Tanta Scientific Nursing Journal

Tanta Scientific Nursing Journal

Prof Dr Rahma Soliman Bahgat Board Director and Editor in chief

Dr Manar Zaky Elwelely Editor Secretary

Volume 4 Number. 1 May, 2013

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Editorial Advisory Board

Prof Dr Farial Abdal Aziz : Community Health Nursing Alexandria University

Prof Dr Gamalat Elsaid Mansy : Pediatric Nursing, Alexandria University

Prof Dr Bassema Azat Goid : Community Health Nursing, Tanta University

Prof Dr Nazek Ebrahim AbdElghany: Community Health Nursing, Alexandria University Prof Dr Fouada Shaban : Nursing Administrative Tanta University

Prof Dr Seham Hamoda : Nursing Administrative Tanta University

Prof Dr Rahma Soliman : Pediatric Nursing, Tanta University

Prof Dr Sanaa Abdal Aziz : Psychiatric and Mental Health Nursing , Alexandria University

Prof Dr Zeinab Loutfy: Psychiatric and Mental Health Nursing ,Ain shams University

Prof Dr Sanaa Ala eldeen: Medical Surgical Nursing, Alexandria University

Prof Dr Nahed Elsabahy: Medical Surgical Nursing, Alexandria University

Prof Dr Sanaa Nour: Obstetric and gynecological Nursing, Zagazig University

Prof Dr Magda Mourad : Obstetric and Gynecological Nursing , Alexandria University

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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 The authors still retain the right to post, without permission, their own published manuscript either as link to the online version of the manuscript on the website of the 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 Preparation of Manuscript: Format: three complete copies should be submitted

- Should be printed on A4 80 gm paper, 1.5 line space with 2.5 cm margins. Manuscripts should not exceed two column, 12 pages, and inclusive references. CD containing the manuscripts should be enclosed - Title of manuscripts: should be concisenot more than 15 words and include the name of the authors(s) professional 5itle and institution affiliation Abstract: not exceeding 200 words, should be included , ti 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 abbreviations: used 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 of abbreviations should be spelled out the first time they are used. Symbols, others than standard statistical symbols, should be identified the first time used Subject and methods: Should include setting where the study was done subjects of the study and criteria for selection, tools for data collection and study design and procured.

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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 Discussion: The findings with other relevant studies in the field of studies in the field of study Conclusion Recommendations References: 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 week‘s time. 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] Three copies of the manuscripts and CD that should be sent to Tanta Scientific Nursing Journal Subscription information Online access is open to all readers at no subscription fees Print version subsection

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Contents

Subject Page

1- Mothers' Satisfaction Regarding Emergency Nursing Care of their Children 7

2- Assessment of knowledge and Practicing Regarding Breast Self - Examination among female students at South Valley University. 27

3- Enhancing the Quality of Life for Children with Cerebral Palsy At Benha City 47

4- Knowledge of preparatory students working in Agriculture about work hazards 79

5- Quality Nursing Care Versus Patient satisfaction and nurses job satisfaction in Zagazig University Hospitals 111

6- Development of Students' Assessment System to Conform Academic Standards at Faculty of Nursing Tanta University: 123 A Case Study

7- Influence of Intramuscular Dexamethasone on Labor Duration in Primigravidas 143

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Mothers' Satisfaction Regarding Emergency Nursing Care of their Children

Sahar Mahmood El-Khedr Lecturer of Pediatric Nursing, Faculty of Nursing, Tanta University.

Abstract

Background: Patient satisfaction is considered an important indicator of the quality of care from the perspective of the consumer. There is a growing interest in patient satisfaction as an outcome of care. Parents satisfaction "especially mothers" with a pediatric practice is very important because mothers are always involved in medical treatment of their children. Satisfied patients are more likely to comply with treatment, take an active role in their own care. There is evidence that satisfaction with pediatric medical visits is related to parents‘ compliance with medical regimes, understanding and retention of medical information, and continuity of care . Few studies have examined patients' satisfaction with emergency nursing services. Pediatric patients who seek emergency care require skilled and timely assessments by experienced emergency care nurses. The study aims to assess mothers' satisfaction regarding emergency nursing care of their children. This is a descriptive study design, that was carried out at Tanta Emergency Hospital. Convenient sample of eighty children and their mothers were involved in the study. One tool was used to collect data, the first part was a questionnaire sheet to assess socio-demographic data about children and their mothers. A second part was a Consumer Emergency Satisfaction Scale (CESS). The results of this study revealed, statistical significant difference in the total nursing care and total education. Statistical significant correlation was detected between professional qualities and both nurses‘ attitudes and the way the nurse welcome the mothers and their children. It is recommended that further researches are needed to capture pediatric children opinions about the emergency care provided to them. Application of triage system in emergency room to improve the quality of care. Key words: Emergency nursing care, Mothers' satisfaction.

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Introduction

Satisfaction can be defined as the extent Patient satisfaction is defined as the of an individual's experience compared perception of patient needs and with his / her expectations. Evaluating expectations being met. It is rapidly to what extent patients are satisfied with becoming a primary indicator for health services is clinically relevant. evaluation and comparison of quality in Satisfied patients are more likely to health care plans. Patient satisfaction, or comply with treatment and, take an parent satisfaction in case of children active role in their own care. They under medical care, is a construct from continue using medical care services, social research, which describes the stay within a health care provider and satisfaction of patients with demanded maintain with a specific system. In services from the health care system.(4,5) addition, health professionals may Specifically the term "patient benefit from satisfaction surveys that satisfaction" is described by the identify potential areas for service discrepancy between the quality of the improvement and health expenditure medical care expected from the patient may be optimized through patient- and the perceived quality of medical guided planning and evaluation (1) treatment. The special aspect of the Satisfaction is not some pre-existing concept of patient satisfaction is that phenomenon waiting to be measured, quality standards are not evaluated any but a judgment, people form over time more by teams of experts but by the as they reflect on their experience. patients themselves. (5) Patients‘ satisfaction with health care Quality assessment studies usually they received becomes a priority measure one of three types of outcomes: issue.(2) Satisfaction is increasingly medical outcomes, costs, and client being linked with improvements in the satisfaction. Patients are asked to assess quality of health care and improved not only their own health status after

health outcomes. There is an increasing receiving care but also, their satisfaction impetus for shared decision making and with the services delivered. person centered care. It is considered an Mothers satisfaction with nursing care important indicator of quality care from provided to their children is very the perspective of the consumer. (3) important because it can be used as an

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indicator of the quality of care. Mothers patients in the emergency or critical are also involved in medical treatment phase of their illness or injury. (8,9) of their children. It is indispensable that Nationwide, there are an estimated 30 the nurses includes the parents in the million Emergency Department (ED) treatment regime and the care of their visits per year for patients under 18 children. Compliance with medical years of age, accounting for one-fourth regimen and understanding of medical of all ED visits. Egypt has assigned top information are the major responsibility priority to the improvement of its of the parents especially mothers. (6) standard of pediatric care since 1979. Satisfied mothers are more likely to be Egypt was still suffering from a high compliant and cooperative. Monitoring mortality rate of children under five. and evaluating consumer satisfaction The cause of death was mainly from with health care is a crucial input in curable diseases such as respiratory improving the quality of health system infections and diarrhea. Had it not been and changes in the system as well as for the delay of appropriate treatment, providing feedback for health care the lives of a significant number of professionals and policy makers. children could have been saved. while Measures of consumer satisfaction with the quality of pediatrics had reached health care can provide important almost a satisfactory level, the assessment of quality of health care not emergency medical services had been adequately captured by other health neglected. (10) service statistics such as patient The process of care in the emergency throughput, waiting times, consultation department can vary depending on times and proximity. In fact, it has been country or hospital size. The suggested that patient satisfaction is a characteristics of the patient in the major quality outcome in itself. (7) emergency department can also vary Emergency care continues to be a due to a wide variation in presenting challenge for the pediatric population. illnesses, injuries and mental states. The Children who seek emergency care patients also differ in age, from young require skilled and timely assessments children to elderly people. Attending the by experienced emergency nurses. emergency department is an unplanned Emergency Nursing is a nursing situation and the patient is usually specialty in which nurses care for

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experiencing pain, fear and/or anxiety. tasks. The role of the emergency nurse Sometimes life-saving procedures are is expanding, with demands for needed. However, for most patients in advanced skills, monitoring and the emergency department, minor documentation. (16) medical interventions are sufficient. Nurses in the ED are responsible for Common reasons for children seeking meeting the various needs of their emergency care include asthma, fever, pediatric patients. The nurse also, needs diarrheas, pain, allergies, fractures and to consider that, children physiological broken bones, and trauma. The patient‘s and psychological responses to stressors transit time can range from a few are not the same as those of adults. minutes to several hours and depends on Treatment plans varies according to the patient flow, which fluctuation the acuteness and problems presented by patients‘ reasons for attending the the children. Educating children and emergency department and the need for their mothers about their condition and (11) more or less urgent medical attention. treatment, addressing effective means of Overcrowded emergency departments self-care and adaptation to change in mean long waiting times. Patients with lifestyle, and if necessary, discussing non-urgent health-related problems are ways to prevent recurrence of sickness often classified as inappropriate patients are integral parts of the plan of care. A in the emergency department. (12) On the hospital ED is recognized as the front

other hand, the inability to obtain access door where a significant number of to primary care is a common reason for inpatient admissions take place. The non-urgent patients to attend the tremendous increase in the number of emergency department (13, 14) Long wait patients visiting ED has contributed to times may also lead to some patients patient dissatisfaction. Satisfaction with leaving the emergency department the health care services and health care without being seen by a physician. This provider is a predictor of overall patient is a threat to patient safety and the satisfaction. (17) quality of care in emergency Subjects and Method departments.(15) Nurses in the Subjects emergency department spend less than Design: half of their time on direct patient care This is a descriptive study design that was

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used to assess the mothers' satisfaction was consisted 12 items that regarding emergency nursing care of their demonstrated assessment of nursing Setting: care, while teaching is recorded in 3 Tanta Emergency hospital. items. The CECSS also contains four Sample: negatively worded filter items to A convenient sample of 80 mothers of minimize response set bias. It was

children under 12 years who admitted to classified into five-point Likert-type Pediatric Emergency Department of rating scale demonstrating the degree of Tanta Emergency Hospital, over a satisfaction with each statement. period of three months. The mothers Possible responses ranged from strongly who fulfilled the following criteria were disagree (1) to strongly agree (5). A included in the study: higher score represents a higher degree 1- Mothers' ages ranged from 25-45 of satisfaction with ED nursing. A total years. score of more than 60% indicated 2- Free from any communication or satisfaction, while the score less than psychological problems 60% indicated dissatisfaction. A pilot Tools: A questionnaire sheet was used study was conducted on 8 of mothers in this study. It consisted of two parts. minor modifications were made to the The first part of the tool was developed questionnaires. Also validity and by the researcher to collect socio- reliability of the questionnaires were demographic data about the children tested. and their mothers involved in this study, B-Methods: it included children's ages, gender, and Data collection: medical history. Mothers age , level of The researcher collected data from education, and occupation were also Tanta Emergency Hospital. Approval assessed. The second part of the tool was taken from the responsible was Consumer Emergency Care authorities before starting to collect Satisfaction Scale (CECSS). It was data. Ethical consideration of privacy, developed by Davis in 1988 and revised confidentiality, and the rights of the in 1997 to examine patient satisfaction mothers to withdraw from the study at to nursing care. (18,19) The CECSS tool any time were also considered.

