Rajiv Gandhi University of Health Sciences s159

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE

ANNEXURE –II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1 Name of the candidate and Mrs ANITHA JOHNSON address IST YEAR MSc NURSING (in block letters) S.C.S COLLEGE OF NURSING SCIENCES

KECT TOWER

ASHOK NAGAR, MANGALORE

2 Name of the institution S.C.S COLLEGE OF NURSING SCIENCES

ASHOK NAGAR, MANGALORE

3 Course of study and subject MSc NURSING

MEDICAL- SURGICAL NURSING

4 Date of admission to course 20.05.2010

5 Title of the topic:

A STUDY TO ASSESS THE EFFECTIVENESS OF SELF INSTRUCTIONAL MODULE ON PREVENTION OF NOSOCOMIAL PNEUMONIA AMONG STAFF NURSES IN SELECTED HOSPITALS AT MANGALORE.

1 6 BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“Our knowledge is a receding mirage in an expanding desert of ignorance.”

Will Durant

In modern health care, there are many adverse events that threaten patient safety. The environment of the health care facilities exposes patients to considerable risk of acquiring infection. Health associated infection are a major concern in all secondary and tertiary care hospitals. Despite advances in control and prevention of these infections, they continue to remain a major adverse effect of hospitalisation. It is estimated that in India, 40% of patient infection is caused due to hospital acquired infection.1

Nosocomial pneumonia, also known as hospital acquired pneumonia occurs in 0.5-5% of all nosocomial infections. It is much more frequent in mechanically ventilated patients. The risk factors include host factors like co-morbidity and age ,aspiration, cross contamination due to poor infection control practice and by inhalational equipments like steam inhaler, ventilator, nebulizer etc. It not only causes mortality in patients but is also associated increased length of stay and hospital cost.2

Millions of health professionals employed directly or indirectly involved in patient care are accountable for ensuring that patients, visitors and employers are kept safe. If antibiotic treatment fails on a grand scale, the only protection left in the post antibiotic era will be the highest imaginable quality of evidence based infection prevention and control

2 practice.3 Knowledge and awareness can be obtained only by continuous education of health professionals, thereby protecting patients from various infections.

6.1 NEED FOR THE STUDY:

“It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.”

Florence Nightingale

Nosocomial pneumonia is the second most common nosocomial infection worldwide. Nosocomial pneumonia constitutes a major complication in hospitalised patients particularly in those who are critically ill and immunocompromised. It increases the hospital stay by 7-9 days. Incidence of hospital acquired pneumonia is 5-10 cases per 1000 hospital admissions. There is a 6 fold increase in nosocomial pneumonia among mechanically ventilated patients.Though it is prevalent in all the wards of the hospitals but 24-27% of all nosocomial pneumonia are acquired in medical intensive units and coronary care units. Nosocomial pneumonia is the leading cause of death from hospital acquired infections.4

3 Hospital acquired pneumonia is a significant public issue in Asian countries. A national and local surveillance on epidemiology, aetiology and diagnosis of hospital acquired pneumonia reported that in Asia, hospital acquired pneumonia occurred at a rate of 5-10 cases per 1000.In Asian countries hospital acquired pneumonia is associated with crude mortality rate up to 70% and attributable rate as high as 33-35%.5

Pneumonia is an infection of the lung parenchyma involving alveolar spaces.Nosocomial pneumonia can lead to complications like respiratory and circulatory failure, pleural effusion ,empyema lung abcess, septicaemia, acute respiratory distress syndrome ,septic shock and death. These complications can be prevented if health care staff takes necessary timely and prompt actions like following standard precautions, hand washing, sterilization and disinfection of objects used for patient care, chest physiotherapy, oral hygiene etc. Hospitals with effective infection control and surveillance programme have significantly lower rates of pneumonia compared to those without such programmes. Hence, identification of high risk patients and staff education are essential to reduce and prevent nosocomial infection. 6

Nosocomial pneumonia is associated with morbidity and mortality. A study conducted in Mumbai ,India on the prognostic factors associated with hospital acquired pneumonia among 282 consecutive patients revealed that co- morbidity was found in 94% patients .Diabetes(32.81%),septicaemia(19.27%), cancer (6.25% and HIV (3.12%) were the common co-morbid condition seen in patients with hospital acquired pneumonia. The other risk factors were renal diseases and chronic obstructive pulmonary disease and the overall mortality was 29.43%.7

