regard caring behavior skill respectively pre, post and follow up the implementation of training program .The results revealed that there is highly statistically significant relation between total mean score of studied nurses regard

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Table (1): The Effect of Training Program on The Total Mean Score of Studied Nurses Regarding Substance Abuse Attitude Survey Pre, Post and Follow up The Implementation of Training Program

Difference Paired T-test Items Comp. Mean ± SD Mean SD t P-value

Pre . ± . Pre-Post - . . - . . Pre-Follow Substance Post . ± . - . . - . . abuse attitude up survey SAAS Follow Post-Follow . ± . . . . . up up

* Significant at P < 0.05

Table (2): Distribution of The Studied Nurses in Relation to Their Mean Score of Non- Stereotypes Attitude Subscale Pre, Post and Follow up The Implementation of Training Program.

Difference Paired T-test Items Comp. Mean ± SD Mean SD t P-value

Pre ± Pre-Post - - Non stereotypes Post ± Pre-Follow up - - Attitude Follow ± Post-Follow up up * Significant at P < 0.

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Table (3): The Effect of Training Program on The Total Mean Score of Studied Nurses Regarding Caring Behavior Skill Pre, Post and Follow up The Implementation of Training Program.

Difference Paired T-test Items Comp. Mean ± SD Mean SD t P-value

Pre ± Pre-Post - -

Pre-Follow Caring Post ± - - up behaviors skill Follow Post-Follow ± up up

* Significant at P < 0.05

Table (4): Distribution of The Studied Nurses in Relation to Their Mean Score of Caring Behavior Subscale (Human Needs Assistance) Skill Pre, Post and Follow up The Implementation of Training Program.

Difference Paired T-test Items Comp. P- Mean ± SD Mean SD t value

Pre ± Pre-Post - -

Human Pre- needs Post ± Follow - - assistance up skill Post- Follo ± Follow w up up * Significant at P < 0.05

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V: Discussion Additionally the researcher gave subjects Substance use disorder is a major problem nurses homework as post simulation that the world is facing. Substance use activity that enhanced nurses' attitude as disorder not only ruins the social fabric of this homework provide them opportunity society but it contributes significantly to be more explore to their attitude toward towards disease and violence. SUD patients and become more self- Emerging result of the present study awareness about their attitude which leads revealed that the training program has to personal and professional growth. In positive effect on nurse attitude toward theoretical sessions the researcher gave it substance use disorder patients by using lecture interwoven with group immediately and after three month from discussion. Group discussion was used to implementation of the training program. enhance interest and promote active This result may be due to training program involvement of nurses. Additionally the development which mainly based on the researcher was very keen to implement studied nurses' needs in addition to its program in a warm and friendly clarity, simplicity, frequent repetition, and environment which helps nurses to share motivating staff to participate in both and express their negative attitude freely. practical and theoretical sessions of the This result is supported by Rawat training program. (Table 1) in his study found that there This enhancement of the nurses' attitude were significant improvements in nurse also may be due to the way of attitude after intervention than before .In implementation of training program in the same line Tierney (2013) showed which researcher used role play and significant improvements for nurses' simulation as a method of teaching. This attitude toward patients with substance use method help nurses to be more self- disorder after program implementation. awareness for their attitude toward patients Society has the tendency to label and particularly their negative attitude stereotype people who are abusing drugs. .Additionally role play and simulation as a There is a stigma that is attached to these method of implementing of program give people. Nurse as a member of society also the researcher opportunity to demonstrate follows the views of society and stigmatize positive attitude that mainly helped in those SUD patients. This leads to poor replacing negative attitude by positive one attitude and poor quality of nursing care .

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with consequent harm to the patient. use disorder patients are unique and their (Table 2) needs are urgent and therefore their This study was carried out with the hope of intervention should cater for their needs, eradicate nurses stigma toward SUD this require from nurse to be more self- patients, at the same line the result of confidence, more self-autonomy. This presented study improved that there was refers to the topical importance of training positive change on nurse attitude toward of caring behavior skills which enable SUD patients .this improvement may be nurses to provide effective care for those due to the implementation of the program. patients. (Table 3) For example in one of the session In the consistent with this current study the concerned with stigma. This success was result pointed out the caring behavior skills due to during implementing session one of of nurses shaped positively after the the nurse said that they saw SUD patients implementation of training program. This as unacceptable person, dangerous and result may be due to successful effect of drug seeker, as the result of what has been training program which consist of seven said the researcher intended to change practical training sessions about different myths and mis- concepts about SUD caring behaviors such as (humanistic skills, patients by revealing real-life experiences supportive skills, self-dependent skills, of stigma , like statement'' SUD patients teaching and learning skill in order to aren't drug seeker''. ''Drug abusers are enhance caring behavior skills of nurses. acceptable patients''. ''SUD like any other The researcher used mainly role play, disorder can be treated and prevented'' demonstration and re demonstrations as change of this stigmatized view of patients method of teaching also used lecture and lead to improved nurses' attitude toward group discussion, visual aids, video and those patients. This result was in line with, role play was carried out between studied Mansour (2011) in their study observed nurses themselves and studied nurses with that there was statistical significant relation researcher. Handout papers about of non-stereotypes attitude subscale before simulated situations and scenario were and after program. distributed to all studied nurses at the Caring is a central concept to psychiatric beginning of each session. nursing and the nurse is vital in caring with For example the researcher implement substance use disorder patients so that the communication skills like active listening nurses must be understand that substance skills, silence, open end question, proud

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opening, and assertiveness. Another plays an important role within the nursing example in implementation of teaching and process and its results, and it is also a learning skills as mental preparation skills, fundamental component of the treatment. diversifying stimuli skills, and stimulating Alongside with that this study intended to motivation skills, positive and negative promote nurse humanistic skill, in reinforcement ,after the researcher provide consistent with this result, it was notice all knowledge about these skills by using that there was significant increase in mean attractive power points and after listening score of (humanism, faith -hope) skill of video or scenario to qualified nurses when studied nurses' toward substance use deal effectively with patients and use disorder patients immediately after and effective caring behavior skills. the after three months of implementation of researcher played role of nurse and studied the training program compared with before nurses played role of patients to make role the implementation of the training play of effective and therapeutic response program. (table4) This result may be between nurse and patients while giving related to the effort made from researcher care to substance use disorder patients. in order to provide wide knowledge for This result was supported by Cristina et nurses about humanistic skills and make al., (20 in their study who observed effective role play about humanistic skills that there were significant improvements (empathy, sharing hope skill) that help in nurse caring behavior skills after nurses to practice them effectively. intervention than before .Additionally This coincides with Mousa’s study 5) Hunter in his study support the that showed that all nurses achieved same result. While Justin & Sleeper high level of humanistic skills following in their study revealed that the completion of theoretical and practical there was poor quality of nursing caring contents of the training program. behavior skills toward substance use Similarly, a study done by Kahriman et al disorder patients and this require more revealed the same result for improvement to deal effectively with those Mousa’s study. This finding was patients. contradicted with Williams & Stickley Nursing is a profession committed to the in his study who stated that promotion of human beings. It takes into humanistic skills are a personality trait that consideration their freedom, uniqueness cannot be easily taught, in the same line and dignity, therefore communication the results of the current study contradicted

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with Nunes et al., (2011) which found  Purposeful training workshop about that nurses' levels of humanistic skills did positive nurse attitude toward SUD not change or were more likely to decrease patients. after intervention.  Hospital policies must encourage VI Conclusion and Recommendations nurses to attend in-service training Based on the results of the present program about new health issues and study. The findings confirmed the its trends related to SUD. importance of nurses' attitude and nurses References caring behavior skills in management of Keltner N. Psychiatric Nursing. 6th ed. substance use disorder, and also confirmed U.S.A: Mosby Co.), 2011; 361- the effect of the training program on Boyd M. Psychiatric Nursing enhancing the nurses‟ attitude and Contemporary Practice. 5th ed. perception of caring behavior toward Philadelphia: Lippincott, 2012;588- substance use disorder patients. It can be concluded that the majority of studied World Health Organization (WHO). nurses had a high level substance use As Burden of Mental Disorders disorder attitude and caring behavior skills Looms Large. Countries Report Lack that enable them to deal effectively with of Mental Health. Programs Accessed SUD patients after the implementation of June http://www.who.int/inf-pr this training program. Total score of Insurance Program Administered by attitude and caring behavior skills before Lockton Affinity, LLC© 2016 intervention was significantly different Copyright by Lockton Affinity, LLC. from immediately after and at follow up. All rights reserved. Based on the previous findings of the Hamad A. Percentage of Addiction in present study and conclusion, the Egypt . minister of health following recommendations are ,2015Avialable at suggested http://alwafddicd.org  Introduction of effective nursing Connolly J. The Illicit Drug problems. attitude and caring behavior skills Health Research Board, 2010; 40 (10). related to substance use disorder - patients in students curriculum. Mohr w. Psychiatric Mental Health

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Nursing. 7th ed., Philadelphia: Philadelphia: Lippincott, 2014;588- Lippincott Co.)2014; 89 - . Sullivan E. Nursing Care of Clients Rassool G. The Responses of health with Substance Abuse, Philadelphia: care professionals to Substance use St. Louis Mosby Co.)2008;8- . and misuse Journal of Mental Health Vidbeck S. Psychiatric Mental Health Nursing .2010 ;13 (5). 68- Nursing. 6thed. USA: Lippincott Howard H & Chung l . Nurses Williams, Co.) 2 . Attitudes toward Substance misusers. Chappel J& Schnoll N. Physician Substance Use and Misuse 2009 Attitudes. effect on the treatment of - chemically dependent patients. 2011; Connell O Elizabeth & Margaret - L, “The Importance of Critical Care Boyd M. Psychiatric Nursing, Nurses' Caring Behaviours as Contemporary practice 5th ed. Preceived by Nurses and Philadelphia: Lippincott .2015;24- . Relatives ” Intens Crit Care Miller S.,saitz R . principles of Nurs 24 (2016): 349– . addiction medecine. 5th ed. Essen V & Sjoden L. “The Philadelphia: wolters Kluwer . Importance of Nurse Caring Behaviors Chung J & Changh J .Nurses‟ as Perceived by Swedish Hospital Attitude towards Alcoholic Patient in Patients and Nursing Staff ” Int J Nurs accident and emergency department. Stud 40 (2013): 487– Hong Kong Journal of emergency Chappel J& Krug R. The Substance Medicine, 2013; 10(2): 104- . Abuse Attitude Survey. An instrument Happell B &Taylor C .Negative for measuring attitudes. Journal of Attitudes towards clients with drug Studies on Alcohol - and alcohol related problems. New Cronin S & Harrison B. Caring Zealand. Journal of Mental Health Behaviors Assessment Tool. Nursing. 2012; (10) 87- Assessing and measuring caring in Barbara G& Faltz V. Substance Use nursing and health science. New York: Disorders.7th ed : Lippincott Springer Co,) 1988; 724- Co.)2017;116. Rawat,F . Attitudes of nurses and Boyd M. Psychiatric Nursing health practitioners towards Contemporary Practice. 5th ed. substance abuse and their attitudes

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towards intervention at primary Workers Journal of Pshychiatrıc health level Medical journal. 2009; Nursing, 2016; 3(1): 6- 17 (12): 154 – Williams & Stickley . Humanistic

Tierney, M. Improving nurses‟ skills are a personality trait that attitudes toward patients with cannot be easily taught . Journal of

substance use disorders Education and Practice 2010; Mansour et al., change of this -

stigmatized view of patients lead to Nunes, P. Williams, S & Stevenson,K. improved nurses' attitude toward empathy decline in students from five those patients. Jordan The National health disciplines during their first Academies Press. - year of training. International Journal Justin A & Sleeper1 "Stigmatization of Medical Education, 2011; 2:12- by nurses as perceived by substance abuse patients. Addiction Journal. - Cristina, S & Margarita, B etal. Nurses' training on dealing with alcohol and drug abuse .Impact of drug abuse . Addiction Journal . -

Hunter,E. Multidisciplinary care in the management of substance misuse and mental health problems. Journal of

Pshychiatrıc Nursing Mousa , M. Empathy toward Patients with Mental Illness among Baccalaureate Nursing Students: Impact of a Psychiatric Nursing and Mental Health, Journal of Education and Practice, 2015;6(24) :98- Kahriman et al. Emphatic Skill Levels of Primary Health Care

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Effect of Psycho- Educational Program about Violence on Nurses' Knowledge and Practice

Amina Ahmed Wahba El-Salamony , Dr. Zebeda Abd-Elgwad Elsherif , Dr. Mervat Hosny Shalaby , Prof. Adel Abd El Kareem Badawy

.Assistant lecture of Psychiatric & Mental Health Nursing Dept. Faculty of Nursing kafr Elshiekh University. [email protected]

. Assistant Prof. of Psychiatric & Mental Health Nursing Dept. Faculty of Nursing Tanta University.

. Professor of Neuropsychiatry Department Faculty of Medicine Tanta University

Abstract Background: Violent behavior of psychiatric patients is a public health problem. It presents obvious risks of injuries or death of assailants and their victims. Aim: this study aimed to evaluate the effect of the psycho-educational program about violence on nurses' knowledge and practice. Design: A quasi- experimental research design was utilized in this study. Setting: The study was conducted at Tanta Psychiatric and Mental Health Hospital affiliated to ministry of health and population. Tanta city, Algharbya Governorate, Egypt. Subject: A sample of 50 randomly selected psychiatric nurses were recruited for this study. Tools: Two tools were used to collect data; tool I part1: socio-demographic characteristics for nurses, part2: Structured Nurse's Knowledge Questionnaire. Tool II: Observational Checklist for Nurses' Practice Related to Patient Violence. Results: The main result of this study revealed, highly significant improvement in nurses' level of knowledge and practices toward violent patient after implementation of psycho-educational program. Also, there were statistically significant positive correlation between nurses' level of knowledge and level of practice related to psychiatric patients' violence immediately after and 3 months after implementation of the educational program where (r =0.861, P=0.019) (r =0.418, P= 0.003) respectively. But, there were no statistically correlation between nurses' level of knowledge and practice related to violence before implementing the program as r = 0.180, P= 0.211. Conclusion: The present study concluded that, the educational program sessions played an important role in improvements of nurses' level of knowledge and practices toward violent patient. Recommendations: This study recommended implementing further educational program for nurses concerning the pattern of communication and behavioral management for violent patients is very important. Key words: Educational Program, Violence, Nurses' Knowledge, Nurses' Practice.