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Interview was conducted with mothers. Almost, three quarters of the mothers Simple explanation about the aim of the (72.5%) were house wife compared by study was done for them. Those who 12.5% and 15% who were worker and agreed to participate were involved in employees respectively. the study, before discharging from the Mothers ' satisfaction about nurses Emergency Hospital. attitudes and nursing care received were Statistical analysis illustrated in table (2) . Equal percent of SPSS software package version 17 was the mothers (18.75%) described nurses used for statistical analysis. Simple attitudes as either genuine or caring. frequencies mean, standard deviation, Twenty eight point seventy five of the χ2 , P test and Pearson' correlations mothers reported that nurses were were used when appropriate. helpful. Nearly three quarters of the Results mothers (73.75%) mentioned that their Figure (1) shows distribution of children received basic nursing children' age . It was clear that nearly intervention , compared by 26.25% of two third of children (32.5%) aged from the mothers who reported that, their 7 < 10 years. One quarter of children children received specific nursing (25%) aged between 10-12 years while, intervention. Forty one point twenty 20% and 22.5% of the children aged five percent of the nurses were efficient, between 1 < 4 year and 4<7 years 28.75% were knowledgeable and respectively. The mean age of children 18.75% of the nurses were treating was 5.21+3.52. everyone equally according to mothers As regards table (1), nearly equal description. Nearly half of the mothers percent of the mothers (26.25% and 25 (48.75%) mentioned that the nurses %) aged from 30 < 35 years and were welcomed them in a good way between 40 - 45 years respectively. The compared to 33.75% of the mothers mean age of the mothers was who said that nurses were welcomed 32.02+7.43 . Slightly less than half of them in a bad manner while receiving the mothers (46.25% ) had diplomat their children. Statistical significant degree. Twenty seven point five were differences were found in mothers illiterate and 20% had bachelor degree. satisfaction with nursing care, nurses

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professional qualities and the way significant difference was found in the nurses welcome them while receiving total nursing care provided to children them. (P=0.000). Three quarters of the Figure (2) shows the distribution of mothers reported satisfaction with the mothers according to waiting time, It health teaching provided to them and was evident that, slightly less than half their children. They mentioned that, of the mothers waiting between 45 < 60 nurses told them about the children's minutes. Eighty eight point seventy five problems and, the expectation that may percent were waiting more than 60 occur at home. Statistical significant minutes compared by 18.75% and 7.5% difference was found regarding total who waited between 30 < 45 min. and < teaching(P=0.000). 30 minutes respectively. The mean of Mothers overall satisfaction regarding waiting time was 51.31+19.61. emergency visit was evident in table Table (3) shows mothers ' satisfaction (4). It was clear that, nearly equal according to CECSS. It was clear that, percent of 41.25% and 40 % of the three quarters of the mothers were mothers were reported good and fair satisfied by the nursing care provided to satisfaction with the emergency visit. their children. They mentioned that the There was statistical significant nurses know something about my difference (P=0.022). Mothers illness, explained things in terms that mentioned that, they like the service, they could understand. Nurses were environment, nurses behavior and understanding when listening to flexibility, the percentage of the children's problems and, appeared to responses were 25%, 22.5%, 28.75% take time to meet their needs were and 23.75% respectively. Nearly one reported by the same percent (75%) of third of the mothers (35%) mothers. Sixty five percent of the recommended to enhance the waiting mothers mentioned that, the nurses room. Twenty five percent explained procedures before they were recommended to increase the number of done and 60% of the mothers reported nursing staff . that, the nurses were sure that all their As regards table (5), statistical questions were answered. Statistical significant correlation was found

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between the satisfaction of total care waiting time and total care, there was and mothers education. Negative negative correlation that was correlation was found between statistically insignificant, this means education, occupation, and satisfaction that, with the increasing waiting time with waiting time. Also, negative the satisfaction with total nursing care correlations were found between was decrease. Negative correlation also mothers occupation and satisfaction observed between nurses attitude and with both total care and total education. total nursing care that means that, Table (6) shows the correlations negative attitudes leads to between mothers satisfaction with dissatisfaction with total care. Statistical nurses professional characteristics, total significant correlations were detected care and total teaching. As regards, between professional quality and nurses there was significant correlation attitudes and between professional between total care and total teaching. quality and the way the nurse welcome Regarding the correlation between the the mothers and their children.

Figure (1) Distribution of children according to age.

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Table 1. Percent distribution of mothers according to demographic data . Items n. = 80 % Age in years: 20 - 13 16.25 25 - 18 22.5 30 - 21 26.25 35 - 8 10 40 - 45 20 25 Mean + SD = 32.02+7.43 Education: Illiterate 22 27.5 Diplomat 37 46.25 Bachelor 16 20 Post graduate 5 6.25 Occupation House wife 58 72.5 Worker 10 12.5 Employee 12 15

Table 2. Percent distribution of mothers according to satisfaction about nurses attitudes and nursing care received.

Items n.=80 % χ2 P

Nurses attitudes Genuine 15 18.75 Calm 16 20 Helpful 23 28.75 4.750 0.314 Caring 15 18.75 Understanding 11 13.75 Received nursing care Basic nursing intervention 59 73.75 18.05 0.000* Specific intervention 21 26.25 Professional Qualities of Nurse: Efficient, 33 41.25 Knowledgeable 23 28.75 16.20 0.001* Privacy respected 9 11.25 Treated everyone equally 15 18.75 Nurses welcomed the patients: Very Good 14 17.5 11.72 0.003* Good 39 48.75 Bad 27 33.75 *Significant at< 0.05 level.

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Figure (2) Distribution of mothers according to waiting time Table 3. Percent distribution of mothers according to satisfaction according to Consumer Emergency Care Satisfaction Scale (CECSS) . Satisfied Unsatisfied

n=80 % n=80 % Caring: The nurse.... 1 performs her duties with skill. 30 37.5 50 62.5 2 knows something about child's illness. 60 75 20 25 3 knows what treatment child' need. 44 55 36 45 4 explained procedures before they were done. 52 65 28 35 5 explained things in terms that I could understand. 60 75 20 25 6 understand when listening to child's problem. 60 75 20 25 7 seems genuinely concerned about child's pain. 40 50 40 50 8 is gentle when performing painful skill. 50 62.5 30 37.5 9 seems to understand how child's felt. 62 77.5 18 22.5 10 gives me a chance to ask questions. 40 50 40 50 11 appears to take time to meet child's needs. 60 75 20 25 12 sure that all my questions were answered. 48 60 32 40 Total Nursing care χ2 / 38.80 P / 0.000* Teaching: The nurse.... 1 instructs me about home self care 40 50 40 50 2 tells me about my problems 60 75 20 25 3 tells me what to expect at home 60 75 20 25 Total Teaching χ2 / 37.94 P / 0.000* *Significant at< 0.05 level.

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Table 4. Percent distribution of the overall mothers' satisfaction about their ER visit.

Items n= 80 % χ P 2 1) Emergency visit  Good 33 41.25  Fair 32 40.0 7.67 0.022*  Poor 15 18.75 2)What did you like in ER?  Service 20 25.0  Environment 18 22.5 0.70 0.873  Nurse behavior 23 28.75  Flexibility 19 23.75 3) Efforts to enhance emergency  Increase number of nursing staff 20 25.0  Large Wating room 28 35.0 5.20 0.158  Increase number of equipment 14 17.5  Presence of doctors all time 18 22.5 *Significant at< 0.05 level.

Table 5. Correlations between mothers socio-demographic data and satisfaction with total care , total education and waiting time.

Waiting time Total care Total education

Items R P r P r P

Mothers' age 0.032 0.777 -0.090 0.427 0.010 0.928

Education -0.096 0.397 0.220 0.050* 0.071 0.532

Occupation -0.075 0.507 -0.030 0.793 -0.011 0.922

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Table 6. Correlation matrix between mothers' satisfaction with nurses professional characteristics and total care and total teaching.

Total Waiting Nurses Received Profession Items Total care teaching Time attitude care al quality

R 0.311 - - - - - Total teaching P 0.005** - - - - -

R -0.139 0.022 - - - - Waiting time P 0.219 0.847 - - - -

R -0.029 0.019 -0.085 - - - Nurses attitude P 0.796 0.869 0.454 - - -

R 0.102 0.059 0.101 0.014 - - Received care P 0.367 0.603 0.372 0.902 - -

R 0.119 0.129 0.119 0.226 0.040 - Professional quality P 0.293 0.255 0.293 0.044* 0.727 -

R 0.014 0.104 0.027 0.090 0.065 0.335 Welcoming patients P 0.902 0.358 0.815 0.430 0.569 0.002**

Discussion Patient satisfaction is an indicator of the professional medical care, that mothers quality of care. Patient satisfaction is an of children visiting a pediatric practice attitude, a person‘s general orientation are satisfied in general. This study aims towards a total experience of health to assess children's satisfaction with care. Without patient satisfaction there emergency care from the mothers' is no good care. Patient satisfaction perspectives. should form part of continuous Statistically significant differences improvement. It is a method of regarding mothers satisfaction with evaluating the quality of health services nurses professional qualities was shown provided to patients. Emergency care in the current study. Nearly half of the continue to be a challenge for pediatric mothers mentioned that, nurses were patients. That is the reason why it is efficient and, welcomed the children in very important. A part from a good a good manner. The findings of the

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present study are consistent with the makethem busy and can't tolerate long study of Daniel I.(2012) who explored waiting time. that patients' satisfaction with nursing The results of the present study is care are variable, answerable, congruent with the study of Feddock explainable, trustful, respectful, CA et.al (2005) who reported courtesy and available. The current significant negative correlation between findings support the importance of the parent satisfaction with the pediatric interpersonal aspect of nursing practice. day center visit and waiting times. (22) (20) Previous studies conducted by Kane The findings of the present study et.al(2007) ( 21) support the findings of contradict with the study of Zahnarzt the present study, he reported that G.(2011) and the study of Anderson RT patients expect several nursing qualities (2007) Who expected higher rate of such as, kindness, quick responses to satisfaction regarding waiting time. The patients' needs, and availability of mean waiting period in their study was adequate time to provide nursing care. 13,74 minutes, which is a suitable time The current study revealed that, slightly in contrast to the average calculated half of the mothers waiting in the ED, waiting time of 28 minutes for pediatric between 45 < 60 minutes. The mean of day centers (23-25 ) waiting time was 51.31+19.61 minutes. In the current study, three quarters of There is a negative correlation between the mothers were satisfied by the mothers education , occupation and nursing care and there is a statistical satisfaction with waiting time. A significant difference in the total possible explanation of this finding nursing care and total teaching. could be, that the majority of parents Statistical significant correlation tend to overestimate their waiting time between the satisfaction of total care and therefore, a consequence of long and mothers education was reported. It waiting time is a negative correlation to may be due to the natural positive overall satisfaction. It could be also relation between level of education and explained that negative correlation may awareness, that make the educated be due to mothers occupation, that mothers more appreciating to nursing

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performance. No significant correlation regarding overall mothers' satisfaction was found between mothers 'age and with the total nursing care and total satisfaction with total care. Negative teaching provided to their children. correlations also, observed between Statistical significance correlation was total care, total education and mothers' found between the total care, total occupation. This negative correlations education and mothers' satisfaction with explain the fact that, with increase age nurses professional characteristics. and occupation there is a decrease on Recommendations the patience and the ability to tolerate 1. Further researches are needed to stressors. The pre-occupied mothers capture children' opinions about the need high level of performance in a emergency care provided to them. short time. 2. Application of triage system in The results of the present study are emergency room to improve the congruent with the findings of Bacon & quality of care. Mark (2009) who reported that there is 3. Developing an educational program a correlation between patients' for nurses working in Emergency satisfaction and cultural background, Department. age, and education. (26) Other studies 4. Enforcing patients' satisfaction as an didn't find any relationship between indicator of the quality of nursing patients' satisfaction and demographic care provided in Emergency variables, Laschinger et.al (2011). ( 27) Department. Conclusion 5. Further studies are needed to Mothers were generally satisfied with evaluate the effectiveness of triage the care provided to their children by nursing care in decreasing the health emergency nurses. Measuring patients' hazards resulting from delaying in satisfaction with emergency nursing nursing / medical interventions. care remains a major challenge for Reference health care providers. Patients' 1. Lari M.A., Tamburini M. & Gray satisfaction has become an integral part D., Patients' needs, satisfaction, and of quality of pediatric emergency care. health related quality of life: There is a significant difference Towards a comprehensive model,

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Health and Quality of Life 7. Abdel-Haq A, Paditz E, et.al., Outcomes 2004, 2:32. Internal Quality Assurance in the http://www.hqlo.com. Children‘s Sleep Laboratory - 2. Taylor, C. & Benger, J.R. Patient Surveying Parental Satisfaction satisfaction in Emergency with the ‗Sleep Laboratory for Medicine. Emergency Medicine Children Survey, Dresden‘ and Journal 2004, 12(3): 528-532. Subsequent Optimization. 3. Michael P. Simple tips to improve Somnnologie 2005, 9:33-51. patient satisfaction, American Ojanen Thomas D. Special Academy of Emergeny Medicine, considerations for pediatric triage 2011;18(1):18–19. in the Emergency Department. 4. U.S. National Center for Health Nurs Clin North Am. 2002;37:145– Services Research and 159. Development: Computer simulation 8. Middleton DR, Burt CW., model for evaluation of the health Availability of pediatric services care delivery system. Washington and equipment in emergency DC: US Government Printing departments: United States, 2002- Office; 1973. 2003. Advance Data 2006; 367:1- 5. Weissenstein A., Straeter A., et.al., 16. Parent satisfaction with a pediatric 9. The Pediatric Emergency Care practice in Germany: A Project , Terminal Evaluation, questionnaire-based study, Italian www.jica.go.jp/egypt_2001. Journal of Pediatrics, 2011, 10. Baillie L. An exploration of nurse- http://www.ijponline.net. patient relationships in accident and 6. Amponsah E.N. Determinants of emergency. Accid Emerg Nurs. Consumer Satisfaction of Health 2005;13: 9-14. Care in Ghana: Does Choice of 11. Nystrqm M, Nyden K, & Petersson Health Care Provider Matter?, M. Being a non-urgent patient in an Global Journal of Health Science, emergency care unit – a strive to October, 2009: 1(2)50-61. maintain personal integrity. Accid