Nosocomial pneumonia is also associated with 4 increase length of stay and hospital cost. A cohort study was conducted in USA on impact of hospital acquired pneumonia practice guidelines on outcomes in surgical trauma patients. The study examined the outcomes of two surgical intensive care unit cohorts treated for pneumonia before and after guideline implementation for nursing personnel .The surgical trauma intensive care unit pneumonia practice guideline significantly improved outcomes in terms of length of stay, mechanical ventilation days ,mortality and total cost of admission and cost of care. This shows that nurses play an important role in preventing hospital acquired pneumonia.8

In India, the overall incidence of nosocomial pneumonia associated mortality rate ranges from 37-47.3%. A country with great diversity, India has on one hand state -of- the- art corporate hospitals and on the other hand, there are basic health care centres which are all strapped for resources. Lack of education and awareness among health care staff is one of the most prominent issues of our country. The National Accreditation Board of Hospitals, established under Quality Council of India has standard guidelines for an effective infection control programme to reduce nosocomial infection in patients and staff. 9

The success of a nurse who practices infection control techniques is measured by determining whether the goals for reducing or preventing infection are achieved.10 Prevention is always better than cure. Education of health care personnel is the cornerstone of an effective infection control programme. With increasing awareness and knowledge, nurses can not only reduce nosocomial pneumonia rates but also reduce the related mortality, reduced length of hospital stay and reduced health care cost. Hence the investigator felt the

5 need of preparing a self instructional module on prevention of nosocomial pneumonia for staff nurses.

6.2 REVIEW OF LITERATURE

A review of literature is a systematic identification, location ,scrutiny and summary of written materials that contain information on research problem.11

A study was conducted in Chile to evaluate the impact of an interventional programme in decreasing the rate of nosocomial pneumonia associated due to depressed consciousness. The intervention consisted of an educational programme for the health care staff on Centre For Disease Control recommended practices (position patient upright at 300-450, aspiration of secretions and verified placement of enteral feeding tube).Surveillance was done by infection control nurse. The rate of nosocomial pneumonia due to depressed consciousness before the intervention was 2 cases per 1000 patient days which reduced to 1.3 cases per 1000 patient days(OR 0.65,IC 0.45-0.93,P=0.016) after the interventional programme. The study concluded that with an evidence based interventional programme, it is possible to reduce nosocomial pneumonia rates, prevent deaths and decrease hospital cost.12

A study was conducted in New Zealand among 134 critical care nurses to identify the knowledge deficits concerning nosocomial pneumonia prevention. A survey design using a mailed self administered questionnaire was used .The nosocomial pneumonia score ranged from 21%-92%.The mean and median was 48%.Items related to knowledge about nosocomial pneumonia risks had the highest mean score (67%) 6 compared to items addressing nosocomial pneumonia prevention (43%)or the role of devices in the transmission of nosocomial pneumonia (45%).The study identified several important deficits in nosocomial pneumonia knowledge and concluded that there is a need for critical care nurses to have greater exposure to nosocomial pneumonia prevention education ,guidelines and research.13

A study was conducted in Karnataka, India among health care workers to assess the impact of education on knowledge, attitude and practices regarding nosocomial infection. The study included a total of 150 health care workers which comprised of 50 doctors,50 nurses and 50 ward aids .Interventions were applied in the form of an education module. In the excellent category, pre-intervention knowledge score was 10% which increased to 84% after the intervention. But after 12 month and 24 months, the knowledge score declined to 74% and 30%. It was concluded that education has a positive impact on retention of knowledge, attitude and practice in all categories of staff and suggested that yearly education modules will help retention of knowledge in the area of nosocomial infections. It would also translate in a behaviour change of attitude and practices that would help in reducing the incidence of nosocomial infection.14

A experimental descriptive study was conducted in Italy to evaluate the nurses knowledge and to highlight the causes that hinder guideline implementation of pneumonia prevention protocol among 106 nurses working in the intensive care units. A questionnaire was administered enlisting 21 non pharmacological strategies.54.8% declared that they were poorly informed.80.9% said that they applied one or more strategies and 17.9% said they applied none. The reasons given