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Introduction number of past violent events, a history of Violence is one of the most difficult impulsivity, male gender, young problems facing psychiatric nursing in adulthood, lower intelligence, history of recent years. Violent behavior has been head trauma or neurological impairment, identified as a national health concern and dissociative states, history of military a priority for intervention in the United service and weapons training. Also, States, where occurrences exceed 2 million diagnoses of major mental illness, per year - . Psychiatric nurses have a persecutory delusions, command higher chance of being the first hallucinations, treatment non adherence, professionals in contact with violent and also, depression, hopelessness, patient. Thus they should be able to suicidality and\ feasibility of homicidal identify them and discontinuing the cycle plan are risk factors for violence . of violence . Studies of violence in psychiatric hospitals Violence has been defined as any act, indicate that violence in healthcare settings word, even attitudes such as an is significant and needs to be stopped . It intimidating facial expression, that creates is vital to nurses that, hospitals adopt fear or negative feelings, leading to prelisted protective factors for violence . physical or psycho-social unwanted These factors includes providing security, results. Violence also can be defined as assessment and documenting the risk of any actions, or inaction, premeditated and violent behavior of patients, alarm done consciously or unconsciously, with systems , providing fair assignments, and the intention to harm, whether physically, restricting public access during providing emotionally, psychologically, or spiritually care for patients; improving security . It is a multifaceted problem, which may systems and measures, restricting public take on several forms such as verbal abuse, access, and controlling visiting times physical assaults, aggression, harassment, security officers, camera systems, a closed- bullying, intimidation, threatening . door policy; and adequate staff numbers Physical, verbal violence and sexual are very helpful in dealing with harassment are the major types of violence violence . reported in psychiatric setting . There are numerous consequences of Regarding the risk factors for violence, it violence on nurses, most of these was founded that, the risk of future consequences considered psychological violence increases linearly with the consequences, that may include becoming

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suspicious, feeling anger, patients‟ first point of contact with the embarrassment depression lack of nurses‟ health system, learn breakaway techniques safety all the time in the work place; fear to promote personal safety, self-defense or stress; becoming anxious; being super- techniques , and ways to avoid provoking alert or watchful and on guard; and post patients. Other essential skills include traumatic stress disorders symptoms - . assessment of the environment for hazards, Psychiatric nurses are the first clinical staff - escape routes, effective to make contact with patients and their communication strategies and skills, families, and keep close relationships with assertiveness techniques, conflict them. Accordingly, the nurses should have resolution, stress and anger management the knowledge and skills of emergency . Therefore, this study provides the care, as well as evaluate the precise baseline data, based on the psycho circumstances, and determine cases of educational program for nurses can be physical, sexual, or violent behavior and developed to correctly identify violent injury and provide appropriate nursing, and situations and provide effective legal services to the patients . Also, intervention. nurses should be particularly sensitive to Aim of the study: The aim of this study the violent client's need to feel safe, secure, was to evaluate the effect of the psycho - and in control of his or her body. They educational program about violence on should take care to maintain the client's nurses' knowledge and practice. personal space, assess the client's anxiety Research hypothesis: Level of knowledge level, and ask permission before touching and practice of psychiatric nurses‟ him or her for any reason, and nurses increased after implementing the psycho- should apply these cautions to all clients in educational program about violence. the mental health setting . Subjects & Method Many nurses have not been trained to Research design: manage explosive situations. So, violence A quasi- experimental research design was threatens the welfare of the psychiatric used in this study. patients, staff and visitors alike Research setting: .Accordingly, psychiatric nurses need to be The study was conducted at Tanta Mental skillful in violence assessment to assist in Health Hospital affiliated to the Ministry prevention and implementation of various of Health and Population. It has a capacity strategies, identify indicators of violence at of 65 beds divided into four wards two

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wards for females and two wards for knowledge regarding psychiatric patients' males. It also provides health care services violence. The validity and reliability of this to three governments, namely Gharbya, El- tool was done by the original researcher it Menofeya, and Kafr- El-sheikh. Tanta city, was (0.97%). The questionnaire consisting Algharbya Governorate, Egypt. It works 7 of 23 questions, there are three responses days/ week, 24hrs/ day. for each question: incorrect (0), partially Subjects: correct (1), and completely correct (2). It A sample of 50 psychiatric nurses includes group of questions to assess the (calculated using Epi- Info software) 20 of nurse's level of knowledge related to: them work in female ward, and 30 nurse  Knowledge about nature of violence, it works in male ward, they were selected included: the meaning, high risk factors randomly for this study. These subjects and knowledge about most common fulfilling the following criteria: diseases associated with violence (4 - Willing to participate in the study. items), - Provide direct care to psychiatric  Knowledge about behavior, and patients. predictable signs of violence ( 3items), - Have previous experience in  Knowledge about patient's needs and psychiatric field. methods of prevention of violence (4 - Both sex. items), Tools of the study:  Knowledge about treatment of violence: The data of this study was collected using types, indications, and purposes (4 the following tools: items), Tool I: Structured Nurse's Knowledge  Identifying the role of nurse towards Questionnaire , it divided into two parts therapeutic environment, seclusion and Part one: Socio-demographic restraint (7 items), characteristics for nurses: Which  Information related to basic items in includes, nurses' name, age, sex, level of recording violence (1 items). education, years of experiences, marital Scoring system: status, residency. Evaluation of this questionnaire was as Part two: Structured Nurse's follows: Knowledge Questionnaire: - Less than 50% = Poor knowledge This questionnaire was developed by about violence Mohammed to assess nurse's

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- From 50 – 75% = Fair knowledge Method about violence The following steps were followed in this - More than 75% = Good knowledge study: about violence This study was approved by the Tool II: Observational Checklist for research and ethical committee at Nurses' Practice Related to Patient faculty of nursing, Tanta University. Violence. An official letter was obtained from It was developed by the researcher - faculty of nursing, Tanta University to to assess the nurse's practice in dealing the director of Tanta Mental Health with patients' violence. There are two Hospital to obtain his permission for responses for each question: done (1) not data collection. The director was done (0). The questionnaire includes 30 informed about the goal of the study, items grouped into 5 subscales, namely: the date and time of data collection  Acceptance of the patient as a human before permission. being (8 items), . Ethical consideration.  Use of therapeutic communication  Informed consent to participate in the skills (9 items), study was obtained from the nurses  Reduce environmental stimuli (2 after explanation of the purpose of the items), study.  Maintain safety environment (5  Assure the participants about their items), privacy and confidentiality of the  Help patient to learn self-control obtained data, and it used only for the behavior (6 items). purpose of the study. Scoring system:  The participants were informed that Every nurse can receive scores ranging they have the right to withdraw from from minimum (0), and maximum (30) the study at any time if they want. grades classified as follows: Preparation of tools - Less than 65% = unsatisfactory . Observational Checklist for Nurses' practice in dealing with patients' Practice Related to Patient Violence violence. (Tool II) was developed by the - More than 65% =satisfactory practice researcher after reviewing the - in dealing with patients' violence. literature, and was translated

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into Arabic language by the Knowledge Questionnaire) and then researcher. they were asked to fill it as pre . Tool (II) was tested for content intervention assessment. This was done validity by a jury of five experts in the as a self report in an individual basis, field of psychiatric nursing and was and in the presence of the researcher. proved to be valid. This was completed in around 25-30 . Before embarking in the actual study, minutes, and tool II (Observational a pilot study was carried out on 10% Checklist for Nurses' Practice Related of the subjects (5 nurses) after taking to Patient Violence) which applied by their oral approval and explanation the the researcher through indirect purpose of the study to ascertain the observation to each nurse during their clarity and applicability of the study contact with violent patients. The time tools and to identify obstacles that of observation was at least 25 minutes might be faced during data collection. in the morning shift because the After collecting pilot study, it was number of nurses are more available in found that each nurse require 25-30 the morning shift than other shifts. This minutes to fulfill study tools and no phase aimed to determine the study modification was done for all tools .It subject's needs as a base line of was applicable and clear to nurses in training program. pilot study. Those subjects were ii. Planning Phase: - selected randomly and they were  The psycho-educational program was excluded later from the study sample. `developed by the researcher based on . Internal consistency of tool (II) was data from the assessment phase and assessed using Cronbach's Alpha reviewing of the recent related coefficient which yielded values of ( r literatures. - The prepared program was translated into a Actual study: it was divided into the simplified Arabic language by the following phases: researcher and revised by the i. Assessment Phase: - supervisors to ascertain its content and . The researcher selected 50 nurses who appropriateness and applicability. meet inclusion criteria. Accordingly, the required . The selected nurses undergo a pre-test modifications and corrections were using tool I (Structured Nurses' carried out.

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 The educational program aimed to . The educational program was improve nurses‟ knowledge and implemented on 9 sessions represented practice about violence of psychiatric as follow: patients. The program was achieved Session 1: Include introductory through theoretical and practical parts session, establishing relationship, in which each one of them has set of obtain verbal consent, explain aim of specific objectives. The theoretical the program and its' schedule. part of educational program aimed to Session2: Involve teaching about provide studied nurses with theoretical definition of terms related to violence, knowledge about psychiatric patients' high risk factors of violence. violence. The practical part of the Session 3: Include teaching about the program aimed to provide them with most common disease associated with skills required for dealing with violence, predictable signs of violence, violence of psychiatric patients. patients' needs (physical, iii. Implementation Phase:- psychological). . The training program was carried out Session 4: Include discussing different in the training room at Tanta Mental ways of violence de escalation and Health Hospital on small group basis. prevention. This room was prepared specifically Session 5: Include discussing by the hospital for continuing teaching psychiatric nurse's role toward and training nurses and consisted of 12 patients' violence including process of chair arranged in a circle shape, assessment and intervention. portable laptop and data show. Session 6: Include teaching treatment . The study subject (50 nurses) was modalities that may be used for violent divided into several subgroups (10 patients (psychopharmacological nurses for each). each subgroup treatment). received nine session (one session / . Session 7: Include teaching, training day / three days / per week /for 3 about behavior therapy regarding weeks). All sessions was given at the violence. morning shift. The time of each session take about two hours.

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Session 8: Include discussing and . At the end of each session, nurses training about the therapeutic were asked questions on what was communication skills, and the presented at the session to assess their therapeutic environment for managing understanding. This was followed by violence. summarization of the main points Session 9: Include training about discussed in each session. physical treatment e.g. seclusion& . At the end of the program for each restraint, termination of the program, subgroup, printed booklet of the and immediate posttest. educational program was given to all Regarding giving program content: study subjects. Generally Specifically . In both theoretical and practical . The theoretical sessions was given sessions, the researcher was the using lecture interwoven with initiator, provider of knowledge discussion and sometimes between studied nurses and researcher, demonstration method. Group and encouraged exploration of their discussion was used to enhance responses, issues or concepts. The interest and promote active researcher also acted as a group leader involvement of nurses. In addition to who operated as a facilitator, teacher, the examples, and illustrations which and trainer Nurses‟ individual provided by the researcher for differences and level of understanding, assuring understanding and the their clinical experiences were all subjects also provided additional taken into consideration during examples from their own personal and teaching-training sessions. All over professional experiences. Lecture was the sessions, nurses were always given in clear, simple manner using motivated to share in these sessions attractive power point presentations either externally (by rewarding them which prepared by the researcher in a with giving them paper notes and simplified and meaningful Arabic pens, and offering tea breaks), and language for the study subjects and internally by positive comments and appropriate for allocated time. satisfying their needs for knowing by . In the practical sessions, the answering their questions, and researcher used mainly role play, expressing their emotions. demonstration and re demonstrations

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as method of teaching also, used response and this were discussed in lecture, group discussion, visual aids the next session. and video. Role play was carried out . for example in implementation of between studied nurses themselves communication skills and teaching and and studied nurses with researcher. learning skills like positive and Handout papers about simulated negative reinforcement, behavior situations and scenario were contract and application of seclusion distributed to all studied nurses at the and restraint after the researcher beginning of each session. In each provide all knowledge about this skills practical session, simulated nurse, by using attractive power points and patient situations presented by the after listening video or scenario to researcher through data show and then qualified nurses during dealing discussed with the studied subjects. effectively with violent patients and . Firstly, the researcher allowed nurses use effective skills, the researcher to think critically and give wide range played role of nurse and studied nurses of their own responses to the situations played role of patients to make role and analyze each one, after that the play of effective and therapeutic most therapeutic responses were response between nurse and patients presented at the end of each situation‟s while giving care to violent patients. discussion in addition to giving iv. Evaluation Phase: rationale and analysis to each choice. The evaluation of the implemented . In most of the sessions, nurses brought program was done by reapplying of tool I, clinical situations which also tool II to psychiatric nurses and perform as discussed with them. Also, role same as pre- test. This was done as playing for simulated scenario was follows:

used as a teaching method in showing - Immediately after implementation of therapeutic response to the clinical the program. situations and such method help the - Three months later after program nurses to know how they convey the implementation. appropriate response. Also, after each session, nurses were given a - The study was conducted in July 2017 homework in which each nurse writes and finished in January 2018. other situations with its therapeutic

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Statistical analysis: showed that, 8% of studied nurses had a . The collected data was organized, good level of knowledge regarding tabulated, coded, and statistically patients' violence before the educational analyzed using SPSS software program. While it increased to reach 82% statistical computer package version to fall in the same category immediately after the educational program . Statistical presentation and analysis of implementation compared with 78% of the present study was conducted using nurses fall in the same category three frequency, percentage, arithmetic months after the educational program mean, standard deviation, the linear implementation. correlation coefficient, chi-square, Table 2: Represents distribution of the analysis of variance [ANOVA] tests, studied nurses in relation to their mean and Paired t-test. score of knowledge about violence before, Results: immediate, after educational program. it Table 1: Presents the distribution of studied can notice that studied nurses had mean nurses according to their socio-demographic score of knowledge about violence before and work characteristic. The results revealed program (40.4200±8.15185) while this that, (54%) of studied nurses were < 30 years level became (61.9200 ±9.48864) with the mean age + years, immediately after program then descends the majority of them were female (66%). after three month to become Regarding their marital status, (70%)of (61.1400±11.04353). The results revealed nurses were married and (52%) of nurses that, there were statistically significant come from urban areas. In relation to their differences between nurse's knowledge educational level, (44%) of studied nurses about violence before and immediately had bachelor of nursing. Regarding after the educational program while P- experience year in nursing as a general, value = 0.000. but, there were no (40%) of them had experience >10 years, and statistically significant differences between (38%) of studied nurses had experience less mean score immediately after and three than 5 years in psychiatric nursing with mean, months after the educational program ( + 4.66032) years. implementation where (t= .369, P-value = Figure 1: shows studied nurses' total score of knowledge about violence before and Table 3: Presents the distribution of the after educational program. The results studied nurses in relation to their mean

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score of practice related to patients' . and this differences were violence before, immediate and three statistically significant as P value months after educational program. The In relation to, maintain safety environment results revealed that, in relation to (section IV), the results revealed that, there "accepting the patient as human being " were statistically significant differences (section I) there were statistically between mean score before the program, significant differences between mean score immediately post and three months after before the program and immediately after the program implementation at P value = the program as (t= 2.432 at P value=0.019) and also, there were statistically significant Regarding, helping patient to learn self- differences between mean score before and control behavior (section V), the results three months after the program revealed that, nurse's ability to learn implementation at (t= 4.563, P value= patient self-control behavior was improved 0.000). While there were no statistically after program as there were statistically significant differences between mean score significant differences between mean score immediately after the program and three before the program, immediately post and months after the program implementation three months after the program while P where(t= 1.387, P value= 0.172). value <0.05. Regarding, nurses' skills about "Use Finally, regarding the total mean score of therapeutic communication skills" (section studied nurses' practice related to patient II), the results showed that, there were violence, the results revealed that, there statistically significant differences between were statistically significant differences mean score before the program, between mean score before the program immediately after and three months after and immediately after at (t= 13.931, P the program implementation at P value value=0.000) as well as between mean score before and three months after the Concerning, "reduce environmental educational program implementation at (t= stimuli" (section III) the results illustrates 7.502, P value= 0.000), also, there were that, studied nurses mean score before statistically significant differences between program was(2.5200 ± whereas mean score immediately after the program this level became ± ) and three months after the program at (t= immediately after program then descend 2.995, P value= 0.004). after three month to become ( ±

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Table 4: illustrates the correlation between psychiatric nurses' level of knowledge and level of practice related to psychiatric patients' violence. The results revealed a statistically significant positive correlation between nurses' level of knowledge and level of practice related to psychiatric patients' violence immediately after and 3 months after implementation of the educational program where (r= 0.861, P- value= 0.019) (r= 0.418, P-value= 0.003) respectively. But, there were no statistically correlation between nurses' level of knowledge and level of practice related to psychiatric patients' violence before implementing the educational program as r= 0.180, p-value= 0.211.