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Emerg Nurs. 2003;11:22-26. Nursing Science, 1997;2(1-2):35- 12. Howard MS, Davis BA, et.al., 47. Patients‘ perspective on choosing 18. Saiboon I., Eng. Ho. Krishnan B., the emergency department for non- et al., A Study of Patients‘ urgent medical care: a qualitative Satisfaction with the Emergency study exploring one reason for Department (ED) of Hospital overcrowding. JEmerg Nurs. Universiti Kebangsaan Malaysia 2005;31: 429-435. (HUKM), Med & Health 2008; 13. Lee G, Endacott R, & Flett K, 3(1): 7-13. Bushnell R. Characteristics of 19. Daniel I, The Relationship between patients who did not wait for Nurse Staffing and Patient treatment in the emergency Satisfaction in Emergency department: a follow-up survey. Departments, Institute of Health Accid Emerg Nurs. 2006;14: 56-62. Policy, Management and 14. Vieth TL, & Rhodes KV. The Evaluation University of Toronto, effect of crowding on access and 2012. quality in an academic ED. Am J 20. Kane, R. L., et.al. " Nursing Emerg Med. 2006;24:787-794. Staffing and Quality of Patient 15. Schriver JA, Talmadge R, et.al., Care." Evidence Emergency nursing: historical, Report/Technology Assessment current and future roles. J Emerg No. 151 Agency for Healthcare Nurs. 2003;29:431-439. Research and Quality, 2007; 1-115. 16. Elder, R., Neal, C., et.al., Patient 21. Feddock CA, Hoellein AR, et.al., satisfaction with triage nursing in a Can physicians improve patient rural hospital emergency satisfaction with long waiting department. Journal of Nursing times? Eval Health Prof 2005, Care Quality19, 2004; 3: 263-268. 28:40-52. 17. Davis, B.A., Bush, H.A. and 22. ZahnarztG.,2011, [http://www.agz- Thomas, S.W. Measuring consumer rnk.de/agz/content/2/ satisfaction with emergency aktuelles/akt_00584.php],. department nursing care. Journal of

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23. Anderson RT, Camacho FT, & Balkrishnan R: Willing to wait?: the influence of patient wait time on satisfaction with primary care. BMC Health Serv Res , 2007; 7:31. 24. Y F Choi, T W Wong, & C C Lau, Triage rapid initial assessment by doctor (TRIAD) improves waiting time and processing time of the emergency department, Emerg Med J. 2006 April; 23(4): 262–265. 25. Bacon, C. T. & Mark, B. "Organizational effects on patient satisfaction in hospital medical- surgical units." Journal of Nursing Administration, 2009; 220-227. 26. Laschinger, H., Gilbert, S. & Smith, L. "Nursing Outcomes; The State of the Science." Jones & Barlett, Learning , 2011.

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Assessment of knowledge and Practicing Regarding Breast Self - Examination Among Female Students At South Valley University

Sayed Ahmed Taha MD Departments of Obstetrics & Gynecology, Faculty of Medicine, South Valley University, Kena Manal Farouk Moustafa MD Department of Obstetrics & Gynecology, Faculty of Nursing, Assuit University South Valley Universities (Kena), Egypt Sahar Fahmy Gawad MD Lecturer of Obstetrics & Gynecology, Faculty of Nursing, South Valley Universities (Kena) Reda Refahi Ali Ms Sc Department of Obstetrics & Gynecology, Faculty of Nursing, South Valley Universities (Kena), Egypt

Abstract: Objectives: To assess the knolwedge of univeristy female students about breast self examination (BSE) including the facilities, sources and the impact of residence and level of parents‘ education on these knolwedge.

Subjects and Method: The study included all female students of faculties of Specific Education (Group I) and Archaeology (Group II), South Valley University, Qena, Egypt. The study relied on a specially designed self-administered questionnaire developed by the researchers and consisted of three parts: The first part included collection of personal data, the second part was concerned by the knowledge of students about BSE, and the third part was concerned by the performance of BSE.

Results: Radio and TV constitute the main source for 36.3% of females had knowledge, reading about BSE and communication facilities on the internet were the following sources in Group I, while personal communication data sources are the main in group II with significant difference of distribution according to source of knowledge between both groups. Only 63 females do BSE, 30 do it monthly, 45 do it 6 monthly and 25 do it

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yearly; 18 females do it before date of menstrual period, 21 do it after period and 24 females do it at any time with non-significant difference between both groups. There was non-significant difference between both groups as regards the method of performing the BSE and the feedback action to notice breast changes. For both groups, irrespective of rural or urban inhabitance, the majority of females had their information through radio and TV, books and magazines are highly used by rural females of group I but by urban females of group II. Rural inhabitants performing BSE was significantly higher in both groups compared to urban inhabitants. There was significant difference between both groups categorized according to residence as regards knowledge about the methods of BSE. Educated mothers significantly affected their girls knowledge and application of facilities for gaining information and significantly higher frequency of proper choice of timing of BSE.

Conclusion: Knowledge about BSE is still underdeveloped and controlled by the residence, level of education of the mothers, the availability of knowledge providing facilities and even these knowledge needed to be corrected as regards how and when to practice BSE. Thus mass surveys for provision of knowledge among higher school and university student is mandatory to develop and correct their knowledge about BSE

Keywords: Cancer breast, Breast self-examination, Screening, Questionaire

Introduction Cancer is becoming an increasingly Breast cancer is a major public health important factor in the global burden of problem for women throughout the disease. Worldwide, the estimated world. In the United States breast number of new cases each year is cancer remains the most frequent cancer expected to rise from 10 million in 2000 in women and the second most frequent to 15 million by the year 2020 and out cause of death. In 2007 it is estimated of all these new cases 60% will develop that breast cancer will account for 26 % in the less developed parts of the world. of cancer cases and 15 % of cancer Approximately 20 million people are deaths, which translates to 176, 296 new alive with cancer at 2003 and by 2020 cases and 40, 515 deaths (2). there will probably be more than 30 According to institutional data from million (1). South Egypt Cancer Institute, breast

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cancer is the second common cancer in herself looking at and feeling each frequency after bladder cancer. breast for possible lumps, or swelling (6). Incidence of new cases was 11.62 % The value of performing BSE on a relates to all new cases attended during monthly basis and reporting findings to 2005. So it is the most prevalent cancer the clinician should be emphasized, among Egyptian women and constitutes specially including that the treatment of 29% of National Cancer Institute cases. disease detected early in its course is Median age at diagnosis is one decade much more likely to be successful younger than in countries of Europe and compared with treatment started later, North America and most patients are after disease had time to progress, it premenopausal (3). should be explained that a women will Breast self Examination (BSE) has been become expert in knowing her own advocated for years as good method for breast and when something has early detection of breast masses and a changed, it is then the task of clinician large percentage of women discover to determine the significance of the their breast cancer accidentally or change. Because breast cancer during BSE. Women at high risk for considered the leading type of cancer in breast cancer are especially encouraged women, So Clinical breast examination to be attentive to the importance of and BSE are the secondary preventive early detection through routine BSE. methods used for screening in the early Moreover, BSE may be of a real value detection of the breast cancer (7, 8). for younger women who do not yet get The current prospective study aimed to regular mammograms (4, 5). assess the knolwedge of univeristy The effectiveness of BSE is determined female students about breast self by the woman's ability to perform the examination including the facilities, procedure correctly, by her knowledge sources and the impact of residence and of her own breast tissue, and by the level of parents‘ education on these density of her breast tissue. BSE: Is a knolwedge. method of finding abnormalities of the Subjects and Method breast, for early detection of breast The current prospective comparative cancer. The method involves the women study aimed to include all female

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students of faculties of Specific  Doing of BSE: Yes or No. Education (Group I) and Archaeology  Frequency of doing BSE: monthly, (Group II), South Valley University, 6-monthly or yearly. Qena, Egypt. Data collection was  Date of doing BSE: before or after started at Feb till May 2010 through two menstruation, or no definite time. weekly visits to the colleage. The study  Methods of BSE: observation and relied on a specially designed self- view for the external shape, size administered questionnaire developed of breast, color of breast, presence by the researchers after review of of abnormalities in breast, or all literature and interviewing experts in the previous. By pressure and Nursing Obstetrics and Gynecological touch using three middle fingers, Specialties. by circular motion, touch all parts The designed questionnaire consisted of of breast, examination of axillary three parts: The first part included lymph nodes. By notes: record collection of personal data including notes, detect the next exam, all the Student's name, age, name of faculty, previous. residence, educational level of mother  The position preferred during and father, occupation of mother, and examination: while standing in front of facilities as computer and internet. The a mirror, while lying down, while second part was concerned by the taking a shower or all the previous. knowledge of students about breast self-  The mode of BSE: circular motion, examination (BSE) including having from enter to outer, with clockwise, knowledge about BSE or not, and the from upper to lower, from side to side, source of knowledge either mother, others. books, magazine, radio & TV, friends,  What parts of hands used when do family, computers and internet and exam: the palm of hands, fingertips or others as conferences and lectures. The all hand. third part was concerned by the  What is the feedback of finding any performance of BSE including the abnormality in breast: tell following BSE data:

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 mother, go to doctor, search in were rural areas inhabitants. As regards books and internet, go to friends mother job, 84% and 77.7%, in both or others. groups, respectively were housewives  The exact time for BSE: Monthly, and remaining mothers were employee weekly, 7-10 days from the 1st Table 2 show that hree hundreds and day of menstruation, the same day sixty-five subjects (73%); 65% of from every month if not Group I and 78.3% of Group II, were menstruation, and others. found to have no knowledge about BSE Statistical analysis with significant difference in favor of Data collected were analyzed and Group II. As regards the source of tabulated and statistically compared knowledge, Radio and TV constitute the using SPSS (Version 15, 2010) main source for 36.3% of females had program. Data are presented and knowledge, reading about BSE and mean±SD, number, percentage and communication facilities on the internet were analyzed using Chi-square to were the following sources in Group I, determine significance between while personal communication data numerical variables. P<0.05 was sources are the main in group II with considered significant significant difference of distribution Results according to source of knowledge Table I shows that mean age of studied between both groups (Fig. 1). Only 63 subjects was 19.52±2.41 years in Group females do BSE, 30 do it monthly, 45 I and 19.75±2.74 years in Group II with do it 6 monthly and 25 do it yearly; 18 77.5% and 67.3% of both groups, females do it before date of menstrual respectively, were in range of 17-20 period, 21 do it after period and 24 year and 22.5% and 32.7%, respectively females do it at any time with non- were older than 20 years. About 70% significant difference between both and 62% of mothers of studied subjects groups, were educated and about 83% and 62% As regards Table 3 All subjects in both groups, respectively, were concerned with BSE conduct educated. Majority of studied subjects; examination by various methods; 84% in group I and 51.7% in group II however, the number of females

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concerned with the presence of mass of being rural or urban inhabitant, while and examining their axillae for lymph in group I about 35.7% of females had nodes was higher among group I no computer facility with significantly females, despite the difference was non- higher frequency of having computer significant. The number of females facility in group II. For both groups, responded about recoding notes about irrespective of rural or urban their previous and oncoming BSE was inhabitance, the majority of females had significantly higher in Group I their information through radio and TV, compared to Group II, (Table 3). books and magazines are highly used by There was non-significant difference rural females of group I but by urban between both groups as regards the females of group II, other sources are method of performing the BSE, nearly similar between both groups with however, the applicability of circular significant difference of the frequency motion was significantly higher in of source of information among groups Group I compared to Group II and the according to location of inhabitance. use of either palm of hand of fingertips Rural inhabitants performing BSE was was significantly higher in Group I significantly higher in both groups compared to Group II. The frequency of compared to urban inhabitants; females doing BSE weekly and/or however, timing of performing monthly was also significantly higher in examination showed non-significant