7 for not applying the strategies were lack of necessary protocols, high cost, and the possibility of causing discomfort or side effects to the patient. It was concluded that pneumonia prevention protocol are widely applied by nurses ,but not in a responsible and informed manner .It is important to ensure that nurses receive continuous training and are involved in drawing up and updating departmental protocols for care and behaviour.15

A study was conducted in Texas to examine critical care nurses knowledge about the use of ventilator bundle to prevent ventilator associated pneumonia among 61 nurses in coronary and surgical intensive care units. Education sessions were held and changes in nurses knowledge was evaluated by a questionnaire before and after the sessions. After the education session nurses performed good on 8 out of the 10 items tested (p from .03to < .001).The areas of most significant improvement were elevation of head of the bed, oral care, checking of nasogastric tube for residual volume. It was concluded that education sessions designed to inform nurses about the ventilator bundle and its use to prevent the ventilator associated pneumonia,which is the most common device associated nosocomial pneumonia has a significant effect on participants’ knowledge and subsequent clinical practice.16

A four year controlled ,prospective ,quasi experimental study was conducted in Thailand to determine the effect of an educational programme to prevent ventilator- associated pneumonia in medical, surgical and cardiac intensive care unit. The educational programme involved respiratory therapists and nurses. A self study module with pre-intervention and post-intervention assessment, lectures, fact sheets and posters was given. After the intervention, the rate of ventilator associated pneumonia reduced by 59%(8.5 cases per 1000 ventilator days ;p=0.22).This study revealed 8 that a focussed educational intervention resulted in sustained reductions in the incidence of ventilator associated pneumonia, duration of stay, cost of antibiotic therapy, and cost of hospitalisation. As hospital acquired pneumonia can be due to several objects especially ventilators ,so a reduction in the rate of ventilator-associated pneumonia will also decline the rate of nosocomial pneumonia.17

A descriptive questionnaire survey was conducted in Karnataka, India to assess the training needs of the staff nurses on infection control, the mode of delivery preferred by them, allocation of educational contents ,factors facilitating their infection control education and the strategies to deliver the infection control education to the nurses working in 8 selected 7 hospital in Udupi and Mangalore. There was 100% agreement by the respondents that infection control training is relevant.98.4% agreed that infection control training should be mandatory to the nurses and majority 91.85% preferred that they require infection control training. Majority of them preferred self study (77.03%) as their preferred mode of teaching and learning. It was concluded that the first step of a well designed infection control program is to design standard protocols and train health care providers. Ultimately controlling infection is everyone’s duty and responsibility and when it comes to infection prevention, knowledge is a real power18.

6.3. STATEMENT OF THE PROBLEM:

A STUDY TO ASSESS THE EFFECTIVENESS OF SELF INSTRUCTIONAL MODULE ON PREVENTION OF NOSOCOMIAL PNEUMONIA AMONG STAFF NURSES

9 IN SELECTED HOSPITALS AT MANGALORE.

6.4. OBJECTIVES:

Objectives of the study are:

1. To assess the pre-test knowledge scores on prevention of nosocomial pneumonia among staff nurses as measured by structured knowledge questionnaire.

2. To evaluate the effectiveness of self instructional module on prevention of nosocomial pneumonia among staff nurses in terms of gain in post-test knowledge scores.

3. To find the association between pre-test knowledge scores on prevention of nosocomial pneumonia among staff nurses with selected demographic variables.

6.5 OPERATIONAL DEFINITION

Effectiveness: In this study effectiveness refers to determine the extent to which the self instructional module has achieved the desired effect and is measured in terms of gain in post-test knowledge scores.

Self Instructional module: In this study, self instructional module refers to self contained written material which can be used by the staff nurses for learning prevention of nosocomial pneumonia.

Prevention: In this study, prevention refers to all the measures that will hinder the occurance of nosocomial pneumonia in a patient.

Nosocomial Pneumonia: In this study, it refers to hospital acquired pneumonia which is an infection of the lung parenchyma that was not present at the time of admission and 10 manifests the symptoms after 48 hours of hospital admission.

Staff Nurses: In this study, staff nurses refer to registered nurses personnel who are working as staff in a hospital after completion of BSc Nursing/Post Certificate BSc nursing/General Nursing and Midwifery course.