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Table (1): The Distribution of the Studied Nurses According to Their Socio- Demographic and Work Characteristics

Socio-demographic Studied nurses ( n=50) Characteristics No. % Age in years: < . 30 – > Mean + SD + Sex: Males Females . Marital status: Single Married . Divorced Residence: Urban . Rural Educational level: Nursing diploma Bachelor of nursing . Technical nursing institute Experience at general nursing in years

– > . Experience at psychiatric nursing in

years . – > Mean + SD +

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Figure (1) Comparison of Studied Nurses’ Total Score of Knowledge About Violence Before, Immediate and Three Months After Implementation of The Educational Program.

Table (2) Distribution of the studied nurses in relation to their mean score of knowledge about violence before, immediate and three months after implementation of the educational program.

Studied nurses’ knowledge about Paired T-test Educational violence (N = 50) program Mean ± SD Comparison T P-value

Before – Before ± Immediate *

Immediate ± Before -After 3 * months After 3 Immediate- ± months After 3 months *Statistically significant

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Table (3) Distribution of the studied nurses in relation to their mean score of practice related to patients' violence before, immediate and three months after educational program.

Paired T-test Items Comparison P- Mean ± SD T value I. Accept the Before ± Before -Immediate . patient as Immediate ± Before -After 3 months human being After 3 Immediate-After 3 ± months months II. Use therapeutic Before ± Before -Immediate communication Immediate ± Before -After 3 months skills After 3 ± Immediate-After 3 months months III. Reduce Before ± Before-Immediate environmental Immediate ± Before-After 3 months stimuli After 3 Immediate-After 3 ± months months IV. Maintain Before ± Before-Immediate safety Immediate ± Before-After 3 months environment After 3 Immediate - After 3 ± months months V. Help Before ± Before-Immediate patient to learn self-control behavior Immediate ± Before-After 3 months After 3 Immediate-After3 ± months months Before ± Before-Immediate Immediate ± Before-After 3 months Total performance After 3 Immediate-After 3 ± months months *Statistically significant

Table : Correlation Between Nurses’ Knowledge and Level of Practice Related Patients' Violence Nurses' level of Nurses' level of practice related to psychiatric knowledge about patients' violence psychiatric patients' R P violence Before intervention Immediately after After 3 months

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Discussion represented improvement in the total Nurses serve as the frontline care providers knowledge level immediately after and in the country's health system particularly after three months from implementation of the mental health system. These nurses, the educational program compared with face the huge challenge of providing before the implementation of the nursing care to violent psychiatric patients. educational program. Such result can be Patients' violence is a global issue, and relatively understood in the light of the major problem in both developed and immediate effect of educational program developing countries which represented in sessions which were based on nurses' the use of physical force, verbal abuse, needs besides its clarity, simplicity. threat or intimidation, which can result in Additionally, at the end of each session harm, hurt or injury to self or to another nurses were asked questions on what was person. Fear from patients' violence affects presented at the session to assess their the performance of Health Care Providers understanding and this was followed by (HCPs) and decreases their responsiveness summarization of the main points to healthcare needs of the patients. - discussed in each session. The positive Thus, it is required for nurses to have the impact of the training program may also be necessary knowledge and skills to manage explained by the fact that this program mentally ill, violent patients without being meets the recommendations formulated in hurt in the process. In order to do this, the literature regarding staff training to psychiatric nurses need to be educated and prevent violence - . For instance, The trained in understanding patient's violent program also includes recommendations behavior to increase the confidence of made by Abu Al Rub et al.(2010) ), psychiatric nurses when confronted with according to whom a training program violent patients and to be able to reduce the should include the recognition of verbal risk of injuries to both psychiatric nurses and nonverbal signs of aggression, risk and patients. assessment and management, de-escalation The present study aimed to evaluate the tactics, and post-incident support. Also, in effect of the psycho - educational program review of the literature on this subject, about violence on nurses' knowledge and Beech and Leather (2009) , reported practice. that a good training program should Regarding knowledge of studied nurses contain theory (understanding aggression about patients' violence, the present study and violence in the workplace), prevention

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(assessing danger and taking precautions), practice violence prevention and interaction (with aggressive people), and management over a period of time by

post-incident action (reporting, given a simulated clinical situations. In investigation, counseling, and other follow addition to the homework that was given to up). nurses, as post simulation activity In this line, the result of the present study enhanced nurses' practice toward patients' come in agreement with the study done by violence. As such homework increases Arguvanli S. et.al.(2015) , who revealed their motivation to improve their skills that, aggression management training which leads to personal and professional program (AMTP) was found to increase growth. At the same time during practical knowledge level of nurses and led to sessions, the researcher used the role positive changes at their aggression playing as a teaching method in showing perceptions. Similarly, Kollipara S. et.al. effective response to the clinical situations 5 ., revealed that, the significant and such method help the nurses to know effect of training program was found on how they convey the appropriate response knowledge scores of the staff nurses in effective manner. This result is in regarding management of patient with accordance with study done by Fathy violent behavior. In contrast to this finding, Sh.(2012) , who founded that there were Bekelepi N. (2015) , founded that, the highly statistically significant differences majority of participants had not received between nurses' level of skills pre/ post any kind of training in the management of counseling. violence and the training that is provided, In the same direction, Baig, L. et.al. is not effective to equip them with the , proved that, the intervention knowledge and skills to manage in-patient group had higher perceived confidence violence. levels and coping skills to deal with In relation to, nurses' level of practice aggression when compared with the related to patients' violence, the result of control group. In contrast to this finding, the present study illustrate that, there were Tema et al. (2011) , reported that, nurses statistically significant differences between felt that they did not receive enough nurses' level of practice before and after training in order to gain enough knowledge implementation of the educational and be skilled in handling violent patients. program. This may be due practical However, Letlape H. (2012) asserts that sessions which allow nurses to effectively psychiatric nurses who attend in-service

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training and are empowered with latest no correlation between psychiatric nurses' psychiatric knowledge and skills are more level of knowledge and level of skills to effective when dealing with violent deal with psychiatric patients' violence. psychiatric patients and are able to reduce Conclusion and Recommendations the risk of injuries to both nurses and Conclusion: patients. Psychiatric inpatient aggression and Finally, regarding correlation between violence is commonly reported emergency psychiatric nurses' level of knowledge and that requires immediate, prompt nursing level of skills to deal with psychiatric interventions to reduce and prevent its patients' violence. The results of the negative consequences on both patients present study revealed that there is a and staff in inpatient psychiatric settings. statistically significant positive relationship Based on the findings of the present study, between nurses' level of knowledge and it can be concluded that the level of skills to deal with psychiatric implementation of the educational program patients' violence. This result indicated that sessions showed highly statistically when nurse's knowledge about violence significant improvements in nurses' level increased, in return, the psychiatric nurses' of knowledge about violence, and nurses' level of skills to deal with the violent practices toward violent patient. patient increase. This results may be Additionally, there is a statistically positive interpreted by the fact that" in order to deal relationship between nurses' level of effectively with violent patient nurses must knowledge about violence and their level have sufficient knowledge data base that of practice toward violent patient. help them to understand everything about Accordingly, when nurses' level of patients' violent behavior". Furthermore, knowledge about violence increased, their the educational program cover all ability to deal with violent patient necessary knowledge about violence of improved. psychiatric patients that needed to Recommendations: intervene effectively with violent patient Recommendations regarding education: and also the researcher motivate the  Adding a qualitative research studied nurses to apply learned knowledge approach that enrich the nurses' in clinical field during dealing with violent theoretical and practical background patient. This result is contrary to Fathy concerning psychiatric patient violence Sh.(2012) , who showed that, there were management.

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 Implementing further educational upgrade their knowledge and skills program for nurses concerning the regarding violence periodically. pattern of communication and References: behavioral management for violent Stevenson K., Susan M., Jack S., patients. Mara L. and LeGris J. Registered  Generalize the application of the nurses‟ experiences of patient violence educational programs for all psychiatric on acute care psychiatric inpatient nurses to provide a better understanding units: an interpretive descriptive study, about violence of psychiatric patient BMC Nursing, 2015; 14:35 and how to deal effectively with them. Stuart G. Principle and Practice of  Continuous In-service training Psychiatric Nursing. by mosby Th programs need to be implemented for ELSEVIER, 10 ed. 2 - nurses to provide necessary knowledge - . and skills about violence of psychiatric Vide beck S. Psychiatric Mental Health patient in clinical practice area. Nursing. Philadelphia. Lippincott th  Establish workshops and holding Williams and Wilkins Company ed. seminars to help the nurses refresh their - knowledge about violent patient and Franz S. Aggression and violence discuss their daily problems facing them against health care workers in Germany in workplace. – a cross sectional retrospective Recommendations regarding hospital survey. BMC Health Services administration: Research, 2010; 10(3): 1–  Provide ways of accessing Bimenyimana E. The Lived information to nursing staff as Experience of Aggression and internet unit, library books and Violence in a Gauteng Psychiatric digital library to be able to know Institution. Unpublished MC new trends about assessment and Psychiatric Nursing Mini-dissertation. management of violence of Johannesburg: University of psychiatric patient. Johannesburg. 20 -  Developing in-service an Farrell G., Shafiei T. and Chan S. educational department to help in Patient and Visitor Assault on Nurses preparing nurses prior to work to and Midwives: An Exploratory Study

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The Effect of Internal Disaster Management Intervention Program on Nursing Staff Knowledge and Skills

Eman Mohamed Ali Hassan , Reda Abd El-Fatah Abo Gad , Safaa Mohamed El Demerdash

Nursing Administration, Faculty of Nursing

Assist.Prof. of Nursing Services Administration, Faculty of Nursing , Tanta University

Abstract:

Background: Disaster is unforeseeable event that destroys lives and affects people, ruins possessions and disturbs environment. Nursing staff play a vital role in dealing with the victims of such events, so, it is essential for nursing staff to be prepared in facing the consequences of disasters. Aim: Identify the effect of internal disaster management intervention program on nursing staff knowledge and skills. Design: A quasi- experimental design was used. Setting: The study was conducted at Tanta Emergency Hospital, Tanta University. Subject: sample of 35% of total nursing staff (n = 175) were included. Tool: nursing staff knowledge regarding internal disaster management was used included part I: Characteristics data of nursing staff, part II: Nursing staff knowledge regarding internal disaster management, and part III: Nursing staff perceived skills about procedures dealing with internal disaster management. Results: Preprogram, majority of nursing staff had poor knowledge, while post program, more than two-thirds of nursing staff had good level of knowledge with statistical significant improvement on nursing staff levels about internal disaster management pre than post program. As well as, preprogram, more than half of nursing staff had low level of perceived skills, while, post program about two-thirds of nursing staff had high level of perceived skills with statistical significant improvement in nursing staff skills dealing with internal disaster management pre than post program. Conclusion: Nursing staff knowledge and skills was improved after implementation of disaster program. Recommendation: Nursing staff need continuous courses and training for disaster management and incorporate emergency care and disaster management skills into undergraduate curricula.

Keywords: Internal disaster management, Intervention program, knowledge and skills, Nursing staff.