Group I compared to Group II, (Table 4). difference between both groups The feedback action to notice breast categorized according to site of changes during BSE showed non- inhabitance (Table 6). significant difference between both There was significant difference groups despite the increased frequency between both groups categorized of asking a doctor or searching the net according to residence as regards was higher among group I subjects, knowledge about the methods of BSE, (Table 5, Fig. 2) this was reflected as the significantly All females accustomed to perform BSE higher frequency of those interested in in group II had computer alone or in the breast appearance more than the addition to internet facility, irrespective presence of breast mass in rural women

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compared to urban women. This interest mothers taught their daughters to was documented by the method used for examine the whole breast with either practicing BSE as manifested by fingertips or palm of hand and not to significantly higher frequency of forget the axilla. Moreover, educated examination while standing in front of mothers advised their daughters to mirror (Table 7). examine the breast while standing Educated mothers significantly affected especially in front of the mirror so as to their girls knowledge and application of allow perfect observation and/or while facilities for gaining information as lying down so as to allow proper touch. manifested by the significant difference However, illiterate mothers advised of the availability of communication their daughter to do BSE mostly while facilities and scientific sources of taking shower, (Table 9). information as books and magazines and this was reflected on the frequency of practicing BSE which was significantly higher in both groups included educated mothers. Moreover, maternal education allowed significantly higher frequency of proper choice of timing of BSE; after menstruation in comparison to those whose mothers were illiterate, (Table 8). Mothers‘ education significantly affected the choice of method for practicing BSE with illiterate mothers taught their daughters to mainly use the observation and only to look for the mass, while educated mothers taught their daughters to observe the external shape, color and size of the breast and to also look for mass. Also, educated

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Table (1): Distribution of the students according to socio-demographic characteristics among both groups

Specific Archaeology P value education (no=300) (no=200) Age (years) 17-20 years 155 (77.5%) 202 (67.3%) >20 years 45 (22.5%) 98 (32.7%) =0.009 Mean 19.52±2.41 19.75±2.74 Mother Educated 141 (70.5%) 186 (62%) =0.03 education Illetrate 59 (29.5%) 114 (38%) Mother Educated 167 (83.5%) 225 (62%) =0.015 education Illetrate 33 (16.5%) 75 (38%) Residence Rural 168 (84%) 155 (51.7%) <0.001 Urban 32 (16%) 145 (48.3%) Mother‘s job Housewives 168 (84%) 233 (77.7%) >0.05 Employee 32 (16%) 67 (22.3%) Data are presented as mean±SD & number; percentages are in parenthesis

Table (2): Distribution of the students according to knowledge about BSE

Specific Archaeology P value education (no=300) (no=200) Knowledge Yes 70 (35%) 65 (21.7%) =0.001 about BSE No 130 (65%) 235 (78.3%) Source of Mother 5 (7.1%) 8 (12.3%) knowledge Books and 13 (18.6%) 8 (12.3%) magazines Radio & TV 23 (32.9%) 26 (40%) =0.0163 Friends 10 (14.3%) 3 (4.6%) Family 3 (4.3%) 5 (7.7%) Computer & Net 11 (15.7%) 5 (7.7%) Other 5 (7.1%) 10 (15.4%) Facilities Computer 31 (44.3%) 26 (40%) Computer & Net 17 (24.3%) 18 (27.7%) >0.05 No 22 (31.4%) 21 (32.3%) Do you make Yes 35 (50%) 28 (43.1%) >0.05 BSE No 35 (50%) 37 (56.9%) How many Every month 10 (28.6%) 20 (30.8%) times you do Every 6 months 14 (40%) 31 (47.7%) >0.05 BSE Every year 11 (31.4%) 14 (21.5%) What is the Befroe 11 (31.4%) 7 (25%) exact date for menstruation >0.05 doing BSE After menstruation 11 (31.4%) 10 (35.7%) No definite date 13 (37.2%) 11 (39.3%)

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Data are presented as number & percentages are in parenthesis

40

35

30

25

20 (%)

15

10

5

0 Mother Books and Radio & TV Friends Family Computer & Other magazines Net Specific education Fig. (1): Sources of knowledge about BSE in two groups Archaeology Table (3): Distribution of the students according to methods of BSE

Specific Archaeology P education (no=65) (no=70) By External shape 19 (27.1%) 10 (15.4%) observation Size of breast 11 (15.7%) 10 (15.4%) and look Color of breast 5 (7.1%) 6 (9.2%) >0.05 abnormal mass 20 (28.6%) 13 (20%) All previous 15 (32.9%) 26 (40%) By Touch & Bellow collarbone 5 (7.1%) 10 (15.4%) Pressure Touch breast by the three 10 (14.3%) 15 (23.1%) middle fingers Touch with circular 15 (21.4%) 15 (23.1%) motion >0.05 Touch & press all parts 10 (14.3%) 5 (7.7%) of breast Exam lymph mode 10 (14.3%) 5 (7.7%) All previous 20 (28.6%) 15 (23.1%) By note Record notes 10 (14.3%) 20 (30.8%) Determine the next time 10 (14.3%) 15 (23.1%) =0.01 of exam All previous 50 (71.4%) 30 (46.1%) Data are presented as number & percentages are in parenthesis

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Table (4): Distribution of students according to knowledge about methods preferring when doing exam in both group

Specific Archaeology p education (no=65) (no=70) Methods While standing in front to 20 (28.6%) 15 (23.1%) you prefer a mirror during BSE While lying down 15 (21.4%) 20 (30.7%) >0.05 While taking a shower 20 (28.6%) 15 (23.1%) All previous 15 (21.4%) 15 (23.1%) Mode of Circular motion 30 (42.9%) 10 (15.4%) BSE From enter to outer 5 (7.1%) 10 (15.4%) With clockwise 20 (28.6%) 20 (30.8%) =0.002 From upper to lower 10 (14.3%) 10 (15.4%) From side to side 5 (7.1%) 15 (23.1%) Others 0 0 Part of hand The palm of the hand 20 (28.6%) 20 (30.8%) used for Fingertips 35 (50%) 15 (23.1%) <0.001 BSE All hands 15 (21.4%) 10 (15.4%) Others 0 20 (30.8%) Exact time Monthly 30 (42.9%) 25 (38.5%) for doing Weekly 15 (21.4%) 10 (15.4%) BSE 7-10 days from 1st day of 20 (28.6%) 15 (23.1%) menses =0.03 The same day every 5 (7.1%) 10 (15.4%) month, irrespective of menses Data are presented as number & percentages are in parenthesis

Table (5): Distribution of students according to action taken on finding any changes in their breast

Specific education (no=70) Archaeology p (no=65) Tell mother 20 (28.6%) 15 (23.1%) Go to doctor 20 (28.6%) 15 (23.1%) Search in books & net 15 (21.4%) 10 (15.4%) >0.05 Go to friends 5 (7.1%) 5 (7.7%) Others 10 (14.2%) 20 (30.8%) Data are presented as number & percentages are in parenthesis

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35

30

25

20 (%) 15

10

5

0 Tell mother Go to doctor Search in Go to friends others books & net Specific education Fig. (2): Actions taken on finding any changes in the breast Archaeology Table (6): The relation between residence & knowledge about BSE in both groups.

Specific education Archaeology Rural Urban Rural Urban P (n=46) (n=24) (n=23) (n=42) Facilities Computer 30 0 13 21 (50%) (65.2%) (65.5%) Computer & Net 5 10 10 21 (50%) (10.9%) (41.7%) (44.5%) <0.001 No 11 14 0 0 (23.9%) (58.3%) Source of Mother 5 - 3 (13%) 6 =0.003 infromation (10.9%) (14.3%) Books and 13 - - 9 magazines (28.3%) (21.4%) Radio & TV 6 (13%) 21 10 16 (87.5%) (44.5%) (38.1%) Friends 10 - - 2 (4.8%) (21.7%) Family 1 (2.2%) - 4 - (17.4%) Computer & Net 7 1 (4.2%) 3 (13%) 4 (9.5%) (15.2%) Other 4 (8.7%) 2 (8.3%) 3 (13%) 5 (11.9%) Doing BSE Yes 25 10 15 13 (31%) (54.3%) (41.7%) (65.2%) =0.008 No 21 14 8 29 (69%) (45.7%) (58.3%) (34.2%) Time of Befroe 15 5 10 12 BSE menstruation (32.6%) (20.8%) (66.7%) (92.3%) After 14 16 3 (20%) 1 (7.7%) menstruation (30.4%) (66.7%) >0.05 No definite date 17 (37%) 3 2 0 (12.5%) (13.3%) Data are presented as number & percentages are in parenthesis

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Table (7): Relation between residence & knowledge about methods of BSE in both groups

Specific education Archaeology P Rural Urban Rural Urban (n=46) (n=24) (n=23) (n=42) By External shape 17 (37%) 2 (8.3%) 7 3 (7.1%) observation (30.8%) and look Size of breast 11 0 7 3 (7.1%) (23.9%) (30.8%) Color of breast 3 (6.5%) 2 (8.3%) 4 2 (4.8%) <0.001 (17.4%) Abnormal mass 5 15 2 (8.7%) 11 (10.9%) (62.5%) (26.2%) All previous 10 5 3 (13%) 23 (21.7%) (20.8%) (54.8%) By Touch Bellow 5 0 8 2 (4.8%) &Pressure collarbone (10.9%) (34.8%) Touch breast by 10 0 8 7 (16.7) the three (21.7%) (34.8%) fingertips Circular motion 12 3 4 11 (26.2) (26.1%) (12.5%) (17.4%) <0.001 Touch & press 6 (13%) 4 0 5 all parts of (16.7%) (11.9%) breast Exam lymph 7 3 0 5 mode (15.2%) (12.5%) (11.9%) All previous 6 (13%) 14 3 (13%) 12 (58.3%) (28.6%) Notes Record notes 10 0 13 7 (21.7%) (56.5%) (16.7%) Determine next 10 0 3 (13%) 12 <0.001 time (21.7%) (28.6%) All previous 26 24 7 23 (56.5%) (100%) (30.4%) (54.8%) Methods While standing 20 0 11 4 (9.5%) you prefer in front to a (43.5%) (47.8%) during mirror BSE While lying 12 3 2 (8.7%) 18 down (26.1%) (12.5%) (42.9%) <0.001 While taking a 8 12 (50%) 8 7 shower (17.4%) (34.8%) (16.7%) All previous 6 (13%) 9 2 (8.7%) 13 (31%) (37.5%) Data are presented as number & percentages are in parenthesis

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Table (8): Relation between mother education and knowledge about BSE among both groups

Specific education Archaeology P Educated Illiterate Educated Illiterate (n=49) (n=21) (n=47) (n=18) Facilities Computer 30 0 21 0 (61.2%) (44.7%) Computer & 5 10 16 (34%) 10 <0.001 Net (10.2%) (47.6%) (55.6%) No 14 11 10 8 (28.6%) (52.4%) (21.3%) (44.4%) Source of Mother 5 0 9 0 infromation (10.2%) (19.1%) Books and 13 0 8 (17%) 1 (5.6) magazines (26.5%) Radio & TV 6 21 16 (34%) 10 (12.2%) (100%) (55.6%) Friends 10 0 1 (2.1%) 1 (5.6) =0.003 (22.4%) Family 1 (2%) 0 4 (8.5%) 0 Computer & 8 0 5 2 Net (16.3%) (10.6%) (11.1%) Other 6 0 4 (8.5%) 4 (12.2%) (22.2%) Doing BSE Yes 28 7 25 3 (57.1%) (33.3%) (53.2%) (16.7%) =0.003 No 21 14 22 7 (42.9%) (28.6%) (46.8%) (83.3%) Time of Befroe 18 0 15 0 BSE menstruation (36.7%) (31.9%) After 13 24 21 8 <0.001 menstruation (26.5%) (100%) (44.7%) (44.4%) No definite date 18 0 11 10 (36.7%) (23.4%) (55.6%) Data are presented as number & percentages are in parenthesis

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Table (9): The Relation between methods of BSE and education of mother among both groups.