6.6ASSUMPTION:

The study assumes that:

1. Staff nurses will have basic knowledge regarding prevention of nosocomial pneumonia.

2. Self instructional module will enhance the knowledge of staff nurses regarding the prevention of nosocomial pneumonia.

6.7. DELIMITATION:

The study is delimited to

1. Staff nurses who are working in selected hospitals at Mangalore.

2. Staff nurses who are registered in state nursing council.

6.8. HYPOTHESIS:

Hypothesis will be tested at 0.05 level of significance.

H1: the mean post-test knowledge scores of the staff nurses on prevention of nosocomial pneumonia will be significantly higher than their pre-test knowledge scores.

H2: there will be significant association between the pre-test knowledge scores with selected demographic variables

11 MATERIALS AND METHODS

7.1. SOURCE OF DATA COLLECTION

Data will be collected from staff nurses working in a selected hospital at Mangalore.

7.1.1. RESEARCH DESIGN:

The research design for the study will be pre-experimental design that is one group pre-test post-test design.

Pre-test Administration of self Post –test instructional module

O1 X O2

O1=administration of structured knowledge questionnaire on prevention of nosocomial pneumonia

X=administration of self instructional module on prevention of nosocomial pneumonia on 1st day

O2=reassess the knowledge using the same structured knowledge questionnaire on the 7th day

7.1.2. SETTING:

The study will be conducted in selected hospitals at Mangalore.

7.1.3.POPULATION:

In this study the population consists of staff nurses working in selected hospitals at Mangalore.

7.2.METHODS OF DATA COLLECTION:

7.2.1. SAMPLING PROCEDURE:

Sample will be selected by purposive sampling technique.

12 7.2.2. SAMPLE SIZE:

Sample size will be 40 staff nurses working in selected hospitals at Mangalore.

7.2.3. INCLUSION CRITERIA:

1. Staff nurses who have completed basic BSc Nursing degree,Post Basic BSc Nursing and General Nursing and Midwifery courses.

2. Staff nurses who are registered in state nursing council.

3.. Staff nurses who are willing to participate in the study.

7.2.4. EXCLUSION CRITERIA:

1. Staff nurses who are not available at the time of data collection.

2. Auxiliary Nurse Midwives are excluded.

7.2.5. INSTRUMETS INTENDED TO BE USED:

Structured knowledge questionnaire on prevention of nosocomial pneumonia developed by the researcher. It consists of two parts

Part I :demographic data

Part II : structured knowledge questionnaire on prevention of nosocomial pneumonia.

7.2.6. DATA COLLECTION METHOD:

Prior to data collection permission will be obtained from the concerned hospital authority for conducting the study. Written informed consent will be taken from the subject selected for 13 study. Pre-test knowledge will be assessed by using structured knowledge questionnaire. Then a self instructional module will be administered. After seven days post test knowledge will be assessed by the same structured knowledge questionnaire.

7.2.7. DATA ANALYSIS PLAN:

The data will be analysed by using descriptive and inferential statistics.

7.3. Does the study require any investigations or intervention to be conducted on patients or other animals? If so please describe briefly.

Yes, the study will be conducted on staff nurses to assess the knowledge on prevention of nosocomial pneumonia.

7.4. Has ethical clearance been obtained from your institution in case of 7.3?

Yes, ethical clearance has been obtained from the institution.

14 8 LIST OF REFERENCES

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12. Nercelles P, Perano ZR.Interventional programmes in nosocomial pneumonia associated to depressed consciousness in a Chilean teaching hospital: 7 year old follow up. American Journal of Infection Control 2004 May ;32(3):E48.

13. Soh KL,Koziol J, Mclain JK,Wilson J. Critical care nurses’ knowledge in preventing nosocomial pneumonia. Australian Journal of Advanced Nursing2007;24(3):19-25.

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16. Delos, Reyes AFT, Ruppert SD,Shiao SYPK.Evidence- based practice:use of ventilator bundle to prevent

16 ventilator associated pneumonia..American Journal of Critical Care2007;16:20-27.

17. Apisarnthanarak A,Pinitchai U ,Thongphubeth K,Yuekyen C,Warren DK Jack JE et al.Educational programme to reduce ventilator associated pneumonia in a tertiary care centre in Thailand:A 4 year study.Clinical Infection Disease 2008 Feb ;46(3):479.

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