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Introduction emergency takes place to reduce its scope. A disaster is a situation or event which Mitigation includes the process of danger overwhelms local capacity necessitating a identification, assessment of life and request to a national or international level property threat in order to limit potential for external assistance. Hospitals and other causalities, and adverse impact of natural health care facilities classify disasters as and technological hazards. either internal or external. Internal Second: Preparedness phase is targeted on disasters cause disruption of normal preparing activities to be taken when a hospital functions due to injuries or deaths disaster occurs i.e. planning preparedness of hospital personnel or damage. External measures proper maintenance and training disasters are those that do not affect the of emergency services, developing and hospital infrastructure but do tax hospital exercise of emergency population warning resources due to numbers of patients or methods combined with emergency types of injuries. An effective response to shelters and evacuation plans, stocking disaster begins with effective planning and piling of supplies and equipment. Third: programming, but must include many other Response phase includes activities during steps. Each of these steps depends on the and immediately following the disastrous strength of other links in the disaster event. It is a period of triage, stabilization, management chain. emergency care and evacuation. Fourth: An important goal of disaster management recovery phase which aims to ensure is building a culture of awareness that hospital activities and systems return to preparation is not only possible, but also, normal functioning. Disaster management will greatly reduce the consequences from phases are complimentary phases to disasters in terms of human and economic prevent, prepare, respond and recover from loss. Internal disaster management is effects of disaster. based upon four distinct phases: It is evidence that there is a lack of written mitigation, preparedness, response and emergency hospital plans, as a result many recovery. First: Mitigation phase is the nursing staff are not aware of their action taken to reduce both human responsibilities and roles during disasters suffering and property loss resulting from and therefore confusion is bound to arise. extreme natural phenomena. This phase Thus, hospital preparedness plan should is focused on taking precautionary be a part of every hospitals fundamental measures before an actual disaster or operational plan as it can prepare the

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hospital and its nursing staff for small and fully or even avoid the disaster large scale accidents and humanitarian altogether. disasters. Aim _of the study Significance of the study The aim of the study was to:- Nursing has always been a profession that Identify the effect of internal disaster required currency of knowledge and management intervention program on clinical skills through continuing education nursing staff knowledge and skills. input, because of the rapidly changing Research hypothesis: knowledge base and innovative treatment Nursing staff attended internal disaster regimens. An intervention program was management intervention program developed, implemented and evaluated to expected to had knowledge and skills inform the education of nursing staff about regarding internal disaster management. disaster preparedness and response and to Subjects and Method gauge their willingness to volunteer in a Subjects disaster before and after the intervention Research design: program. The intervention program utilized A quasi- experimental study design was a pre- and post-survey method to evaluate used in the present study. the effect of the education on nursing staff. Setting: These changes are occurring at an The study was conducted at Tanta increasingly rapid rate, particularly in Emergency Hospital, Tanta University. disaster care. Nursing staff need to be Tanta Emergency Hospital capacity 465 educated in potential disasters. It is beds. essential to ensure that all nursing staff Methods understand the implications of disasters. Official permission to conduct the The warning system may be the only study was obtained from responsible difference between stocking up on needed authorities. supplies and protection and facing the Ethical consideration: Nursing staff disaster wholly unprepared. Nursing staff informed consent was obtained after warning and alert system has immense explaining of the nature and purpose of value to a disaster management system. It the study. Confidentiality of the provides nursing staff with awareness of an information was maintained and the impending hazard event before it occurs right to withdrawal is reserved. and allows them to prepare themselves

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After reviewing of the related literature Data collection: Program sessions for and different studies in this field, the nursing staff on usable knowledge for study tool was developed and part II and perceived skills for part III translated into Arabic. of internal disaster management was Tool was reviewed with the supervisors implemented. and then was presented to a jury of 5 The intervention program: Experts to check content validity of its - The intervention program about internal items. The experts were three: one disaster management was designed by the Professor and two Assistant Professor researcher after reviewing recent relevant of Nursing Services Administration literature and based on assessed need Faculty of Nursing, Tanta University. - This program was conducted in four One Professor of Nursing Services phases: Assessment phase, development of Administration and One Assistant the educational intervention phase, Professor of Nursing Services implementation of the educational Administration in Menoufia intervention phase, and finally evaluation University. phase. . The experts responses were represented Aim of the educational intervention was in four points rating scale from ranging to evaluate the effect of internal disaster from (4-1);4=strongly relevant management intervention program on 3=relevant 2=not relevant 1=strongly knowledge and skills of nursing staff. not relevant. Necessary modifications Objectives of the educational were done including; clarification and intervention: simplifying work related words. The At the end of the sessions nursing staff content validity value for part II was have to be able understand knowledge and 93.21% and for part III was 94.23% demonstrate skills regarding internal (appendix III) disaster management as follow: A pilot study was conducted on 10%of - Disaster concepts and plan. nursing staff (n= 18). They were - Internal disaster and internal disaster excluded from the subject. It was done management. to test tool’s clarity and applicability. - Phases of disaster management Then needed correction was done. The - Dealing with procedures of fire, estimated time needed to complete the explosion, gas leakage. Infection and questionnaire items was approximately food poisoning 20-30 minutes. Reliability of tools was tested using Cronbach's Alpha which was its value &

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Results Table (1): Percentage distribution of nursing staff according to personal characteristics (n=175)

The studied nursing staff Variables personal characteristics items (n=175) N % Age in years: - -

Gender: Male Female Qualification: Diploma degree in nursing Technical Institute of nursing Bachelor degree in nursing Experience in years: - - -

Job title: -Staff nurse -Head nurse - Nurse supervisor Attending training courses: Yes No If yes, name of courses: - Fire courses. - Courses of emergency, infection control and CPR. -Courses of CPR and infection control. -Courses of infection control ,fire courses and poisons types.

CPR=Cardiopulmonary resuscitation

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Table (1) shows percentage distribution of nursing staff characteristics. More than forty (43,3%) of nursing staff were from age 30-40 years old, while, more than one-fifth (20.6%) of them aged 40 or more years old. Majority (95.4%) of nursing staff were female. More than forty (45.7%) of nursing staff had diploma degree in nursing, and more than one-third (34.9%) of them had technical institute of nursing while, minority (19.4%) of nursing staff had bachelor degree in nursing.

As regard years of experience, more than forty (47.4%) of nursing staff had more than 15 years experiences. Majority (80.6%) of nursing staff were staff nurses. Majority (86.3%) of nursing staff were not attend training course, from those attended courses, more than forty (41.7%) of nursing staff attended training courses about fire and more than one -third (37.5%) of them had training courses in CPR and infection control, while, minority (8.3%) of them were attend infection control, fire and poisons training courses.

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Figure (1): Mean scores of nursing staff knowledge about internal disaster management pre and post program intervention (n=175)

Figure (1) show mean scores and mean percent of nursing staff knowledge about internal disasters management pre and post program intervention. There were statistical significant differences on nursing staff knowledge mean scores pre than post program (p=0.0001) as evidence in the table. The total nursing staff mean score knowledge preprogram was 33.15±8.37 with mean percent 46.04% which increased to 57.11±13.1 post program with mean percent 79.3%. Preprogram, the highest mean percent (62.5%) was for nursing staff knowledge in internal disaster types, coding system and initial identification with mean score 8.75±2.30 followed by internal disaster management (definition-importance-process-team) (48%) with mean score 3.36±1.50. Post program the highest (84.4%) mean percent was for nursing staff knowledge on disaster types, causal factors, plan, dimensions with mean score 6.75±1.55 followed by concepts of disaster (84.1%) with mean score 5.89±1.51

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Figure (2): Mean scores of nursing staff knowledge about phases of internal disaster management pre and post intervention program (n=175)

Figure (2) show mean scores and mean percent of nursing staff knowledge about internal disasters management pre and post program intervention. Response phase was scored the highest (47.2%) with mean score5.00±1.68 but the lowest (34.9%) nursing staff knowledge about phases was for preparedness while, post program response phase was scored the highest (78.9%) with mean percent 9.30±2.59.

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Poor

Figure (3): Distribution of nursing staff total levels of total knowledge about intern al disaster management pre and post intervention program (n=175)

Figure (3) shows distribution of nursing staff levels, change and improvement of total knowledge about internal disaster management pre and post program intervention. Preprogram, majority (86.3%) of nursing staff had poor knowledge, while post program, more than two-thirds (69.1%) of nursing staff had good level of knowledge with statistical significant improvement (84.14%) on nursing staff levels about internal disaster management pre than post program(p=0.0001).

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Low perceived skill Moderate perceived skill High perceived skill

Figure (4): Distribution of nursing staff levels of total perceived skills about procedures dealing with internal disaster management pre and post program intervention (n=175).

Figure (4) illustrates distribution of nursing staff levels, change and improvement percent of total perceived skills about internal disaster management pre and post program intervention. There were statistically significant differences on nursing staff levels and mean scores of perceived skills about procedures for dealing with internal disaster management pre than post program (p<0.05) as evidence in the table. Preprogram, more than half (52%) of nursing staff had low level of perceived skills, while post program about two-thirds (65.1%) of nursing staff had high level of perceived skills about dealing with internal disaster management with statistically significant improvement (35.36%) in nursing staff perceived skills dealing with internal disaster management pre than post program (p<0.05).

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Table (2): Relationship and correlation between nursing staff levels of total knowledge and total perceived skills regarding internal disaster management pre and post program intervention(n=175) Levels of total knowledge of nursing staff preprogram

Total nursing staff Poor (n=151) Moderate (n=24)  P perceived skills N % N % ▪Levels of awareness about skills: Low perceived skill Moderate perceived skill High perceived skill

R - P Levels of total knowledge of nursing staff post program Total nursing staff skills Poor Moderate Good  P (n=33) (n=21) (n=121) N % N % N % ▪Levels of perceived skills: Low perceived skill Moderate perceived skill High perceived skill R P *Significant (P<0.05)

Table (2) shows relationship and correlation between nursing staff levels of total knowledge and total perceived skills regarding internal disaster management pre and post program intervention. Preprogram, there was statistically significant difference between level of nursing staff total knowledge and total perceived skills (P= 0.0001). More than half (53.6%) of nursing staff who had poor level of total knowledge also had low level of perceived skills regarding internal disaster management, while more than half (58.3%) of nursing staff who had moderate level of total knowledge had moderate level of perceived skills. Post program, more than two thirds (66.9%) of nursing staff had good level of knowledge and high level of perceived skills, followed by 63.6% of nursing staff who had poor knowledge with high perceived skills, while, more than half (57.1%) of nursing staff who had moderate level of total knowledge had high perceived skills on internal disaster management.

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Discussion Diab and Mabrouk (2015) revealed Internal disaster management is the range that the nurses had poor knowledge of activities designed to maintain the regarding disaster and hospital disaster control over disaster and emergency preparedness at pretest. Also, Abo-gad situations and to provide a framework for found that majority of nurses had helping persons at risk, avoid or recover poor knowledge about internal disaster from the impact of the disaster. Disaster management at preprogram. Similarly, management is an integrated process of Chimenya and Ncube (2011) found planning, organizing, coordinating and that majority of had poor knowledge about implementing measures that are needed for disaster management. Meanwhile, effectively dealing with its impact on Sandmann (2009) revealed that people. majority of nurses had poor knowledge Nursing staff knowledge about internal regarding disaster preparedness. disaster management Preprogram, nurses’ knowledge on Preprogram, analysis of the present results concepts of disaster, disaster types, causal revealed that the majority of nursing staff factors, plan and dimensions. Present study had poor total knowledge about internal results revealed that nurses had low mean disaster management. In fact, majority of percent because majority of nurses gave nursing staff had wrong answers to wrong answers to concepts of disaster, concepts of disaster, disaster types, causal disaster types, causal factors, plan and factors, plan and dimensions in preprogram dimensions (table 2,3&4). This result is (table 2,3&4). These results reflect the confirmed with Abo-gad (2014) Abd absence of training courses regarding Elazeem et al.,(2011) who revealed that disaster management as evidenced in (table there was a lack of knowledge about the 1), majority of nursing staff not attended disaster plan, and its related items is quite training courses. Berhanu (2016) found alarming. that a considerable number of Post-program, the current study result professionals had limited opportunities for revealed that the majority of nursing staff training. had good knowledge about concepts of In the same line with the present result disaster, disaster types, causal factors, plan Jeanne(2017) who revealed that nurses and dimensions of internal disaster do not possess the necessary knowledge management (table 2,3 &4) with high disaster and hospital disaster preparedness. mean percent. This result reflects the effect

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of the intervention program about internal dealing with internal disaster management disaster management since, the majority of were low (table 11). Possible explanation nursing staff gave correct answers to its of this result may be that because nursing items in the post program. Education can staff perceived themselves as not well- help nurses adopt preparatory measures by prepared and had low level of knowledge improving their knowledge of the regarding disaster management. So that, relationship between preparedness and the result may enable the organizations and disaster risk reduction. Moreover, educated their staff to review their existing plans nurses have better understanding of what and make improvements where required. preparedness measures to take. In the same line with the present results The current study result is confirmed by was Shabbir and Afzal (2017) Jeanne Hoffmann and Muttarak (2017) who who found that practices of the mentioned that education can enhance the majority of participants in study were acquisition of knowledge about disaster, very poor regarding the emergency and values and priorities, as well as, the disasters situations and preparedness. Also, capacity to plan for the future and to Diab and Mabrouk (2015) revealed allocate resources efficiently. Also, Diab that the studied nurse had unsatisfactory and Mabrouk (2015) found that there awareness regarding disaster and hospital was statistical significant improvement in disaster preparedness at pretest. As well as, knowledge of nurses regarding disaster Alice and Olivia (2014) found that after application of the guidance booklet there was a lack on awareness of disaster post-test compared to pre-test. As well as, preparedness and responses among Hong Abo-Gad who revealed that most Kong nurses. Moreover, Burnrock nurses had good total knowledge on results indicated that nursing internal disaster management post- students had low response to engage in program. preparedness, and not to be willing to Nursing staff perceived skills about respond pre course. Sandmann procedures dealing with internal found that nurses had lack of awareness disaster management pre and post related to disaster preparedness and program management. Preprogram, present study result revealed Present study results revealed that about that more than half of nursing staff two-thirds of nursing staff had high level perceived skills about all procedures of perceived skills about total procedures

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dealing with internal disaster management management post than pre-program. post-program (Table 11). It is an important Preprogram, majority of nursing staff had issue to determine nurses‟ disaster poor knowledge regarding internal disaster preparedness level as well as factual management, while post program, more information about the occurrence of than two-thirds of nursing staff had good disasters in creating disaster awareness. level of knowledge with statistical This results reflects that the intervention significant improvement on nursing staff program to nursing staff helped them know levels about internal disaster management how to deal with internal disaster and pre than post program. As well as, subsequently increase their ability to face preprogram, more than half of nursing any procedure. staff had low level of perceived skills Along with the present results, Pinar about internal disaster management, while who showed that creating post program about two-thirds of nursing disaster awareness and encouraging staff had high level of perceived skills with positive behaviors in every part of the statistical significant improvement in organization is one of the ways of being nursing staff skills dealing with internal least affected by the threats that may occur disaster management pre than post and minimizing the loss of life and program. property. Also, Abo-Gad (2014) who Recommendations revealed that nurses awareness improved On the basis of the findings that have post program. As well as, Moghaddan et been established, the following al., (2014) showed that continuous recommendations are made: education could affect nursing practices For nursing management: effectively and that disaster aid education  Developing policies for disaster can decrease mortality rates, improve management and pay more attention to health indices, and decrease disaster the problem of internal disaster and expenses. prepared for its management Conclusion  Establishing continuous education The acquired results of the present study and training for nursing staff in and mean score for each subset revealed disaster care to respond in effective that there were statistically significant and rehearsed manner. improvement on nursing staff knowledge and perceived skills about internal disaster

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For faculty: Interdisciplinary Research Journal.  Incorporate mass casualty care and 2015;5(special issue), pp 91- disaster management skills into under Stanhope, M. & Lancaster, J. Public graduate curricula, as student nurses health nursing: Population-centered have served as first responders to health care in the community. (7th ed). disasters even at the risk of personal Philadelphia, USA: Mosby Elsevier. sacrifice. For nurses: Civaner M.M, Vatansever K and Pala  Every member of nursing staff needs K. Ethical problems in an era where to know their roles, responsibilities disasters have become a part of daily life: and their functions through A qualitative study of healthcare workers participating in hospital’s drill. in Turkey. A Peer-Reviewed, Open  Ensured developing a plan is the key Access Journal.2017; 12(3): e0174162. for ensuring that efforts in Coppola.D. Introduction to international preparedness, response, and relief of disaster management. 3rd edition. El disaster. So, involve staff nurses in Sevier company. London. 2015;chapter developing plans and previously 5&1 preparedness, p.292&34. existing plans updated in light of Sundar L & Sezthiyan T. Disaster experience gained in the disaster. management. Sarup & Sons company. References Newdelhi. 2007. chapter1.p5. International Federation of Red Cross Stages of disaster management. 2016. (IFRC). Disaster and crisis management. http://www.fp7-sector.eu/?p=578 2011.https://www.ifrc.org/PageFiles/913 Dasgupta R. Disaster management and 14/1209600-DM-Position-Paper-EN.pdf. rehabilitation. Krishan mittal company. Veenema T.G. Disaster Nursing and Newdelhi.India.2007.www.mittalbooks.com. Emergency Preparedness for Chemical, Show R. Disaster risk reduction methods, Biological and Radiological Terrorism approaches and practices. Kyoto and other Hazards. 3edition Foreword. University. Springer company.Japan. Springer publishing company, New York. 2012, 2013 &2014;chapter1.p:4,9. Warkentin M. Trends & research in the Seroney G. The role of a nurse in disaster decision sciences. Best paper from the management at Kapsabet to district 14 Annual Conference. Mississippi hospital. Maseno University. Baraton State University. USA.2015.