Specific education Archaeology P Educated Illiterate Educated Illiterate (n=49) (n=21) (n=47) (n=18) By External shape 19 0 10 0 observation (38.8%) (21.3%) and look Size of breast 11 0 10 0 (22.4%) (21.3%) Color of breast 4 (8.2%) 1 (4.8%) 6 0 <0.001 (12.8%) Abnormal mass 6 14 11 2 (12.2%) (66.7%) (23.4%) (11.1%) All previous 9 6 10 16 (18.4%) (28.6%) (21.3%) (88.9%) By Touch Bellow 5 0 10 0 &Pressure collarbone (10.2%) (21.3%) Touch breast by 10 0 15 0 the three (20.4%) (31.9%) fingertips Circular motion 12 3 9 6 (24.5%) (14.3%) (19.1%) (33.3%) <0.001 Touch & press 9 1 (4.8%) 4 (8.5%) 1 (5.6%) all parts of (18.4%) breast Exam lymph 7 3 2 (4.3%) 3 mode (14.3%) (14.3%) (16.7%) All previous 6 14 7 8 (12.2%) (66.7%) (14.9%) (44.4%) Notes Record notes 10 0 20 0 (20.4%) (42.6%) Determine next 10 0 10 5 =0.002 time (20.4%) (21.3%) (27.8%) All previous 29 21 17 13 (59.2%) (100%) (36.2%) (72.2%) Methods In front to a 18 2 (9.5%) 15 0 you prefer mirror (36.7%) (31.9%) during While lying 15 0 8 (17%) 12 BSE down (30.6%) (66.7%) =0.001 Taking a shower 10 10 13 2 (20.4%) (47.6%) (27.7%) (11.1%) All previous 6 9 11 4 (12.2%) (42.9%) (23.4%) (22.2%) Data are presented as number & percentages are in parenthesis

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Discussion The current study reported that about from journals and Yan (13) found mass 65% of Specific Education Faculty media such as newspaper as source of sample (Group I) and 78.3% of information for about 37.1% of study Archaeology Faculty sample (Group II) population. do not have knowledge about BSE. This About 40% of study participants finding agrees with that previously depended on Radio and TV for reported in literature; Seif & Aziz (9) obtaining their knowledge about BSE; found that about 25% of a group of this figure supported that previously working women in Ain Shams reported by Seif & Aziz (9) who found University survey about effect of BSE Radio and TV represent about 30% of training program on knowledge, attitude the sources of information about BSE, and practice heard about breast self but was contradictory to Demirkian et examination. Heidari et al. (10) reported al. (14) who found that among nurses & that 21.6% of women residing in South teachers in Turkey the most important East of Iran had good knowledge about information sources for both groups BSE. Balogun (11) found 31.7% of were books & Magazines. On the other female Traders in Ibadan, Oyo state, side, Yan (13) mentioned that Radio and Nigeria were aware of BSE. TV was the major information source of The present study also reflects that, less BSE for about 58.6% of study than one-fifth of female students participants. These findings spot light (18.6% & 13.8% respectively) in both on the fact that effort should be groups obtained their knowledge from intensified in using these media to books and magazine. This finding goes create BSE awareness and emphasize in hand with Seif & Aziz (9) who the importance of early detection as this showed that books represented 13.1% as appears to be better media to reach a source of knowledge about BSE. Also, wider audience. Adenik et al. (12), (2009) conducted a As regards the effect of interpersonal study of knowledge, practice of female communications as a source of health workers in a Nigerians urban city knowledge, about 10% studied female and found 31.1% obtain information students got their information from

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friends. The reported figure agreed Jordanian women practice BSE on Adenik et al. (12) who found that in a monthly basis, Pinar et al. (18) who Nigerian urban city, only 4.1% of study reported a figure of 10.2% among a participants obtained information from group of women in a rural area in their colleagues. However, the obtained Western Turkey. About 50% of females figure was contradictory to the work of practicing BSE monthly do it after the Seif & Aziz (9) who found that in Cairo, end of menstrual period and about 30% Egypt the main source of information of them do it before the period and the about BSE was peer group (47.8%), but remaining had no definite date for this high figure could be attributed to examination. the long time that working women spent Review of literature concerning timing with each other at the workplace, of BSE was discrepant and this could be discussing different issues, which attribute to the extent of knowledge in creates strong relation among each relation to age, level of education and other. type of work of study participants; In the present study, it is found that Milaat (15) reported that only 14.4% of about 50% of female students who had secondary–school female students had knowledge about BSE do it with non- knowledge about time of BSE. significant difference between study Demirkian et al. (14) reported that groups. The reported figure superceded 69.3% and 46.7% of studied nurses and that reported by Heidari et al. (10), teachers, respectively, had a knowledge Milaat (15) and Tanjasiri et al. (16) and about proper timing of BSE and who reported figures of 23.3%, 12% attributed this difference to the fact that and 37% for performing BSE among nurses have correct knowledge about females had the knowledge about it, BSE procedures because of their respectively. profession. Concerning the frequency of BSE, As regards mode of practicing BSE about 30% of study participants who do about 30% of those do BSE prefer to do BSE conduct it monthly, a figure that it while standing either in front of the superceded that reported by mirror or during taking shower and Alkhasawneh (17) who found only 18 of mostly use their palm of hand for

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examination and continuously observe References their breasts and look for masses. These 1. World Health Organization: Global data go in hand with Rosemary, et al., Strategy on Diet, physical Activity and (2010) who conducted a study in Lagos Health, 2003. Available at: among Nursing students, showed that www.who.int\cancer. about 50% of students prefer doing BSE 2. Ferlay, Autier P, Bonio lM: Estimates in front a mirror and about 28% prefer of the cancer incidence and mortality in BSE while taking a shower; however, Europe, 2006; 18(3):581. higher percentage (85.6%) use their 3. Omar SH, Khaled R, Gaafar AR, Zekry palms during BSE, this could be S, Eissa1 and O. El-Khatib: Breast attributed to the fact that this group cancer in Egypt: a review of disease consider proficient group because of presentation and detection strategies, their job or field of work. 1st ed Korba International: London, The present study showed a highly 2003; 9(3): 15-8. significant difference between both 4. Howard Fuchsia RN, MSN, Shannon study groups regarding to facilities and Scott-Findlay RN, BN Article first methods of observation in relation to published online. Breast self residence and mother education. It examination, 2006: 10: 66-70. could be concluded that knowledge 5. Saludeen AG, Akande TM, Musa OI: about breast self examination is still Knowledge and Attitudes to breast underdeveloped and controlled by the cancer and breast self examination residence, level of education of the among female undergraduates in a state mothers, the availability of knowledge in Nigeria. European J. Social Sci., providing facilities and even these 2009; (7):157-65. knowledge needed to be corrected as 6. American Cancer Society: Updated regards how and when to practice BSE. breast cancer screening guidelines Thus mass surveys for provision of released, 2006. Available at knowledge among higher school and www.cancer.org. university student is mandatory to 7. National Cancer Institute: Summery of develop and correct their knowledge evidence, screening breast self about BSE

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examination, 2009. Available at 2009; 4(9)\147-203. Available at www.cancer gov\breast\page5. www.biomedcentral.com. 8. National Cancer Institute: Breast and 13. Yan YY: Breast cancer: knowledge and Prostate Cancer and Hormone-Related perceptions of Chinese women in Hong Gene Variants Cohort Consortium, Kong. Global J. Health Sci., 2009; (1): 2009. Available at: www. 97-105. epi.grants.cancer.gov. 14. Demirkian F, Memis S, Turk G: How 9. Seif N, Aziz M: Effect of BSE training do nurses and teachers perform BSE: program on knowledge, Attitudes and are they reliable sources of practice of a Group of working women. information?, 2004; (6): 234- Journal of the Egyptian Nat. Cancer 238.Available at: www.biomed central. Inst., 2000; 12(2):105-15. 15. Milaat WA: knowledge of secondary 10. Heidari Z, Mahmoudzadeh-Sagheb1 school female students on breast cancer HR, Sakhavar N: breast cancer and BSE in Jeddah, Saudi Arabia. East screening knowledge and practice Medite, 2000;(6):338-44. among women in South East of Iran, 16. Tanjasiri SP, Tanjasiri SP, Sablan- Zehedan University of Medical Santosl: Breast cancer screening sciences, 2003. among Chamorro women in southern 11. Balogun MO, Owoaje ET: Knowledge California. J Women‘s Health, 2000; and practice of breast cancer screening 10(5):479- 85. among female traders in lbadan, 17. Alkhasawneh E: Barriers to and Nigeria Department of Community predictors of the practice of breast self- Medicine, University College Hospital, examination in Jordanian Muslim Ibadan, Oyo State, Nigeria. Annals of women. Unpublished doctoral Ibadan Postgraduate Medicine, 2003;. dissertation, State University of New 32(2):99-102. York, Buffalo, 2002. 12. Adenik, Omuemu: knowledge, 18. Pinar ,Erbay Dilek Özmen, Beyhan attitudes and practice of breast cancer Öztürk, Gökçe Haspolat, Filiz screening among female health Akyıldız, Sümeyra Çoban, and Gamze workers in a Nigerian urban city., Çakıroğlu:The knowledge and attitudes

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19. of breast self-examination and mammography in a group of women in a rural area in western Turkey pub med central BMC Cancer, 2006; (6): 43. 20. Rosemary B, Bassey,Nicholas K: knowledge, Attitude and practice of Breast Self-Examination among Nursing students in Lagos University Teaching Hospital .Academic Journal of cancer Research, 2010; 3(2):11-15.

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Enhancing the Quality of Life for Children with Cerebral Palsy At Benha City

Samah Abdalha Mohammed Amer Assistant Lecturer of Pediatric Nursing, Faculty of Nursing, Benha University. Abd El-Rahim Saad Shoulah, Professor of Public Health, Faculty of Medicine, Benha University, Mirret Mohammed Darouish Professor of Pediatric Nursing, Faculty of Nursing, Cairo University Faten Shafik Mahmoud, Lecturer of Pediatric Nursing, Faculty of Nursing Benha University, Abstract Cerebral palsy is one of a number of neurological disorders that affect body movement and muscle coordination. Nursing intervention of these children is crucial to maintaining their life and improving their quality of life. Therefore, the aim of this study was to enhance the quality of life for children with cerebral palsy through assess mothers' knowledge and practice regarding care of children with CP, design, implement and evaluate the constructed training program according to mothers' deficit. The research hypothesis was enhancing quality of life for children with cerebral palsy. A sample of 80 mothers of children with CP included in this study. The study was conducted at physiotherapy unit at Benha Hospitals. The tools of data collection were 1) mothers and child assessment sheet was constructed by the researcher, 2) Cerebral palsy quality of life questionnaire, developed by (Waters et al., 2006). The results showed significant improvement in mothers' knowledge and practice regarding caring for their children with CP, and also showed slightly improvement in children quality of life after program implementation. The study concluded that the program succeeds in improving the mothers' knowledge and practice regarding CP. After three months of implementation the program, the mothers' knowledge and practice was decline but still

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higher than before the program regarding all items about knowledge and practice. The study recommended that teaching mothers different aspects of caring of their children having cerebral palsy to improve their quality of life updated pamphlets, posters and Arabic booklets about CP to facilitate the improvement of their knowledge. Key Words: Cerebral palsy Quality of life Introduction: Cerebral palsy is a disorder affecting the maintain balance and posture. The central nervous system of newborns and disorders appear in the first few years of infants. It involves damage to the life. Usually they do not get worse over cerebrum, a part of the brain largely time. Children with cerebral palsy may responsible for motor function. One of have difficulty walking. They may also the most common symptoms of cerebral have trouble with tasks such as writing palsy is spasticity, or an increase in or using scissors. Some have other muscle tone and contraction that medical conditions, including seizure interferes with movement. The affected disorders or mental impairment body parts can range from a single limb (National Institute of Neurological to the entire body (Mettleman, 2009). Disorders &stroke, 2010). Cerebral palsy caused by abnormalities Quality of life is the degree of well- in parts of the brain that control muscle being felt by an individual or group of movements. The majority of children people. Unlike standard of living, with cerebral palsy are born with it, quality of life is not tangible thing, and although it may not be detected until so cannot be measured directly. It months or years later. The early signs of consists of two components: physical cerebral palsy usually appear before a and psychological. The physical aspect child reaches 3 years of age. The most includes things such as health, diet, and common signs are a lack of muscle protection against pain and disease. The coordination when performing psychological aspect includes stress, voluntary movements (ataxia); stiff or worry, pleasure and other positive or tight muscles and exaggerated cerebral negative emotional states (Costanza et palsy is a group of disorders that affect al, 2008). a person's ability to move and to

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Quality of life for children with cerebral children requires a team approach palsy refers to subjective well-being (Taylor, 2005). A modern team focuses on the health related component approach focuses on total patient of life satisfaction such as self care, development, not just on improvement mobility, and community. Assessment of a single symptom. Treatment of quality of life reflect personal programs encompass physical and evaluation of daily experience, and behavioral therapy, pharmacologic and resonate with other subjective surgical treatments, mechanical aids, outcomes, such as life satisfaction, and management of associated medical sense of coherence and self concept conditions. In physical, occupational, (Michael et al, 2007). speech, and behavioral therapies, the Education of parents and caregivers of goals include enhancing patient and children with cerebral palsy is a vital caregivers interactions while providing part of success of these children and the family support (Krigger, 2006). most parents and even caregivers do not Rehabilitation management of children fully understand how much can be done with cerebral palsy (CP) brings together and how much hope there is to improve parents and nurses. The primary goal of quality of life for children with cerebral the contact is to improve the individual palsy. In many cases, parents and child's potential and improve the child's caregivers don't even know where begin functional outcomes. Frequently, and how deal and care for their children parents are interested in not just their (Martin, 2006). own child, but the population of The goal of management of cerebral children with cerebral palsy. Physicians palsy is not to cure or to achieve can provide information for both normally but to increase functionality, purposes. Successful parent– improve capabilities, and sustain health professional relationships are rewarding in terms of locomotion, cognitive and powerful. Combining the passion of development, social interaction, and the parent and the expertise of the independence. The best clinical physician can enhance collaboration for outcomes result from early, intensive advocacy efforts that improve outcomes management. Optimal treatment in for children with cerebral palsy (A

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Foundation of Hope for Children International prevalence of cerebral with Cerebral Palsy, 2009). palsy is approximately 1.5-2 cases per Meeting the daily needs of a family 1000 live births. The incidence of member with cerebral palsy can be very cerebral palsy has not changed in more hard. If the child has cerebral palsy, he than 4 decades, despite significant will seek family and community advances in the medical care of support. Help to join a support group to neonates (Thorogood, 2009). talk with other parents who have a child Extrapolation of incidence rate for with special needs so mothers don't feel cerebral palsy in Egypt is 2,234/total alone. Also may find counseling useful, population (US Census Bureau, and help mothers understand and deal Population Estimates, 2010). with the wide range of emotions that The aim of the study was to enhance mothers may feel when their children the quality of life for children with had cerebral palsy. The child will need cerebral palsy through:- help too. Providing emotional support -Assess mothers' knowledge and for the child can help him or her to deal practice regarding care of children with with cerebral palsy (Golonka, 2008). cerebral palsy. Incidence of cerebral palsy: -Design, implement and evaluate the In the industrialized world, the constructed training program according incidence of cerebral palsy is about 2 to mothers' deficit and child condition. per 1000 live births (Thames Valley Research hypotheses: Children's Centre, 2007). In the A training educational program for United States, approximately 10,000 mothers about care of children with infants and babies are diagnosed with cerebral palsy will enhance their quality CP each year, and 1200–1500 are of life. diagnosed at preschool age (United Subjects and Method Cerebral Palsy Research and The present study was conducted with Education Foundation, 2007).The the aim of enhancing quality of life for incidence of cerebral palsy in developed children with cerebral palsy, this will be countries is approximately 2- 2.5/1000 achieved through designing, live births (Singapore, 2008). implementing and evaluating the

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educational program to mothers. - An oral consent was obtained from Study Design each subject to participate in the Interventional study program. Setting; -The tools of this study weren't The study was carried out in Benha touching the subject's shyness. University Hospitals, Benha -The study was conducted in safe Educational Hospitals, and Children places for the mothers. Specialized Hospitals at Benha City. -Data was collected and treated Sample confidentially. A convenience sample of consists of 80 C-Tools of Data collection mothers having children with cerebral Two tools were used for collecting palsy. data Criteria of inclusion 1- Interviewing questionnaire - Mothers have a child with cerebral Questionnaire sheet was constructed palsy. by the researcher, after reviewing - Both sex of children. related literature and under - Age of children, from 4 to 12 years. supervision of the supervisor that Ethical and legal considerations: covered the following. -The necessary official permissions Part I: for data collection and - Socio-demographic data of mothers' implementation of the educational age, level of education, occupation, program was obtained by submission number of children in family, and health of official letters issued from the problem……, etc. Dean of the Faculty of Nursing, - Child's age, sex and birth order. Benha university to the Part II: administrators of the hospitals in - Assessment of the mothers' Benha city. knowledge of regarding cerebral -The aim of the study was explained palsy (Definition, causes, sings & to each subject before applying the symptoms, complication…,etc). tools to gain their confidence and Assessment of mother's practice trust. about care of cerebral palsy (feeding,

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dressing, bathing, toileting…etc). unhappy, 3=unhappy, 5=neither Assessment of the daily living happy nor unhappy, 7=happy and activities of the child. 9=very happy. The few items where 2-Cerebral palsy quality of life this stem and rating scale is not questionnaire for children appropriate, such as items (CPQOL- child), developed by concerning pain, are worded international multidisciplinary team differently. For example: ‗How does of clinical and child health your child feel about the amount of researcher, with collaboration of he pain that they have?‘ The rating parents and children with cerebral scale for item of this kind is, 1=not palsy (Waters et al., 2006). upset at all, to 9=very upset, and Questionnaire for children with cerebral ‗How much pain does your child palsy aged 4 to 12 year it includes: have? ‘ The rating scale for item of - Parent- proxy version (for parents this kind is, 1= No pain at all, to 9= of children aged 4 to 12 years A lot of pain, and also ‗How much comprising 66 items. discomfort does your child - The CP QOL-Child measures the experience? ‘ The rating scale for quality of life of children with item of this kind is, 1= No cerebral palsy. It assesses several discomfort at all, to 9= A lot of aspects of a child‘s life including discomfort. And ‗Is your child physical wellbeing, social concerned about having cerebral wellbeing, emotional wellbeing, palsy? ‘ The rating scale for item of school, access to services, and this kind is, 1= Not all concerned, to acceptance by others. This form 9= Very concerned, and ‗Is your of the Instrument was developed child bothered by hospital visits? ‘ for assessing children aged 4-12 The rating scale for item of this kind years. is, 1= No at all bothered to 9= Very - Most items have the following item bothered, and ‗Does your child worry stem: ‗How do you think your child about who will take care of them in feels about…‘ These items have a 9 the future? ‘ The rating scale for item point rating scale, where 1=very of this kind is, 1= Never, 2=Rare,

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3=Sometimes, 4= Often, to 5= Field of work; Always A-Pilot study Scoring of variables:- A pilot study was carried out on 10% of Scoring the CP QOL- Child the sample for the purpose of Scoring involves two steps: modification and clarification. 1. Items are transformed to a scale with Participants in the pilot study were not a possible range of 0-100. The scores included in the sample. And there was for every time range from 1-9, except no modification of the designed for item ‗Does your child worry about questionnaire. who will take care of them in the B- Operational Design future? ‘ The scores for every time 1-First Phase; range from 1-5, for this item the This phase included assessment of the following formula must be used: knowledge and practice of the mothers If person scored 1, recode to 0 about cerebral palsy through using the If person scored 2, recode to 25 developed tools as a pre-test If person scored 3, recode to 50 2-Second phase; If person scored 4, recode to 75 This phase Included analysis of the If person scored 5, recode to 100 pretest findings and identification of Scoring system of knowledge and mothers' knowledge and practice toward practice . All knowledge variables were cerebral palsy issues then cerebral palsy weighted according to the items educational program was designed. included in each question. A question A Guide booklet:- that implies a 5 items answer have a The booklet was designed by the score of 5 and another that implies 4 researcher using simple Arabic items answer have a score of 4 and so languages and different illustrated on and each item has answer with pictures in order to facilitate subjects unknown that implies 0. understanding. - The mothers' total score was classified 3-Third Phase ;( Planning as the following &Implementation); - Satisfactory > 50% Based on the results from the - Unsatisfactory < 50% interviewing questionnaire and the

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quality of life questionnaire as well as - define concept of cerebral palsy. literature review, and educational - Identify causes of cerebral palsy. program regarding the cerebral palsy - Identify symptoms of cerebral palsy. issues were developed by the researcher. - Identify complications of cerebral - Implementation of educational palsy. program which entails 5 sessions. - Identify treatment of cerebral palsy. - The time of each session will be - List needs of child having cerebral verified 60 minutes, different palsy. teaching strategies e.g. (Lectures, - Identify care of cerebral palsy child. and group discussion) will be used. *General and specific objectives of the - The sessions were conducted at educational program will be designed physiotherapy unit of the previous after hospitals. 4-Fourth Phase; - Program implemented through a Follow up test will be conducted after 3 period of 10 month, taking into months using the same post-test tool. consideration the time allotted the III-: Administrative Design treatment visits which subjects An official approval was obtained to receiving guidance and instructions. conduct the study. The title and -Mother's knowledge and Practice will objectives of the study were illustrated be evaluated by the end of the as well as the main data item to be sessions as a post- test. covered, and the study was carried out General Objectives after gaining the necessary approval. By the end of the cerebral palsy IV- Statistical Design: educational program, mothers of The collected data were organized, children with cerebral palsy will be able categorized, tabulated and analyzed to have adequate and proper knowledge using electronic computer. Data was and practice toward cerebral palsy and presented in the table by using Mean, care for their children. Standard deviation, number and Specific Objectives:- percentage and other statistical tests By the end of the program, the mothers such paired t-test correlation coefficient will be able to: was calculated between socio-

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demographic data and total knowledge significant improvement in knowledge score and between total knowledge mean scores of mothers regarding to score. cerebral palsy items during immediate Results: post test and Three months after test as Table (1) showed that about 65% of compared to pre program mean scores P Children were hospitalized after birth. (<0.001). Regarding child‘s problems after birth Table (4) shows that there was highly 75% of them have hypoxia. And also significant improvement in practice 63.75% were having jaundice and mean scores of mothers about caring for 67.5% were having convulsion. children with cerebral palsy during Regarding to difficult in swallowing immediate post test and after three about 67% of them has difficult in months test as compared to pre program swallowing. And about 67.5% do not mean scores p (<0.001). speak, while 25% of them speak but Table (5) shows that there were with difficulty. And 72.5% having significant improvement in quality of hearing problems. Regarding the life of children with cerebral palsy mean movement of the Children about 30% of scores of mothers regarding to social them can't do any movement, while wellbeing and acceptance during 17.5% walk alone hardly. Also about immediate post test and after three 75% of them having dental problems. months test as compared to preprogram Table (2) revealed that about 62% of mean scores p (<0.05). Except in items - mothers reported that problems facing Get along with adults. The highest mean them due to child disability were score was related to be accepted by economical over loud, followed by family, followed by get along with their difficult transportations about 12%, brothers and sisters. while reported about 10% of them that Table (6) shows that there were highly had no enough rehabilitation service, significant improvement in quality of 7% of them reported un acceptance by life of for children with cerebral palsy society, and finally about 7% reported mean scores of mothers regarding family psychological problems. Physical wellbeing & Functioning Table (3) shows that there were highly domain, during immediate post test and

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after three months test as compared to Get along with mother that there were pre program mean scores p (<0.001). highly significant improvement during Except in items, -Communication with immediate post test and after three people they don‘t know well, and - months test as compared to pre program Ability to keep up academically with mean scores p (<0.001). their peers. The highest mean score was Table (9) shows that there were related to -communication with people significant improvement in quality of they know well followed by -The way life for children with cerebral palsy they use their arms and hands. mean scores of mothers regarding Pain Table (7) shows that there were and impact of disability dimension, significant improvement in quality of during immediate post test and after life for children with cerebral palsy three months test as compared to pre mean scores of mothers regarding program mean scores p (<0.05), except Participation & physical health domain, in items -Child concerned about having during immediate post test and after cerebral palsy, and -mothers' happy, three months test as compared to pre during immediate post test and after program mean scores p (<0.05).Except three months test as compared to pre in items -Ability to participate in social program mean scores. events outside of preschool or school, - Table (10) showed that there was Ability to participate in their positive highly statically significant community, -Physical health, and -The correlation between mothers' education, way they use their legs, that mean and total knowledge & total practice. score was p (<0.001). Also there was a positive significant Table (8) shows that there were no correlation between mothers, significant improvement in quality of occupation and total knowledge & total life for children with cerebral palsy practice. While there was no mean scores of mothers regarding significance correlation between Emotional& self esteem domain, during mothers' age and total knowledge &total immediate post test and after three practice. months test as compared to pre program Table (11) showed that there was no mean scores p ( <0.05).Except in items - positive significance correlation

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between total knowledge and total correlation between total quality of practice before, while immediately post, life and mother's education. And but after three months there were there was no significance positive highly significant correlation. correlation between total quality of Table (12) showed that there was life and mother's age, and Positive statically significant occupation. Table (1) : Percentage distribution of children according to their general health status and problems.