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Kathmandu. Amass casualty Chimenya G.N & Ncube A. Hospital management trainer’s manual. World emergency and disaster preparedness. A Health Organization. Nepal.2006. p.5,7. study of on Andjokwe Lutheran hospital. Aitken L, Marshall A & Chabyer W. Disaster management Training and Critical Care Nursing. 3rd edition. Education Center for Africa. Northern Elsevier Australia, Australian. Namibia.2011. Chapter 2,p.31. Sandmann A. E. "Nurses [sic] Dasgupta R. Disaster management and Knowledge of mass causality emergency rehabilitation. Krishan mittal company. situations, disasters and related laws Newdelhi.India.2007.www.mittalbooks.com regulating nursing practice in michigan Sundar L & Sezthiyan T. Disaster and ohio". Published Senior Honors management. Sarup & Sons company. Theses. Eastern Michigan Newdelhi. 2007. chapter1.p5. University.2011. Paper 211 Berhanu N. Knowledge, experiences and Abd Elazeem H, Adam S., and training needs of health professionals Mohamed G. Awareness of hospital about disaster preparedness and response internal disaster management plan among in South West Ethiopia. Ethiopian health team members in Ain shams Journal of Health. 2016:26(5);415- University Hospital. Life Science Jeanne T. A guide to emergency Journal. 2011; 8(2),pp 42- preparedness and disaster. Nursing Hoffmann R. & Muttarak R. Learn Education Resources, 2017;4,12- . from the past, prepare for the future. Diab G & Mabrouk S. The effect of Impacts of education and experience on guidance booklet on knowledge and disaster preparedness in the Philipinnes attitudes of nurses regarding disaster and Thailand and Roman. 2017. preparedness at hospital. Journal of http://pure.iiasa.ac.at/id/eprint/14520/1/1- Nursing Education and Practice. 2015:5 s2.0-S0305750X15312559-main.pdf (9);p,17. Shabbir R,& Afzal M. Nurses Abo-Gad R.A. Effect of educational knowledge and practices regarding program on nurses‟ knowledge and disaster management and emergency awareness of internal disaster preparedness. 2017.http://scholarsmepub .com/sjmps management. Mansoura Nursing Alice Y and olivia. Nurses competencies Journal.(MNJ):1(2)2014. in disaster nursing implications for curriculum development and public

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health. International journal of environmental research and public health

and Olivia Wai Man. 2014.pp…… Burnock S.N. Educating Nursing Students on Emergency Preparedness: A

pilot program. Rhode Island College. Published. Digital commons@RIC, Master of science in Nursing.2014; 3.

Pinar A. What is secondary school students: Awareness on disasters? Acase study review of international

geographical education on line (RIGEO). Necmettin Erbakan University. Konya. Turkey. 2017.

Moghaddan M, Saeed S & Arab M. Nurses requirements for relief and casualty support in disaster: A qualitative

study. National Institute of Health.2014.

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Effect of Implementation of a Teaching Program about Immediate Postpartum Care on Nurses’ Knowledge and Practice.

Doaa Samir Abou El-Yazeed El-Khawaga , Manal Hassan Ahmed , Manar Zaki Elwelely . Demonstrator of Maternity and Gynecological Nursing, Faculty of Nursing, Tanta University, Tanta, Egypt. Prof. of Maternity and Gynecological Nursing, Faculty of Nursing, Tanta University, Tanta, Egypt. Lecturer of Maternity and Gynecological Nursing, Faculty of Nursing, Tanta University, Tanta, Egypt.

Abstract: Immediate postpartum period refers to the care provided to the parturient woman and her newborn in the first two hours following the full expulsion of the placenta, after the baby is born. These hours are the initial and/or acute phase of the postpartum period. It is a very vulnerable period for both the mother and the newborn. The aim of this study: was to determine the effect of implementation of a teaching program about immediate postpartum care on nurses‟ knowledge and practice Subjects and method: The study was conducted at the postpartum units of Tanta University Hospital, El-Menshawy and El-Mabara Hospitals affiliated to the Ministry of Health. All nurses (40 nurses) who were working in the previously mentioned study settings and provided care to women with normal vaginal delivery were assigned. Two tools were used for collection of data; Tool (I): Structured Questionnaire socio-demographic data and knowledge assessment. It comprised the following parts: Part I: Socio-demographic characteristics of nurses and Part II: Structured Questionnaire of nurses’ knowledge about immediate postpartum care. Tool (II): It was developed to assess nurses‟ performance of immediate postpartum care It comprised the following parts. Part I: Immediate Postpartum Care Nurses‟ Observation Checklist (for women) and Part II: Immediate Postpartum Care Nurses’ Observation Checklist (for newborn). Results: The mean knowledge score of nurses regarding immediate postpartum care and newborn care was increased immediately after implementation of the program with a significant statistical difference P<0.05. The mean performance score of nurses regarding immediate postpartum care and immediate care of the newborn was higher immediately after implementation of the program with a significant statistical difference P<0.05 compared to pre-program. Conclusion and recommendations: The findings of present study revealed that after implementation of teaching program immediately and 3 months later the post program, there was a significant improvement of knowledge as well as performance among the studied nurses regarding the immediate postpartum care and the immediate newborn care compared to preprogram. Planned in-service training programs for all nurses working in the postpartum wards regarding the importance of the first 2 hour immediately postpartum must be conducted in order to improve their knowledge and performance and ultimately improving the quality of health care.

Keywords: Immediate postpartum care.

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I. Introduction to 71% in the postpartum period. Most of Immediate postpartum period is the period the postpartum deaths occur immediately beginning immediately after the delivery after delivery and during the first week of of the placenta and extending up to the first postpartum period . The objectives of two hours after delivery. During the immediate postpartum care are to help the immediate postpartum period, the mother mother adjust to the changes that have and newborn, within the context of their occurred as a result of pregnancy, delivery, family or personal support, should be and childbirth, assess health status of viewed as a unit. The fourth stage of labor mother and newborns, provide guidance is the first 2 hours after the birth of the and information about breastfeeding and baby .It is a crucial time for the mother and care of the newborn, as well as to provide the baby - ). Puerperium is the period immunization for the mother including following childbirth during which the body postpartum rubella or RH prophylaxis if tissues, specially the pelvic organs revert indicated . back approximately to the pre-pregnant It is vitally important that midwives have state both anatomically and the knowledge and skills to determine physiologically. The period is arbitrarily when to be proactive and undertake divided into immediate within 24 hours, specific observations and nursing early up to 7 days and remote up to 6 interventions when there are indications to weeks The “fourth stage of labor” is do so. Therefore, the midwife needs to be termed as “immediate postpartum period ” knowledgeable and recognize what are which represents the period of the first two normal expected outcomes following birth hours after expulsion of the placenta when and also be able to identify signs of what is close observation is desirable to avoid or not normal and when to instigate care that detect postpartum hemorrhage, signs of will involve further investigation, tests and sepsis or hypertension, and when breast to call support of other health feeding is initiated . professionals Then midwife‟s The Maternal Mortality Ratio (MMR) in responsibility is to be competent and able developing countries is estimated at to undertake further necessary education 440/100,000 live births with 46 countries and training required to provide extended having an MMR greater than 500/100,000 care . live births. Between 11% and 17% of such Nurses should provide competent nursing deaths happen during childbirth and 50% care during early (immediate) postpartum

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period. This critical time requires nurses to ii. Setting: be open-mindedness and patient. This skill The study was conducted at the postpartum set requires that nurses should perceive units of Tanta University Hospital, El- that the first 2 hours after delivery are of Menshawy and El-Mabara Hospitals significant concern. Thus, they should affiliated to the Ministry of Health. provide competent care to postpartum Subjects: women and their families taking into All nurses (40 nurses) who were working considerations their beliefs, experiences in the previously mentioned study settings and environment and respecting their and provided care to women with normal human rights and dignity. The nurse's role vaginal delivery were assigned and in labor, birth and immediate postpartum classified as follow: period is a privileged one, as childbirth is  Nurses who were working at Tanta one of the most vulnerable times in University Hospital (22 nurses). women‟s life Thus the nurse should focus  Nurses who were working at EL- on supporting, protecting, advocating and Menshawy Hospital (10 nurses).

empowering women during this time .  Nurses who were working at EL- Aim of the study Mabara Hospital (8 nurses). The aim of this study was to determine the iii. Tools of data collection: effect of implementation of a teaching Tools of data collection were developed by program about immediate postpartum care the researcher based on relevant literature on nurses‟ knowledge and practice. and used to collect data about the study Research Hypothesis: subjects as follows:- Nurses‟ knowledge and practice are Tool (I): Structured Questionnaire expected to be improved post socio-demographic data and knowledge implementation of a teaching program assessment. It comprised the following regarding immediate postpartum care for the parts: mother and her newborn immediately and 3 Part I: Socio-demographic months later. characteristics of nurses such as name, II. Subjects and Method: age, workplace, educational qualification, i. Study design: years of experience and previous training A quasi-experimental design was adopted and courses regarding the immediate to conduct this study.

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postpartum care and Part II: Structured Method Questionnaire of nurses’ knowledge The study was conducted according assessment about immediate postpartum to the following steps:- care. It included (The general Official permissions were obtained to physiological changes, psychological conduct the study from the responsible changes, local physiological changes, authorities at the faculty of Nursing nurses‟ knowledge regarding postpartum and the studied hospitals. care and instructional guidelines given to Ethical and legal considerations: mothers before discharge from the hospital - The nurses have been met prior to as well as care of their newborns). their participation in order to explain Tool (II): It was developed by the the purpose of the study. researcher to assess nurses‟ performance of - An informed consent for participation immediate postpartum care. It comprised in the study was obtained from the the following parts: entire sample. Part I: Immediate Postpartum Care - The study subjects were notified that Nurses‟ Observation Checklist (for the nature of the study will not cause women): It included the immediate any harm or pain. postpartum nursing care and procedures - Confidentiality and privacy was provided by nurses to women during the considered regarding the data immediate postpartum period (the first 2 collected and nurses rights to hours after delivery) and Part II: withdraw from the study at any time. Immediate Postpartum Care Nurses’ Review of the relevant recent literature Observation Checklist (for newborn): It using available local and international included the immediate newborn care as books, magazines was done to plan for (maintenance of clear airway and body the development of the study tools and temperature, assessment of Apgar score at the contents of the educational 1 and 5 minutes after delivery, care of program. umbilical cord stump, detection of any Tool I was developed in Arabic and abnormalities as well as identification and Tool II was developed in English after prevention of hemorrhage through reviewing recent literature and they administration of vitamin K). were tested for content and construct

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validity by a jury of 3 experts in the on the counter shifted between the Obstetric and Gynecological Nursing. three hospitals. Nurses were asked to Tool I and Tool II were applied three participate after explaining the aim of times, the first one pre-test and the the study. Tool I Part I was used to second post-test immediately after assess socio-demographic implementation of the program and the characteristics of nurses and fulfilled third after 3 months post program by them. implementation. - Nurses‟ pre-test was conducted at the A pilot study was carried out on 10% beginning of the session by using Tool (4 nurses) of the proposed sample after I Part II to assess nurses‟ knowledge taking their approval in order to test the regarding immediate postpartum feasibility, and applicability of the period during the first 2 hours after developed tools and to determine the delivery in the presence of the obstacles that may be encountered researcher for necessary clarification. during the period of data collection. Tool II part I and the observational Accordingly, some statements of tool I checklist for the mother and the and II were rephrasing. newborn were used to assess nurses‟ Data collection was conducted in four performance immediately postpartum months period from the 1st of (during the first 2 hours after delivery) December 2017 to the 1st of April used before, immediately and 3 2018, 2-3 days per week during the months later after implementation of morning, afternoon and evening shifts. the program. Data collection started at Tanta - Nurses' knowledge was assessed University Hospitals, then EL-Mabara individually for each nurse by an Hospital and finally EL-Menshawy interview lasted 15 minutes for each Hospital. nurse. In the first and second day 16 The study was conducted into 4 nurses were assessed and 8 nurses in phases: the third day (the last day). Totally the Assessment phase: researcher took 4 hours daily for the - This phase was done before giving first 2 days and 2 hours in the last day. sessions. The researcher met with - Nurses' performance was assessed by nurses at morning, afternoon and the researcher. At least six procedures evening shifts at postpartum ward or were assessed individually for each

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nurse at a rate of 4 nurses every day by break time for 30 minutes, then the for 10-13 days. researcher explained instructional Planning phase: guidelines given to mothers before - The educational program was discharge from the hospital that developed by the researcher based on included breast feeding, maternal data from the assessment phase and nutrition, postpartum exercises, family literature review. Priorities of goals Planning methods, sexual intercourse, and expected outcome criteria were postpartum follow up visits and formulated. The researcher prepared postpartum danger signs. the instructional materials (posters, Second Session: videos, pictures and power point - This session included the presentation) to be used in the implementation of immediate educational program. Colored booklet postpartum nursing care during the was also developed and distributed to first two hours after delivery through every nurse for enforcement and as a demonstration and re-demonstration of reference. procedures that included: assessment Implementation phase: of vital signs, uterus and lochia - The educational program was (uterine height, location, consistency implemented by the researcher after and lochia flow) and perineal care. reviewing of related literatures. Third Session: First Session: - This session included the - The researcher explained the implementation of immediate definition of immediate postpartum postpartum nursing care during the period, physiological (general, local) first two hours after delivery through and psychological changes during demonstration and re-demonstration of immediate postpartum period during breast care, bladder care, bowel the first 2 hours after delivery, care, episiotomy care and infection importance of postpartum care, rest, control measures before, during and position, postpartum exercises, breast after performing procedures that care, breast feeding, bladder care, included (Use aseptic technique, episiotomy and vaginal care, hand washing, wear sterile gloves, prevention of postpartum hemorrhage discard disposable equipment and and prevention of infection, followed