Number Items % =( 80) Child hospitalized after birth - Yes 52 65 - No 28 35 Child’s problems after birth - Hypoxia 60 75 - Preterm 16 20 - Low birth weight 2 2.5 - Trauma 2 2.5 History of jaundice -yes 51 63.75 -No 29 36.25 History of convulsion -yes 54 67.5 -No 26 32.5 Child talking -Yes 6 7.5 -No 54 67.5 - Speak with difficulty 20 25 Child hearing -yes 22 27.5 -No 58 72.5 Awareness of the child to mother -yes 58 72.5 -No 22 27.5 Difficult in swallowing -yes 54 67.5 -No 8 10

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- Simple difficult 18 22.5 Bladder Control -yes 15 18.75 -No 65 81.25 Dental problems -yes 60 75 -No 20 25 Appearance of congenital anomalies -yes 3 3.75 -No 77 77.25 movement ability -Sit with support 3 3.75 -Sit alone 24 30 - Stand with support 11 13.75 - Walk with support 4 5 Walk alone hardly - 14 17.5 Can't able to do any movement - 24 30 body position Hypotonia 47 58.75 Normal 33 41.25 Child irritability -yes 19 23.75 -No 61 76.25 Affected part in the body -Hemiplegia 15 18.75 -Diplgia 21 26.25 -Quadraplgia 44 55

Table (2): Percentage distribution of problems facing mothers due to child disability

Number Items % =( 80) Financial - Economical over loud 50 62.5

- Difficult transportations 10 12.5

- No enough rehabilitation services 8 10

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Social & psychological -Un acceptance by society & family isolation 6 7.5

-Family psychological problems 6 7.5

Table (3): Mean score of mothers' knowledge regarding Cerebral palsy before, immediately after, and after three months Knowledge Mean ±SD Mean ±SD t P After t P Item Immediately Before test Value Before three test value after months Cerebral palsy Definition .402 ±1.200 1. 900±.301 -11.65 <0.001 1.200± .402 1.862±.346 -10.35 <0.001 Causes .191± 1.037 1.750±.435 -13.99 <0.001 .191±1.037 .466±1.687 -12.11 <0.001 Clinical .284 ±1.087 1.850±.359 -14.09 <0.001 .284±1.087 1.800±.402 -13.209 <0.001 picture Treatment .219±1.050 1.750±.435 -13.57 <0.001 .219 ±1.050 1.737±.442 -13.183 <0.001 Complication .157±1.025 1.737±.442 -13.99 <0.001 .157 ±1.025 1.587 ±.495 -10.078 <0.001 Child's Needs .191± 1.037 1.825±.382 -15.10 <0.001 .191±1.037 .435± 1.750 -12.90 <0.001 Total .708± 6.437 1.056±10.812 -03.89 <0.001 .708±6.437 1.39±10.437 -21.94 <0.001

Table (4): Mean score of mothers' practice in daily activities regarding Cerebral palsy before, immediately after, and after three months.

Mean ±SD Mean ±SD t P t P Item Before Immediately Before After three test Value Test value after months Activities of Daily Living (practice) Eating 428±. 1.237 1.812±.392 -10.33 <0.001 428±. 1.237 1.750± .435 -7.701 <0.001 Drinking .392±1.187 1.850±.359 12.45- <0.001 .392±1.187 1.775± .420 -10.09 <0.001 Dressing .382±1.175 1.800±.402 11.47- <0.001 .382±1.175 1.737 ± .442 -9.602 <0.001 Bathing .346±1.137 1.787±.411 10.09- <0.001 .346±1.137 1.725± .449 8.616- <0.001 Teeth .301±1.100 1.862±.346 -15.92 <0.001 .301±1.100 1.825± .382 -13.604 <0.001 Hair .402±1.200 1.812±.392 11.17- <0.001 .402±1.200 1.762±.423 -9.188 <0.001 Walk& run .382±1.175 1.725±.499 -9.826 <0.001 .382±1.175 1.662±.475 -8.669 <0.001 Play .382±1.125 1.687±.466 10.07- <0.001 .382±1.125 1.637±.483 -8.689 <0.001 Sleep .455±1.287 1.925±.265 -11.787 <0.001 .455±1.287 1.887±.317 -9.903 <0.001 Communication .317±1.112 1.750±.785 -11.787 <0.001 .317±1.112 1.700±.461 10.09 <0.001 Toileting .317±1.162 .435±1.750 -10.078 <0.001 .317±1.162 1.687±.466 -9.344 <0.001 Total practice 1.597 2.84±12.90 1.597± 19.137 -15.170 <0.001 2.84±12.90 -7.68 <0.001 ±19.137

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Table (5): Mean of social wellbeing acceptance dimension of quality of life among subject before, immediately after, and after three months. Item Mean ±SD t P Mean ±SD t P Before Immediately test value Before After three test value after months Social wellbeing & acceptance 1-Get along with people, generally 12.25±59.6 65.0±12.33 4.307- <0.001 12.25±59.6 63.75±12.51 -2.973 <0.05

2-Get along with other children at preschool or 27.85 ±16.08 21.01±31.39 2.560- <0.05 27.85 ±16.08 20.075±30.098 -2.189 <0.05 school 3-Get along with other children out side preschool 7.55±52.50 53.44 ±8.66 -4.307 <0.05 7.55±52.50 52.187±7.11 .376 0.05< or school 4-Get along with adults 3.93±50.63 50.94±4.78 2.560 0.05< 3.93±50.63 50.93±4.79 1.650 0.05< 5-Get along with their 16.07 ± 17.91±28.41 -1.754 <0.001 50.63 ± 3.93 26.06±16.35 -.987 0.05< teachers and/or carers 27.84 6-Going out on trips with 12.44±66.88 12.2 ±67.50 -4.307 0.05< 12.44±66.88 65.31±12.25 1.686 <0.05 the family 7-Get along with their 33.95±71.39 33.1±72.31 10.463 0.05< 33.95±71.39 72.00±31.37 -.418 0.05< brothers and sisters 8- Get along with mother 12.56±86.87 12.54±88.43 -2.295 <0.05 12.56±86.87 12.57±87.81 -1.136 0.05< 9-Accepted by their family 20.27±80.62 81.87± 19.06 -2.039 <0.05 20.27±80.62 81.65±16.27 -.686 0.05< 10-Accepted by other children at preschool or 23.42±14.2 16.9±25.97 -1.000 <0.05 23.42±14.2 15.71±24.27 -.992 0.05< school 11-Accepted by other children outside of .000±50.00 50.31±2.79 -1.000 0.05< .000±50.00 50.31±2.79 -1.000 0.05< preschool or school 12- Accepted by adults 47.500±8.53 .000±50.00 2.62 <0.05 47.500±8.53 49.44±5.03 1.725 0.05< 13-Accepted by people in 50.00±9.74 6.62 ±51.9 2.53 <0.05 50.00±9.74 3.93±50.63 .630 0.05< general

Table (6): Mean of Physical wellbeing & Functioning dimension of quality of life among subject before, immediately after, and after three months. Mean ±SD t P Mean ±SD t P Item Before Immediately test value Before After three test value After months Physical wellbeing & Functioning 1- Ability to play on their own 17.31±58.44 15.75±60.3 -1.000 <0.05 17.31±58.44 58.75±58.75 -.276 0.05< 2-How to communication 17.3±62.83 13.31±67.81 -3.672 <0.001 17.3±62.83 66.25±13.83 -2.25 <0.05 with people they know well 3-How to communication with people they don‘t know 7.38±49.06 7.44±49.7 -1.423 0.05< 7.48±49.1 49.68±7.43 -1.42 0.05< well 4-The way other people 8.43 ±49.68 14.25±60.94 -8.040 <0.001 8.43±49.68 60.93±14.25 -8.040 <0.001 communicate with them 5- The way they sleep 11.1 ±53.44 12.7±57.2 -3.734 <0.001 11.1±53.44 55.31±13.007 -1.512 0.05 < 6-The way they use their arms 19.4 ±54.4 17.78±62.8 -6.344 <0.001 19.4±54.4 ±17.76 61.56 -5330 <0.001 7-The way they use their 19.4 ±54.4 18.2±62.8 -6.344 <0.001 19.4±54.4 ±18.20 61.56 -5.330 <0.001 hands 8-The way they use their legs 12.33±27.50 15.4±36.25 -5.905 <0.001 12.33±27.50 34.68±15.14 -5.062 <0.001 9-Ability to keep up 24.1 ±16.93 24.4±18.76 -.747 0.05< 24.1±16.93 ±22.92 17.825 -.351 0.05< academically with their peers 10-Opportunities in life 4.77±49.06 7.27±51.56 -2.963 <0.05 4.77±49.06 50.62±5.59 -2.295 <0.05 11-Ability to dress themselves 13.65±48.13 55.0±14.56 -4.666 <0.001 13.65±48.13 ±13.83 53.75 -3.818 <0.001 12-Ability to eat or drink 17.77±49.38 16.85±61.56 -7.602 <0.001 17.77±49.38 ±16.77 60.62 -6.553 <0.001 independently

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Mean ±SD t P Mean ±SD t P Item Before Immediately test value Before After three test value After months 13-Ability to use the toilet by 15.59±34.38 16.52±44.1 -6.425 <0.001 15.59±34.38 ±14.98 42.81 18.849 <0.001 themselves

Table (7): Mean of Participation & physical health dimension of quality of life among subject before, immediately after, and after three months. 0 Mean ±SD t P Mean ±SD t P Item Before Immediately test value Before After three test value after months Participation & physical health 1-Ability to play with 18.44±56.25 16.68±57.81 -2.295 <0.05 18.44±56.25 ±16.38 56.87 -.705 0.05< friends? 2-Ability to participate at 25.5±14.51 27.34±17.6 -2.433 <0.05 25.5±14.51 16.33±25.14 -2.433 <0.05 preschool or school 3-Ability to participate in 16.96±57.2 16.3±58.13 -1.754 <0.05 16.96±57.2 57.81±15.70 -.532 <0.05 recreational activities 4-Ability to participate in 13.31±32.2 13.25±33.75 -1.921 <0.05 13.31±32.2 32.81±12.94 -.705 0.05< sporting activities 5-Ability to participate in social events outside of 11.32±45.31 16.2±59.7 -8.138 <0.001 11.32±45.31 58.43±15.88 -7.626 <0.001 preschool or school 6-Ability to participate in 10.1±45.94 10.52±50.00 -3.915 <0.001 10.1±45.94 49.06±10.097 -3.031 <0.05 their community 7-Physical health 12.44±45.63 14.22±51.9 -5.132 <0.001 12.44±45.63 50.93±13.45 -3.65 <0.001 8-The way they get around 5.48±48.75 8.87±50.62 -2.531 <0.05 5.48±48.75 49.37±6.86 -1.423 0.05< 9-Ability to do the things 15.9 ±31.9 15.65±34.7 -3.165 <0.05 15.9±31.9 33.12±16.77 -1.070 0.05< they want to do 10-Ability to keep up physically with their peers 14.96±34.42 13.18±37.18 -2.394 <0.05 14.96±34.42 35.93±14.80 -1.129 0.05<

Table (8) : Mean of Emotional wellbeing& self esteem dimension of quality of life among subject before, immediately after, and after three months. Mean ±SD t P Mean ±SD t P Item Before Immediately test value Before After three test value after months Emotional wellbeing& self esteem 1-The way they look 8.32±46.88 6.77±51.25 -3.77 <0.001 8.32±46.88 49.68±6.28 -2.583 <0.05 2-Their life in general 7.73±48.13 8.32±53.12 -3.19 <0.001 7.73±48.13 51.56±6.08 -2.18 <0.05 3-The way they see themselves 6.77±48.75 10.77±51.56 -3.165 <0.05 6.77±48.75 50.31±9.32 -2.295 <0.05 4- The way they see their future 6.77±48.75 10.09±50.93 -2.752 <0.05 6.77±48.75 50.00±8.89 -2.039 <0.05 5-How happy is your child .000±50.00 9.82±54.00 - 4.270 <0.001 .000±50.00 52.81±7.95 - 3.16 <0.001 6-Child‘s access to treatment 33.12±11.78 12.18±34.37 1.423 <0.05 33.12±11.78 11.9±33.75 .575 0.05< 7-Child‘s access to therapy 28.43±11.76 13.01±30.31 -1.42 0.05< 28.43±11.76 12.64±29.69 1.423 0.05< 8-Child‘s access to specialized 36.±12.54 12.57±37.81 2.039 <0.05 36.±12.54 37.50±12.57 1.348 0.05< medical or surgical care 9-Ability to get advice from a 49.37±6.86 5.59±50.63 2.039 <0.05 49.37±6.86 .000±50.00 2.1518 0.05< pediatrician 10-Child‘s access to extra help with learning at preschool or 3.92±49.37 4.77±50.93 -1.921 <0.05 3.92±49.37 2.79±50.31 -1.348 0.05< school 11-The special equipment they have 49.43±14.66 15.94±51.00 2.441 <0.05 49.43±14.66 15.1±51.56 2.295 <0.05 at home 12-The special equipment they 26.50±15.14 26.74±15.75 -1.000 0.05< 26.50±15.14 15.59±25.59 .016 0.05<