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sterilization of the reusable was 1.5 to 2 hours. This phase took 12 equipment). days. Fourth Session: - The educational program was - The researcher explained presented through open discussion, demonstrated and re-demonstrated demonstration and re-demonstration immediate newborn care which between the researcher and nurses, included maintenance of clear airway visual aids, power point presentation, and body temperature, Apgar score video presentation, self-learning assessment at 1 and 5 minutes after module, and actual situation. delivery, assessment of vital signs, - In each session a theoretical part was umbilical cord stump care, and given at first then demonstration of detection of any abnormalities and postpartum procedures by the prevention of hemorrhage through researcher of the above mentioned administration of vitamin K followed practices and the re-demonstration by by break time for 30 minutes. Then the nurses. researcher explained health education Evaluation phase: given to mothers before the hospital The evaluation of the implemented discharge regarding newborn care program was done by: which included: eyes care, cord care, - Assessment of nurses‟ knowledge and baby Bath, immunization, performance was done (three times), anthropometric measurements, before implementation of nursing circumcision care and newborn danger intervention and teaching sessions by signs. using Tool I part II and Tool II part - The educational program was I and II then immediately and after implemented on small group basis. three months post sessions using the Each sub group was encompassing 5 same tools (pre, posttests techniques). nurses. Each sub group was attending - Nurses were distributed (individually) a total of 4 sessions. These sessions for self-filling to assess their were scheduled as 2 sessions per week knowledge using Tool I part II for each hospital. Totally the numbers (knowledge assessment). of sessions were 4 sessions for 4 - Each nurse was observed individually weeks. The duration of each session three times to assess their performance

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while conducting immediate previous training courses, 20% of the postpartum care (during the first 2 studied nurses have taken training courses hours after delivery) for the mother at Ministry of Health. and her newborn using Tool II part I Figure (I): Shows that about (10%) of and II (observation checklist). nurses had good level of knowledge - Comparison was done regarding regarding immediate care of the newborn nurses‟ knowledge and performance preprogram.While immediately after before, immediately and 3 months program, the percentage increased to after implementation of program to (97.5%) then became (90%) 3 months post identify the effect of the teaching program implementation. program on their knowledge and Figure (II): Represents that about (15%) performance regarding immediate of nurses had good level of knowledge postpartum care regarding immediate postpartum care Data analysis: preprogram. While it increased to (92.5%) Data was collected, coded and analyzed immediately after program, and decreased and then organized into tables using the to (80%) 3 months post program statistical package for social science implementation. (SPSS 22) Figure (III): Demonstrates that about III. Results: (32.2%) of nurses had satisfactory practice Table (I): Shows that nurses‟ age ranged regarding immediate postpartum newborn from 20-55 years, with a mean age of care preprogram implementation.While the 9.894. Regarding their educational percentage increased to (69.7%) level, more than one third (40%) of nurses immediately after program, and (63.4%) 3 had completed 3 years nursing diplome. months post program implementation. The table also shows that, 37.5% of the Figure (IV): Illustrates that (37.5%) of the studied nurses had 10-20 years of nurses had satisfactory practice regarding experience. In relation to training courses, immediate postpartum care of the mother it was observed that three quarters (75%) preprogram implementation.While the of nurses didn‟t take any training courses percentage increased to (95%) immediately Regarding time of the last training courses, after program implementation and (80%) 3 20% of the studied nurses have taken the months post program implementation. last training courses since less than 5 years Table (II): Shows a significant correlation duration. As regards to the place of the was found between the total score of

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knowledge and nurses' age immediately after program and 3 months post program where r=0.541 and P=0.010* and r=0.623 and P=0.020* respectively. There was also a significant correlation between the total score of knowledge and educational level immediately after program and 3 months post program where r=0.611 and P=0.001* and r=0.451 and P=0.001* respectively. Moreover, a significant correlation was noticed between the total score of performance and nurses' age immediately after program and 3 months post program in where r=0.643 and P=0.001* and r=0.587 and P=0.001* respectively .There was also a significant correlation between the nurses' educational level immediately after program and 3 months later where r=0.589 and P=0.021* and r=0.487 and P=0.011* respectively.

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Table (1): Distribution of the studied nurses according to their socio-demographic characteristics. The studied nurses Socio-demographic (n=40) Characteristics N % Age (years) ≤ years 31-40 years 41-50 years > 50 years Range - MeanSD .  . Educational level 3 years nursing diplome 3 years diplome & Obstetric diplome Technical institute Nursing bachelor Experience (years) <5 years 5-10 years 10-20 years >20 years Range - MeanSD .  . Training courses None < 5 courses. 5 courses. Time of the last training courses None < 5 years 5 years Place of the previous training courses None Ministry of Health University Other

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Fig (1): Total score level of overall knowledge among studied nurses regarding immediate care of the newborn pre, immediately and 3 months post program

*Significant or P<0.05 Fig : Total score level of the studied nurses’ overall knowledge regarding immediate postpartum care pre, immediately and 3 months post program

*Significant or P< .

Fig : Total score level of the studied nurses’ overall performance regarding immediate newborn care pre, immediately and 3 months post program

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Fig : Total score level of the studied nurses’ overall performance regarding immediate postpartum care of the mother pre, immediately and 3 months post program

*Significant or P<0.05

Table (2): Correlation between the total score level of knowledge and total score level of performance among studied nurses regarding immediate postpartum care and their socio demographic characteristics.

Total knowledge score Total performance score Pre- 3 Pre- 3 Immediately Immediately Socio program months program months after after demographic post post program program characteristics program program r r R r R r P P P P P P - . . - . . Age . . . . Educational . . - . . level . . . . - - - - Experience

Training

course

number * Significant at P<0.05. r = correlation coefficient.

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IV. Discussion: had Bachelor science of nursing and forty Immediate postpartum period refers to the percent of the subjects had experience of 6- first 2 hours after delivery. These hours are 10 years. Hashem (2012) found that the the initial or acute phase of the postpartum majority of the studied nurses were more period. The World Health Organization than 40 years old and all of them had (WHO) describes the immediate postnatal diplome degree with more than ten years of period as the most critical and yet the most experience. Again Hassan et al., neglected phase in the lives of the mothers found that more than half of the studied and their babies; most maternal and/or nurses also aged between 25 and 29 years newborn deaths occur during the postnatal old. period. The fourth stage of labor is a Moreover, the results of the present study crucial period of labor process, because revealed that three quarters of the studied many life threatening complications can nurses didn't attend any training courses accompany this stage of labor. So, it is about the immediate post-partum nursing vital to provide the nurses with a full- care, likewise Hashem (2012) , fledged knowledge and training for the mentioned that, almost all the studied management of the fourth stage of nurses didn't attend any in-service training labor . program about the quality of immediate As regards to the socio-demographic postpartum nursing care. This finding was characteristics of the studied nurses, the dissimilar to Hassan et al., (2016) who findings of the present study revealed that found that more than half of the studied more than one third of the studied nurses nurses attended training courses about were equal or less than 30 years old , had 3 immediate postpartum nursing care this years nursing diplome and more than one may be related to the different third had worked between 10 to 20 years of characteristics of the study subjects. experience. This finding is similar to Kaur With regard to nurses‟ knowledge et al., who found that the regarding immediate care of the newborn, majority of the subjects were in the age the study results revealed a good score group of 26-30 years. level of knowledge immediately after and On the other hand, they found that 3 months post program implementation Hashem (2012) and Hassan et al., compared to only (10%) of them pre findings also disagreed with this program. This finding is in accordance study. They found that less than two thirds with Aschalew (2016) who illustrated

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that about (55.3%) of the study participants Berhe et al., who found that had good knowledge about immediate (76%) of health care providers carried it newborn care. This finding also is in out regularly. Meanwhile inconsistent with congruent with Shinde (2015) who Chaudhary et al., (2015) who stated found that less than half of the staff nurses that the majority of staff nurses had good had knowledge regarding immediate practice about overall immediate newborn newborn care. care. Therefore, the present study revealed After implementation of the educational improvement in the total knowledge score program most of the studied items of care level immediately and 3 months post were obviously and significantly improved program implementation compared by pre in comparison with the findings before implementation of the educational implementation of the educational program. This result may probably be due sessions. This might be due to lack of to the immediate effect of the educational knowledge, the neglecting part of nurses, program sessions supported by the and shortage in the number of nurses, provided booklet about immediate shortage of necessary equipment and postpartum care which was helpful as supplies and also poor documentation ongoing reference. However, 3 months system. On the other hand, the finding is later, the nurses' scores were somewhat dissimilar to Simbar et al., (2017) reduced but still significant which may whom their study demonstrated that the probably be due to the absence of the quality of care was weak among (12.95%) continuing training and education and of nurses regarding many of domains of work overload. By meaning of that postpartum care. improvement of knowledge post program Moreover, working nurses didn't have the in the current study may be attributed to privilege of continuing educational the ability and interest of the nurses to gain program which can highly increase their and update their knowledge. knowledge and improve their skills. Lack As well concerning overall performance of continuous supervision and annual regarding immediate newborn care, there evaluation of their performance, lack of was a significant improvement motivation, absence of job specification immediately and 3 months post program plus shortage in staffing all lead to compared to preprogram (Fig 3). This overlapping when it comes to providing finding is consistent with the study of some items of care and neglecting the

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others. In addition, early discharge after and educational level immediately and 3 delivery decreases the time needed to months post program implementation than provide the instructions and advices preprogram. necessary for parturient women. Last but Furthermore, the present finding is in not least, it cannot be ignored that working harmony with the study of Jaber and nurses are overloaded with administrative Abbas (2011) .They reported positive duties beside their duties as health care statistically significant correlation between providers. the studied nurses knowledge score and The correlation between the total their educational level. This means that knowledge, total performance scores and nurses' level of knowledge and practices is socio demographic data among the studied better with young ages and years of nurses regarding immediate postpartum experience. Obvious improvements of total care in the present study revealed that, nurses' knowledge as well as performance there was a positive statistically significant scores were documented with significant correlation between nurses‟ total statistically differences regarding knowledge score and between their age immediate postpartum care immediately and educational level immediately and 3 and 3 months post program compared to months post program implementation. This preprogram. From the researcher point of study finding is compatible with the view, this improvement might be related to finding of Ibrahim & Abdel-Menim the fact that the majority of the nurses were , Abd El-Fattah and Zein El- young ages (less than or equal 30 years), Dein (2012) who disclosed a positive more than one third of them had 10 to 20 statistically significant correlation between years of experience and nearly one quarter nurses‟ total knowledge score and their of them had received training courses educational level. about immediate postpartum care. This In relation to correlation between the total might be due to that the older nurses knowledge, total performance scores and delegated nursing activities to the younger socio demographic data among the studied nurses and have a little role of assigned nurses regarding immediate postpartum clients beside their administrative roles. care, the present study revealed that, there V. Conclusion: was also a positive statistically significant Based on the findings of the present study, correlation between nurses‟ total it can be concluded that before performance score and between their age implementation of the teaching program

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regarding the effect of immediate VII. References postpartum care on nurses‟ knowledge and . Elfikky A, Tawab N and et al. Clinical performance. There was an obvious lack of guidelines for integrating family nurses‟ knowledge regarding the planning into postpartum and post importance of the first 2 hours after abortion care. 1st ed., Arab Republic of delivery of the baby as well as Egypt, Ministry of health and unsatisfactory performance of the population, 2008; 2- immediate postpartum care provided for . Johnson J. Maternal-newborn nursing the mothers and the baby before demystified. 1st ed., Mexico, McGraw- implementation of the teaching program. Hill Co., 2010; 208- The findings of present study also revealed . Amr J. Basic Essential Obstetric Care: that after implementation of the teaching Protocols for Physicians. 1st ed., Arab program immediately and 3 months later Republic of Egypt, Ministry of health post program, there was a significant and population, 2009; 236- improvement of knowledge as well as . Dutta D and Konar H. Text book of performance among the studied nurses obstetrics, 6th ed., India, New Central compared to preprogram. Book Com., 2009; 145- VI. Recommendations . Maville J and Huerta C. Health This study recommended conduction of promotion in nursing. 3rd ed., Brazil, planned in-service training programs for all Delmar Cengage Learning Com., 2013; nurses working in the postpartum wards - regarding the importance of the first 2 hour . Mridha M and Koblinsky M. Policy immediately postpartum in order to perspective on integrated community improve their knowledge and performance based postpartum care. Available at and ultimately improving the quality of http://www. un.org/ health care. In addition, further research millenniumgoals/index. Html. Retrieved studies are needed regarding the immediate on18- - as well as the general postpartum care to . Davis R. Healthy Mother and Healthy identify and overcome the gaps in the Newborn Care: Postnatal Care. 1st ed., knowledge and performance among New York Boston Women‟s Health different health care providers. Book Collective Com., 2009; 51-

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. Macdonald S and Cuerden J. Mayes‟ nursing care at woman's health Midwifery, 14th ed., New York, university hospital. Assiut, Egypt. Bailliere Tindall Com., 2011; 730- Journal of Nursing and Health Science, . Marshall J and Raynce M. Myles - textbook for midwives. 16th ed., . Aschalew Z. Knowledge, attitude and London, Churchill Livingstone Com., practice of newborn care among - postnatal mothers at governmental . Lynna Y,Gibbs L and Joan C. health centers. Addis Ababa, Ethiopia, Maternity Nursing Care. 2nd ed., Master Thesis. 2016; 34. London, Delmar Cengage Learning . Shinde S. knowledge staff nurses in Com., 2013; 622- immediate care of newborn baby and . Ricci S, Kyle T and Carman S. their implications. Ethiopia, Bulletin Maternity and pediatric nursing.3rd ed., Pharmaceutical Research, 2015; New York, Wolters and Kluwer Com., - - . Berhe and et al. Knowledge and . Monahan F. Review for the NCLEX- practice of immediate newborn care RN examination. 1st ed., Boston, among health care providers in eastern McGRaw-Hill Com., 2008; 96- zone public health facilities. Tigray, . Cashion L .Maternity nursing. 9th ed., Ethiopia, Biomed central pediatrics Canada, Mosby Com., 2012; 467- journal, 2017; 17(157):4- . Datta P. Pediatric nursing. 4th ed., . Chaudhary G. Singh V and Kumar London, Jaypee Com., 2018; 225. D.A study to evaluate the efficacy of . Kaur N and et al. Skill development of self-instructional Module (SIM) on nurses in managing the fourth stage of knowledge and practice regarding labor. Nursing and midwifery research newborn care among staff nurses journal, 2014; 10 (1): 16- working in selected hospitals of Delhi . Hashem S. Assessing the quality of NCR. Journal of Nursing and health immediate postpartum nursing care Science, 2015; 4(2):68- provided to women after cesarean . Simbar M, Dibazari A and et al. section in Tanta city. Master thesis, Assessment of quality of care in - postpartum wards of Shaheed Beheshti . Hassan M, El-Seman A and et al. Re- medical science university hospitals. Audit of immediate normal postpartum

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International Journal of Health Care, -

. Ibrahim H and Abdel-Menim S.

Improving maternity nurses‟ performance regarding prevention and

control of postpartum hemorrhage.

International Journal of Novel Research in Health Care and Nursing, 2016;

-

. Abd Elfattah N and Zein El-Dein N. Assessment of quality of nursing care provided immediately after birth at

university hospital. Life Science journal, 2012; 9(4): 2115- . Jaber A and Abbas M. Assessment of

licensed indigenous midwives'

knowledge concerning prevention and management of postpartum hemorrhage

in Baghdad city. Iraqi National Journal of Nursing Specialties, -

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Effect of Nurse's Therapeutic Communication and Protecting Patient's Rights on Patient's Satisfaction

Dr . Amal Sayed Mohamed , Dr. Asmaa Mohammed Ahmed ,

1) Lecturer of Nursing Administration, Faculty of Nursing, Assiut University, Egypt. 2) Lecturer of Nursing Administration, Faculty of Nursing, South Valley University, Egypt.

Abstract:

Back ground; Emphasis puts todays on nurse's therapeutic communication as a key variable to relief patients from psychological stress, and familiarize them with hospital environment. Aim; determine the effect of nurse's therapeutic communication and protecting patient's rights on patient's satisfaction. Setting; Assiut University Main Hospital. Subjects; Convenient sample of nurses (No.=172) and representative number of patients (No.= 200) based on formula to calculate study subjects. Tools; 1) Structure questionnaire sheet consisted of a) Demographic characteristics b) Communication skills, c) Patients right and Patients satisfaction scale Results; nurses achieve highest mean score in understanding the emotions, and feelings they experienced in hospital environment with their illness, and the needs they wants to satisfy and the lowest mean score for attention to patients verbal and non verbal expressions. There were a highly statistical significant difference regarding departments, years of experience, residence and nurse's therapeutic communication skill and protecting patient's right. The majority of patients were satisfied regarding nurse's communication skill and protection of their right. Conclusion; the majority of nurses were communicate in therapeutic way. The majority of patients were satisfied regarding nurse's therapeutic communication skills but patients admitted to private sector were achieve highest satisfaction score. Recommendations: based on research results the following recommendations are drown; in-services training for nurses who not communicate in therapeutic way. Orient patients to increase their awareness regarding their rights.

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Key Words: Therapeutic Communication, nurses, Patient's, Rights, Satisfaction

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Introduction When peoples communicating with each Communications skills is a very important other's the focus was putted on what concept in all life areas, but therapeutic peoples should say. However, in communication is the needed one for therapeutic communication the focus more medical and nursing professions even with putted on listening to the patients and all staff working at any health care agency customer's needs, ideas, and thought & . because patients and customers has Good listening means not only physical pain as well as spiritual emotions, understanding the words or the information and psychological discomfort from change patients and customers said but also their familiar environment by hospital understanding the emotions, and feelings environment, so if nurses and health care they experienced in hospital environment teams are communicate in therapeutic way with their illness, and the needs they wants the optimal health care outcomes can be to satisfy so, health care team especially attainable easily . nurses who spend a long time with patients Therapeutic communication can be defined try to convey this feelings, and emotions as the exchange of ideas, health into here/his care priority which can be instructions, information, a choice of care displayed by nurses with respecting and and feelings to achieve desirable objectives achieving patient's needs . and strengthen interpersonal relationships Therapeutic and effective communication with patients / customers and health care actually affect patient progress positively, providers . In therapeutic communication patient compliance to health care team process; nurses should clarify the instructions, and treatment plan & . meanings of the message to her/his patients Intelligent nurses can read and understand /customers, and be sure that this meaning their patients emotions as well as their was understood by them using multiple superiors and peers so, she/he can strategies like clarifying expectations, communicate in therapeutic way which direct questions, and repeating what they will reflect appreciations from others so, said . In the health care organization nurses become satisfied with work therapeutic communication can be environment which was reflect positive achieved if the information shared between attitude toward her/his patients from this its members enhances achieving both point patients satisfaction and compliance patients, customers, health care team and with treatment provided will be organizational objectives . increased . If health care team

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communicate with patients and customers The ability to develop a compassionate, in therapeutic way it mean that they have therapeutic communication with patients emotional intelligence as they become able nurses engage patients as partners is to understand and recognize patients critical aspect as healthcare standards to emotions and become able to cope with day require all patients to be fully their patients as well as their colleges . informed and active participants in self- Non therapeutic communication can has care management . To improve patient's negative effect on patient‟s satisfaction satisfaction regarding nurse's therapeutic safety, and quality of care, and has adverse communication skills and make patients effects on patient‟s compliance with more adhere to follow-up care plan nurse's recommended treatment regimens. Also awareness regarding therapeutic lack of use of therapeutic communication communication and how to protect skills may influence patients‟ participation patient's rights should be spread among all in his/her treatment plans that will nurses inversely affect the nurses‟ ability to Human being has mental, physical, and manage patients‟ needs effectively spiritual dimensions and hold rights during Therapeutic relationship is the core of the health and illness people have to quality nursing care and patient's differentiate between human rights and satisfaction . rights to health. The rights of patients are Patient's satisfaction can be defined as the the expectations that must be observed in patients reaction to all aspects of services every health care service. These provided which they experienced from encompass his/her physical, mental, health care members If a patient‟s spiritual and social needs which are perception of their hospital experience manifested as standards, and rules . With meets or exceeds patient's expectation, advancing technologies patient's education, there will be equal degree of satisfaction . and awareness regarding to their rights has Patients satisfaction refers to what patients been increased . think about their treatment plan, evaluating Important talent of nursing is respecting past experience which has focus on the and protecting the human rights and presence of protocol of care coordination, dignity of all patients. The priority of communication with caregivers, and staff healthcare organizations must be responsiveness . protection of patient's rights. The patient's

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bill of rights was created in order to defend Aim of the study: This study aimed to human rights, preserve patients' dignity, determine the effect of nurse's therapeutic and ensure that in case of sickness, and communication skills and protecting especially in emergencies, patients will patient's rights on patient's satisfaction. receive competent care without Specific objectives discrimination . - Determine nurse's therapeutic Therefore, if the patient's rights and communication skills. welfare at risk, it is necessary that a nurses - Measure to what extend nurses undertake their protection. Protection of protects patient's rights. patient is defined as the process of - Assess patient's satisfaction regarding informing patients who seek health care, nurse's therapeutic communication but there are still ignore the methods skill and protecting his/her rights. nurses' learned regarding their role to Research Questions: protect him/her . Nurses must protecting - What are nurse's communication patients against unethical and illegal acts skills? was only a part of patient advocacy, - Are nurses protecting patient's rights? although supporting the patients is a major - Are patients satisfied with nurse's goal of nurses and all health care therapeutic communication skills? professionals . Subjects and Methods Significance of the study: Technical design: Therapeutic communications has important a- Research design: Descriptive study role in improving patients emotional, and design was used in the present research. psychological status which in return can b- Setting: The present study was affect patients progress and outcomes so, conducted at Assiut University Main studying nurses therapeutic Hospital at private sector and general in communication skills and to what extend patients departments (medical & surgical). nurses protect patient's rights is very C-Subjects: Convenient sample of nurses essential and if it has effect on patient's (No.=172) and representative number of satisfaction will give an insight about its patients (No.= 200) based on formula to importance. No studies were done about calculate study subjects which were the three variables together nationally and required randomly selected . internationally

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(2n ) p (1-p)

N= ------D2 Where: N=sample size P= 0.50 D= 0.50x10% =0.005

The selected participant distributed as follows

Unit Nurses No. Patient No.

General medical units

General surgical units

Private sector

d- Tools of data collection: It consisted of Scoring interpretation the evaluator two tools (head nurses) will give a score for the -Tool one structure questionnaire sheet nurse based on three points Likert scale which developed and modified by ranged from 1= disagree to 3= agree, all which includes three main parts; part one, scores will summed up from ˃ 60% and nurses demographic characteristics to above, the nurse communicate in gather data regarding; name of the therapeutic way and below < 60% nurse department, gender, age, marital status, not communicate in therapeutic way. part years of experience, and residence. three nurses protection of patient's right Part two Nurse's therapeutic which consists of (14 items) Scoring communication skills which includes 16 interpretation the evaluator (head nurse) items classified into four dimensions as will give a score for the nurse based on follow; Preliminary relationship includes three points Likert scale ranged from 1= (4items), Attention (4 items), not protecting patients right to 3= understanding (4 items), and job duties (4 protecting patient's rights. Every nurse items) score will be totaled or summed up from

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60% and above mean that the nurse protect Preparatory phase: This phase took about patient's rights and below 60% mean that two months from October to November the nurse not protect patient's rights. 2017 this period used to review the -Tool two structure questionnaire sheet available literature concerning to the study which developed by it includes two main topic, also study tools were prepared, and parts: part one patients personal data translated. The draft of the questionnaire which gather data regarding; gender, age, was reviewed for face validity by taking marital status, and numbers of patient experts opinions to revise comprehension hospitalization. Part two patient's of each statement through a jury which satisfaction regarding nurses comprised from 5 experts (2 professors communication skills which includes 20 from Nursing Administration Department statements all of them will be assessed and 2 professors from Community Health using three point Likert scale ranged from Department and 1 professor from satisfied = 3 to dissatisfied = 1 Psychiatric Nursing Department,) Faculty scoring interpretation will be varying of Nursing Assiut University. Also content according to the 20 statements, highest validity was tested using confirmatory score possible equal 60 and the lowest factor analysis and all items of the tools score equal 20.The researcher ask for used were confirmed and obtain score 1.9 patient's responses which will be summed and more. up and if the patients obtain from 20-35 Pilot study: Was conducted to detect the considered dissatisfied and if obtained obstacles and problems that may be from 36-60 considered satisfied. encountered during data collection phase. IV. Administrative Design: An official Also it helps to estimate time needed to fill permission was obtained from the dean of the questionnaire form. It was carried out Nursing Faculty- Assiut University, on 10% of patients (20 patients) and medical and nursing directors at Assiut (nurses No. =17) every questionnaire took University Main Hospital, and all from 20 minutes to half an hour to be filed. departmental heads of all selected The total period for collection of data in departments. the pilot study takes about 5 days the V. Operational Design: This design participants chosen for the pilot study were explains the steps of actual implementation excluded from the total study sample of the study, including preparatory phase, Reliability was ensured by measuring pilot study, and the field work.

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internal consistency using Cronbach's participation. All study tools were filled in Alpha Coefficients methods and it's result the morning shift. revealed that all statements of study Ethical considerations: The researchers questionnaire α were ≥ obtaining approval from the ethical Fieldwork: After ensuring the clarity and committees at Faculty of Nursing Assiut understandability of the study tools, the University. Oral agreement was obtained actual data collection was started in from all participants after informing them December 2017 up to February 2018. about their rights to participate, refuse, or Patient's satisfaction with nursing withdraw at any time. Total confidentiality therapeutic communication skills was of any obtained information was ensured. filled by the researchers through patient The steps of the study could not entail any interview one at a time after explaining the harmful effects on participants. purpose of the study. Each interview took Statistical design: collected data were about 20 minutes. Also researchers met verified before computerized data entries with all participated head nurses at Nursing were done using statistical software Administration Office affiliated to Assiut package for social science (SPSS v.g. 20). University Main Hospital. 10 head nurses Data were presented using descriptive were interviwed at a time for a day to statistics in the form of frequencies and explain the purpose of the study and then percentages for qualitative variables. Mean all items of the tool were explained and and standard deviation for quantitative discussed with them to clarify how head- variables, Pearson correlation analysis and nurses can evaluate nurse's therapeutic multiple regression analysis were used for communication skill and how head-nurses assessment of the inter-relationships and can assess to what extend nurses protecting ANove test were used P ≤ patient's rights from her/his observation (Significance). and past experience using the predetermined tool and then the researchers distributed the questionnaire form for head nurses and the researchers were available during distributing and receiving the questionnaire, the questionnaires were given to only head nurses who expressed interest in

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Results:

Table (1): Distribution of Nurses Demographic Data at Assiut University Main Hospital (No. = 172)

Nurses Demographic data No. (172) % Mean ± SD Age 34.49 ± 8.18 - . Range ˃ (19.0 – Gender: Male Female . Department: General Medicine General Surgery Private sector . Marital status Single Ever Married Years of exp. ≤ 15.60 ± 7.7 ˃ . (Range 1.0 –

Residence: Rural . Urban

Table (2): Distribution of Nurse's Therapeutic Communication Dimensions for at Assiut University Main Hospital (No. = 172)

Therapeutic Non Therapeutic Dimensions Mean±SD No % No %

 Preliminary relation 10.24 ± 1.87  Attention 9.59 ± 2.06  Understanding 10.33 ± 1.92  Job duties 10.30 ± 1.72

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Table (3): Distribution of Nurses Demographic Data and Communication Skills at Assiut University Main Hospital (No.= 172)

Communication skills Personal characteristics Therapeutic Non Therapeutic P-value No % No % Gender Male

Female Age - ≥ Department General Medicine General Surgery ** Private sector Marital status Single

Ever married Years of ex. ≤ ** ˃ Residence Rural ** Urban Total Communication . . **

(*) significance difference (**) highly statistical significance difference (***) highly statistical significance difference

Table (4): Distribution of Nurses Demographic Data and Protection of Patient's Right at Assiut University Main Hospital n= 172 Patients Personal characteristics Protect Ignore P-value No. % No. % Gender Male

Female Age

- . . ≥ Department General Medicine

General Surgery . *** Private sector . Marital status Single

Ever married Years of ex. ≤ ˃ . ** Residence Rural . . ** Urban Protect patient rights total . . **

(*) significance difference (**) highly statistical significance difference (***) highly statistical significance differenc

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Table (5): Distribution of Patients Personal Characteristics at Assiut University Main Hospital (No.= 200)

Personal characteristics No. % Gender Male Female . Age . - 50 and more Department: General Medicine . General Surgery . Private sector Marital status Single Ever Married . No. of admissions st admission . nd admission and more

Table (6): Distribution of Patients Personal Data and Satisfaction regading nurse's therapeutic communication skills at Assiut University Main Hospital (No.= 200)

Patients Satisfaction P- Personal data Satisfied dissatisfied value No. % No. % Gender: Male

Female Age - 50 and more Departments General Medicine ** General Surgery * Private sector Marital status Single

Ever-married Admissions no. st admission nd admission and more Total satisfaction ** * (*) significance difference (**) highly statistical significance difference (***) highly statistical significance difference

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Table (7): Correlation Matrix between Nurse's Therapeutic Communication Skills, and Protecting Patient's Rights and Patient's Satisfaction at Assiut University Main Hospital (No.= 172)

Protect Therapeutic Preliminary Job Communication Attention Understanding Patient communication dimension relation duties skills score Rights

Preliminary r-value Relation P-value r-value 0. Attention P-value . r-value . . Understanding P-value . . r-value . . . Job duties P-value . . . Communication r-value . . . . skills score P-value . . . . Protect Patient r-value . . . . . rights P-value . . . . .

Table( 8): Multiple Linear Regression Analysis between Patient's Satisfaction, Nurse's Therapeutic Communication Skills, and Protecting Patient's Right at Assiut University Main Hospital (No.=200)

Therapeutic Unstandardized Standardized 95.0% CI communication coefficients coefficients t P-value dimension B SE Beta Lower Upper Preliminary relation - Attention - Understanding - - - Job duties - Patient rights -

Dependent Variable: Patient satisfaction score

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Table (1); Showed that highest percentage them admitted to general medical and . of nurses aged from (30- 40) surgical units . years old and working at private Table (6); Revealed the majority of departments. The majority of study subject patients were satisfied with nurse's were female, married, and had more than therapeutic communication skills. There ten years of experience (88.4%, 82%, and were a statistical significance difference . respectively. Also more than two regarding departments and patient's third of nurses were lived in rural area satisfaction . . Table (7); Depicted that there are positive Table (2); Displayed that nurses working correlation between nurse's therapeutic at Assiut university Main hospital achieve communication dimensions as follows; highest mean score for understanding (Preliminary relationship, attention, dimension and the lowest mean score for understanding, and job duties), protection attention dimension. of patient's rights and patient's satisfaction Table (3); Revealed that there were a with highly significant difference ( P-value highly statistical significant difference . . regarding departments, years of Table( 8): Illustrated the order of nurse's experience, residence and nurse's therapeutic communication dimension and therapeutic communication skill ( . ** , protecting patient's rights which impacted . **, . ** and 0.000**) respectively. positively on patient's satisfaction as Table (4); Ddisplayed that there were a follow highest satisfaction level with statistical significant difference regarding preliminary relationship followed by job department, years of experience, residence, duties, attention, patient rights, lastly and nurse's protection of patient's rights understanding (P-value 0.246, 0.505, ( ...... respectively. respectively. Discussion: Table (5); Illustrated that, more than half Most studies focused entirely on the of patients were female and admitted to the nurse's perception regarding their hospital for the first time ( . % therapeutic communication skills and respectively. Less than half of them aged neglecting the patients‟ perception of the less than 40 years old, the majority of them nurses‟ communication skills . Although were married and more than two third of nurses had the clinical and practical

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competencies, patients still complaints of were married, and more than two third of communication failure with nurses' them admitted to general medical and because nurses were given patient care but surgical units . experienced inability to adequately convey As shown in the present study results a sense of care . A lot of nurses not regarding nurses therapeutic interesting in protecting patient's rights in communication dimensions nurses' achieve health care facilities . the highest mean score for understanding There are certain factors nurses may dimension while lowest mean score for encounter which makes them communicate attention dimension this result go in the in non-therapeutic way such as heavy same line with who found that greater workload, hard and complex nursing tasks, understanding were present between nurses lack of recreation at work, cultural in and patients with highly significant effect compatibility, and sex differences between on nurses and patient satisfaction also nurses and patients successful and agreed with this finding as they found that effective healing process requires that all nurses achieve highest mean score in health care team especially nurses who understanding what patients said and spend the majority of time with patients lowest mean score for giving full attention must develop and maintain therapeutic to patients problems and demands. relationship with patients and must protect This result in contrast with study done by patient's rights from any violence . as they concluded that nurses achieve The present study results revealed that the highest mean score in demonstrating highest percentage of nurses aged from attending behavior and lowest mean score (30- 40) years old and working at private with preliminary relationship. sectors . . Also the majority of The results of the present study may be due nurses were female, married, and had more to nurses try to understand patient's than ten years of experience (88.4%, 82%, complains, culture, values and needs by a and 82.6%) respectively. Finally more combination of the following behavior; than two third of them were lived in rural asking patients about well-being, become a area . . More than half of patients good listener to the patient's words, were female and admitted to the hospital emotion, and body language focuses on for the first time ( . % the patient perception and preference, not respectively. Less than half of them aged try to judging them, and try to understand less than 40 years old, the majority of them his/her needs and problems,

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According to the present research finding years of experiences nurses have the more there were statistical significant effect of therapeutic communication skills were departments where nurses works in, nurses developed as nurses become more wiser years of experience, and nurses residence and good relationship with hospital staff on nurse's therapeutic communication makes nurses satisfied, which in return was skills, and protecting patient's rights (table reflected in dealing with patients also 3,4) this result was congruent with who nurses in private sector achieve higher found that from factors that affect nurses score than other nurses in developing protection of patient rights was years of therapeutic communication skills and experience, and work position. Also protecting patient's rights this may due to agreed with the present study as he in private sector nurses deals with upper examined therapeutic communication and middle social class so they needs experienced by nursing students and found special strategies when dealing with them, that place of residence has significant also regulations and rules which were effect on student's therapeutic applied in private sector, finally work load communication. Similarly, they founded in private sector less than non-private that hospitals department (private and non- sector, as regard place of residence nurses private) in Tehran (Iran) have significant comes from rural areas communicate more statistical differences in protecting patient's therapeutically and protecting patient's rights. rights than nurses come from urban areas. Also this result inconsistent with study As indicated by the research findings there done by as they found that only sex was statistical significant differences difference between nurses and patients has regarding departments and patient negative significant effect on nurse's satisfaction this finding was consistent therapeutic communication skills was in- with as they founded that patient agreement with the present study as he satisfaction in government hospitals at founded that only culture has significant primary, secondary, and tertiary level less effect on nurses protection of patient's than patient satisfaction in private rights hospitals. Those finding may due to nurses The results of the present study may due to supervisors and head nurses regularly there's a different in nurses personality at assess patients satisfaction level in private Assiut University Main Hospital as sector so nurses modify behavior which depicted by the present study the more the not acceptable by patients' as any patient

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complaint will be considered also, nurses patient's rights and patient's satisfaction work load were less when compared with with highly significant difference. non-private sector (free sector) in which Conclusions; In the light of the study nurses experienced high work load which results, the following conclusions can be may leads to neglecting patients emotions drawn: leads to lower patient satisfaction rate than . As regard nurse's therapeutic private sector. communication dimension highest The present study results depicted that mean score related to understanding there were positive correlation between and lowest mean score related to nurse's therapeutic communication attention. dimensions, protection of patient's rights . There were significant effects of the and patient's satisfaction with highly department in which nurse's works in, significant difference. Found that there years of experience, and residence on were congruent with the present study nurse's therapeutic communication findings as they found nurse's therapeutic skills. communication affect patient's satisfaction . There were significant effects of the with highly statistical significant department in which nurses' works in, difference . Also the result go in the same years of experience, and residence on line with the present study as the author nurse's protection of patient rights. found that there is a positive correlation . The majority of patients were satisfied between nurse's therapeutic but patients admitted to private sector communication skills and patient's were achieving highest satisfaction satisfaction in the emergency unit of the score. Islamic Hospital Surabaya with highly . There were positive correlation significant difference . Nurse's between nurse's therapeutic therapeutic communication affect communication, protection of patient's positively patient's satisfaction with highly rights and patient's satisfaction with statistical effect . highly significant difference. Similar findings by which were . By ordering highest nurse's therapeutic consistent with the present study findings communication dimension that will as they found that there were positive affect patient's satisfaction was correlation between nurse's protection of preliminary relationship and the

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lowest was understanding - Park, E.,and Song, M.: Recommendations; Based on the Communication Barriers Perceived by forgoing conclusions, the following Older Patients and Nurses. recommendations are proposed: International Journal of Nursing . Educational programs are necessary to Studies; 2005:42 (2): P.p. 159 – counsel health-care professionals with - Ayman, M., Ahmad, E., Imad, and regard to language, health literacy, and Anani, R.: Patient's satisfaction about empathetic communication needs nurses‟ competency in practicing . In-services training for nurses who not communication Skills Life Science communicate in therapeutic way Journal 2014:11(3)P.p. 23- . Orient patients to be increase their - Lawrence, R., Jeanne, S. and awareness about their rights Melinda, S.: Effective communication . Research report will be given to help guide.org reprint. prentice hall authorized person At Assiut University last updated: October 2017 P.p.233- Main Hospital - Jegede, A.: African culture and health. References Book Wright Publishers. Ibadan. - Laschinger, J. Mcgillis, H., 2013: P.p. 100- Pedersen, K. & Almost, E.: Patient - Owumi, B.: Society and health, social satisfaction with nursing care quality pattern of illness and medical care. in questionnaire Journal of Human readings in medical sociology. E.A. psychology : 11(2):P.p.18- Oke. and B.E.Owumi. Eds. Resource - Nkeng, M.: Guide lines for promoting Development and Management effective therapeutic communication Services 2013, Pp196- in nursing. retrieved on 2016:Jan 25, - Kehoe, D.: Effective communication 2012 From Http://Ezinearticles skills the great course Http://www. .Com/?Guidelines-For-. Atspotcafe.Com/Ebook/Effective%20c - Robbin, P.Stephen T.: ommunication2014%20skills Organizational behavior, Prentice Hall - Daniel, G.: Working with emotional of India, New Delhi, :P.p. 210- intelligence sighted in Effective - Aswathappy, K.: Organizational communication skills the great courses Behavior, Himalaya Publishing House, corporate headquarters 2017:P.p.20- Mumbai Journal of Human - Fawcett J.: Contemporary nursing Psychology 2017:2(3P.p.12- knowledge: Analysis and evaluation of

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تأثير التىاصل العالجي للممرضات وحماية حقىق المريض على رضا المرضي

لمحة عامة : اىخشمٍز فً ٕزة االٌبً ٗبشنو اسبسً عيى اىخ٘اصو اىعالخً ىيََشظبث مَخغٍشاث أسبسٍت ىحَبٌت اىَشظى ٍِ اإلخٖبد اىْفسً ، ٗحعشٌفٌٖ ببٍئت اىَسخشفى.الهدف مه الدراسة : ححذٌذ حأثٍش االحصبالث اىعالخٍت ىيََشظت ، ٗحَبٌت حق٘ق اىَشٌط عيى سظب اىَشظً . مكان إجراء البحث :أخشٌج ٕزٓ اىذساست فً اىَسخشفى اىشئٍسً بدبٍعت أسٍ٘غ العينة: ٗاشخَيج اىعٍْت اىَسخٖذفت ٍِ ٕزا اىبحث عيً: مو ٍب ٕ٘ ٍخبذ ٍِ اىخَشٌط ٗعذدٌٕ )172( ٍَشض مَب حٌ اخخٍبسعٍْت ٍَثيت عش٘ائٍب ٍِ اىَشظً ٗعذدٌٕ ) 200( ٍشٌط. اداوات البحث : حٌ اسخخذاً عذد 2 اسخبٍبّٔ االٗىً اسخببّت ٍنّ٘ت ٍِ ثالثت أخزاء. حعَْج اىدزء األٗه: اسخَبسة اىبٍبّبث اىشخصٍت ىيََشض. اىدزء اىثبًّ : اىخ٘اصو اىعالخً ىيََشظبث. اىدزء اىثبىث : حَبٌت حق٘ق اىَشٌط. االسخبٍبّت اىثبٍّت ٍنّ٘ت ٍِ خزئٍِ . حعَِ اىدزء األٗه: اسخَبسة اىبٍبّبث اىشخصٍت ىيَشظً.اىدزء اىثبًّ: سظب اىَشٌط. النتائج الرئيسية : حققج اىََشظبث أعيً ٍخ٘سػ حسببً ىفٌٖ ٍشبعش ٗأحبسٍس اىَشظً ٗاىزي ىذٌٌٖ خبشة فً بٍئت اىَسخشفى ٍع ٍعبّبة اىَشض . ٗمزىل ىخيبٍت احخٍبخبحٌٖ . مَب حققج أقو ٍخ٘سػ حسببً ىالّخببٓ ىخغٍشاث اىَشظً اىيفظٍت ٗاىغٍش ىفظٍت. ْٕبك فشٗق فشدٌت راث داىت احصبئٍت بٍِ االقسبً , سْ٘اث اىخبشة , ٍحو االقبٍت , ٍٖبساث اىخ٘اصو اىعالخً ٗ حَبٌت حق٘ف اىَشظً.مبُ أغيب اىَشظً ٌشعشُٗ ببىشظً فً ٍٖبساث اىخ٘اصو ىذي اىََشظبث ٗحَبٌخِٖ ىحق٘قٌٖ. االستنتاجات :ٌخ٘اصو ٍعظٌ اىََشظبث بطشٌقت عالخٍت ٗأغيب اىَشظً ٌشعشُٗ ببىشظب عِ اىخ٘اصو اىعالخً ىيََشظبث ىنِ أعيً ٍعذه سظب حققٔ اىَشض بقسٌ اىعالج اىخبص. التىصيات : بْبءا عيً ّخبئح اىبحج ٌ٘صً ببالحً: اىخذسٌب أثْبء اىخذٍت ىيََشظٍِ ٗاىََشظبث ىخطٌ٘ش ٍٖبساث االحصبه اىعالخً ىَِ ىٌ ٌخ٘اصي٘ا بشنو عالخً. ح٘خٍٔ اىَشٌط ىزٌبدة ٗعٌٍٖ بحق٘قٌٍٖ.

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الكلمات األساسية: اىخ٘اصو اىعالخً ، اىََشظبث ، حق٘ق اىَشظى ، سظب اىَشظً .

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رقــم االيــــداع ) 202( لسنة 2012

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