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Mean ±SD t P Mean ±SD t P Item Before Immediately test value Before After three test value after months have at their school 13-The special equipment that is 10.52±52.812 12.09±55.93 -3.359 <0.001 10.52±52.812 54.68±11.31 -1.929 <0.05 available in the community 14-Access to respite care 5.5±51.25 10.29±55.31 -3.915 <0.001 5.5±51.25 53.75±8.98 -2621 <0.05 15-The amount of respite care 6.6±51.87 9.819±54.6 -3.165 <0.05 6.6±51.87 53.43±8.66 -3.165 <0.05 you receive? 16-How easy it is to get respite 5.5±51.25 8.98±53.75 -2.963 <0.05 5.5±51.25 52.50±7.547 -1.423 0.05< 17-Child‘s access to community 7.95±52.81 10.705±55.937 -3.359 <0.05 7.95±52.81 54.37±9.55 -1.686 <0.05 services and facilities

Table (9): Mean of Pain and impact of disability dimension of quality of life among subject before, immediately after, and after three months. Mean ±SD t P Mean ±SD t P Item Before Immediately test value Before After three value after months test Pain and impact of disability 1- Child bothered by hospital visits 49.53±58.75 46.11±70.00 -3.165 <0.05 49.53±58.75 65.00±47.99 -2.295 <0.05 2- Child bothered when he miss 28.55±10.10 24.17±6.98 1.219 0.05< 28.55±10.10 10.72±29.94 -.199 0.05< school for health reasons 3-Child bothered by being handled 35.93±15.00 28.43±8.75 2.295 <0.05 35.93±15.00 13.75±34.65 1.000 0.05< by other people 4-Child worries about who will 15.78±6.56 13.76±5.62 1.754 <0.05 15.78±6.56 6.25±14.06 .445 <0.05 take care of them in the future 4-Child concerned about having 41.16±21.25 35.93±15.00 2.295 <0.05 41.16±21.25 12.50±33.28 2.158 0.05< cerebral palsy 6-Pain does your child have 41.17±21.25 35.93±15.00 2.295 <0.05 41.17±21.25 18.75±39.27 1.000 0.05< 7-Child feeling about the amount 42.82±23.75 38.23±17.50 2.295 <0.05 42.82±23.75 18.75±39.27 1.270 0.05< of pain they have 8-Discomfort do You experience 49.01±61.25 50.17±53.75 2.531 <0.05 49.01±61.25 50.00±50.31 3.165 <0.05 9-Mothers physical health 16.9±62.50 16.80±64.06 -2.295 <0.05 16.9±62.50 63.12±15.89 -.815 0.05< 10-Mothers work situation 11.52±45.00 8.98±46.25 -2.039 <0.05 11.52±45.00 45.31±9.81 -.376 0.05< 11- Family‘s financial situation 11.8±18.44 11.09±20.62 -2.752 <0.05 11.8±18.44 19.37±10.50 -1.000 0.05< 12-Mothers'happy 13.63±53.43 12.09±59.06 -4.789 <0.001 13.63±53.43 58.43±11.89 -3.667 <0.001 13-Mothers'confident that can 30.18±90.00 19.11±96.25 -2.295 <0.05 30.18±90.00 26.50±92.50 -1.000 0.05< report how child feels

Table (10): correlation between total knowledge and total practice regarding mothers' characteristics.

Variable Total Knowledge Total practice Pre program Post program Pre program Post program R p r P R p r P Age .038 0.05< .058 0.05< .220 0.05< .124 0.05< .255* <0.00 .688* .319* <0.00 <0.00 <0.00 Education .646** 1 * 1 1 * 1 .115 0.05 > .104 .319* 0.05 > Occupation .018 0.05< 0.05<

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Table (11): Correlation between total knowledge & total practice before, immediately post, and after three months.

Variable Pre program Post program After Three Months R p R P r P

Total knowledge & .068 0.05< .809** <0.001 .766** <0.001 Total practice

Table (12): Correlation between total quality of life &mother's age, education, occupation, total knowledge, and total practice.

Total quality of life R P Age .165 0.05<

Education .243* <0.05

Occupation .041 0.05<

Discussion Cerebral palsy describes a group of forever. This does not mean that their permanent disorders of the development lives will not be full, rich and of movement and posture, causing rewarding; it simply means that they activity limitation that attributed to non may be different to what they imagined. progressive disturbances that occurred There may be some challenges to be in the developing fetal or infant brain. overcome, yet there will also be the The motor disorders of cerebral palsy same exciting, happy times that all are often accompanied by disturbances families experience. The Centre for of sensation, perception, cognition, Cerebral Palsy we aim to help parents communication, and behaviors, by and families meet the challenges that epilepsy, and by secondary cerebral palsy may pose head on The musculoskeletal problems Anonymus, Center For Cerebral palsy,( 2010) . (2007). To address these challenges, we When a child is diagnosed with cerebral developed the educational program to palsy, the family's lives are changed help children and their mothers to cope

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with cerebral palsy and find way to hearing loss. Meanwhile, the present improve their quality of life. The study revealed that, impairments in program includes practical and communication especially language, information on all aspects of living with which more than half of them having cerebral palsy as well as educational impairment in communication this is activities tailored to meet each child and congruent with Avery & First, (1997) mothers needs. and Hussien, (2002). Who found that Discussion of the studied sample will be expressive and receptive speech presented in the following regarding problems are common in children with types of motor defects in the studied cerebral palsy. children, table (1) it was observed that The present study revealed that more the most common motor defect is than half of children 67.5% having quadriplegia reported about more half history of convulsion table (1). This is of them 55%. This finding is in in agreement with Abdel Monem, accordance with Galijard, (1997), & (2004), Krigger, (2006), and Ahmed, Elsyed, (2003). Who found that half of (2009) who emphasized that one half of cerebral palsy children had spastic children with cerebral palsy quadriplegia. In the present study more demonstrate seizure activity. than half of children have hypotonia, Dental caries is a common health this is in agreement with Ford, et al, problem of cerebral children as found in (1996).who found that more than two this study about 75% of them having third of children with cerebral palsy dental problems; this could be due to suffer from abnormal posture. poor dental hygiene or mothers' Hearing loss is a problem more than ignorance about the importance of two third of cerebral palsy children dental care for their children. Inga et al, 72.5% in the present study having (2001). Found that more than 90% of hearing loss. This result is emphasized children with cerebral palsy have oral by Elsyed, (2003) and Mahmoud, motor dysfunction. The severity of oral (2004). And disagreed with Gersh, dysfunction makes it difficult for some (1997) and Afifi, (2006), who found cerebral palsied children to be that a small percentage of children have adequately nourished. Abnormal

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neuromuscular coordination of the only small percent of children acquire tongue, lips, and cheeks - which leads to CP after birth from head trauma, this is poor dental alignment and periodontal in agreement with this study that about problems. And the incidence of dental 2.5% percent of children have trauma, caries is increased among cerebral palsy this disagree with Ball & Bindler, children result from improper dental (2006) who mentioned that head trauma hygiene, congenital defects, high is consider as a major source of brain carbohydrate intake and retention, injury, and subsequent motor dietary imbalance with poor nutritional dysfunction. intake, inadequate fluoride, and Jaundice is reported as other risk factors difficulty in mouth closure and of CP children Ball & Bindler, (2006) drooling. mentioned that hyperbilirubinemia Regarding the risk factors of cerebral predisposed the child to a higher risk palsy, table (1) the result emphasized factor of CP, and also Price & Gwin, that more than two third of mothers (2008) who added that untreated high have natal problem which hypoxia more level of bilirubin can cause CP. In common problem. Preterm is consider addition to Pillitteri, (2007) who the second risk factor about 20% of mentioned that neonatal them were preterm is at congruent with hyperbilirubinemia was consider a Mohamed, (2008) and Ahmed, (2009) cause of CP, but now it is rarely causing who mentioned that a preterm birth CP because of improved management of child is at risk for cerebral palsy, while hyperbilirubinemia. London et al, (2007) reported that very Urinary incontinence is a problem premature child is also at risk for CP children with CP, the present study because of his or her immature CNS, reported that more than 80% of them compared with Moustafa, (2002) he have problem with bladder control this added that around forty percent of agreement with fouad, (2003), El syed, children with CP have been prematurely (2003) and Ahmed, (2009) who born. reported that poor bladder control was Head trauma is other risk factor of CP, the comments urinary problem of CP Hitchcock et al (2003) reported that children and added that the problem of

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bladder control occurred in sixty two of mothers for their children with percent of cerebral palsy children are cerebral palsy, which is supported by often the result of neurological fouad (2003) & Ahmed (2009) who problems. found that most of mothers had From this study it is clear that, about unsatisfactory practice in relation to two third of mothers had a lack of teeth care of their children. The practice regarding feeding technique of investigator explains that may be due to their children with CP, table ( 3 ), as unawareness of mothers about the they did not follow the correct feeding importance of teeth brushing for their technique during child feeding, such as children and to the habits of brushing suitable child position, using special their teeth after each meal. feeding equipment, a small piece of These results go in the same with hard food at one time, supporting jaw Mohamed (2004) & Ahmed (2009) during feeding, and making pressure who found in his study that oral hygiene down these results are consistence with measures were not practiced by most of Mohamed (2004) who reported that mothers for their children with CP, and there is considerable lack of mothers added that could be due to ignorance of practice regarding feeding technique of oral hygiene. And also Afifi (2006) their children with CP. added that the incidence of dental caries Hinchciffe (2003) added that if feeding has increased among CP children as a and drinking problems of the children result of improper oral hygiene care or with CP are managed poorly, they may ignorance of mothers about the worsen over time and cause harmful and importance of teeth care. serious health problems, and reported Concerning the mothers practice in that appropriate handling of children at relation to personal hygiene (child meal times and careful management of bathing, dressing, and hair care) the food and feeding techniques can present study indicated that more than minimize these careful and some times two third of mothers had considerable to prevent them from occurring. lack of their practices regarding The present study clarified that teeth personal hygiene care for their children care was not practiced by the majority with CP. From the investigator point of

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view, the source of information for the child position, regular change of majority of mothers regarding personal position during sleeping, and sleep and hygiene care of their children was from wake up at stable time to prevent noise their relatives who may have and help child to sleep) from the incomplete correct or incorrect investigator point of view this may be information regarding personal hygiene due to unawareness of mothers about of their child. This result is supported the measures that should be adapted for by Afifi, (2006) & Ahmed, (2009) who their children to help them to sleep or reported that the majority of mothers they didn't receive any teaching had deficits in how to deal with the program regarding the complication that most aspect of their child care. occur for their children such as risk of The current study revealed that the bed sores if they didn't practice these majority of mothers didn't train their CP measures during child sleep especially children about toilet training. This could with children have quadriplegia, this be due to unawareness of mothers about result was supported by Ahmed, the importance of toilet training, and (2009). how to prevent or manage bladder and Pediatric nurse should professionally bowel problems such as urinary train for caring of cerebral palsy incontinence and constipation, that may children. On other hand, improving be associated with cerebral palsy, which mothers' knowledge regarding cerebral is in consistence with Falvo, (2005) palsy children. So, it is the who reported that bladder and bowel responsibility of the pediatric nurse as problems can manage through toilet health educator to assess the self care training program that help child to requisites of the regarding care for their establish a regular evacuation schedule, cerebral palsy children. The current this was in agreement with Ahmed, study show that the majority of mothers (2009). had deficit in most aspect of item of The present study revealed that more care were neglected, after than half of mothers have considerable implementation there is improved in lack of practice regarding child sleep mothers' practice as the majority of (suitable place or special bed, suitable them had been scored satisfactory. This

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may be due to the facts that the better practice among educated mothers researcher taught each mother compared to among illiterate. After individually about daily care, let them program still there was a significant demonstrate most of care techniques in difference between mothers' practice front of the researcher and their level of education which Regarding relationship between emphasized the effect of mothers' level mothers' knowledge and their level of of education in their total practice. Also education, it was noticed that before the this study proved that there was no program there was significant difference effect on mothers job and total level of between illiterate and educated mothers' their practice whenever before or after while this difference disappeared after program implementation which proved program implementation. This result that Egyptian mothers taken their ideal proved that all mothers were interested role in all different situation although of in how to gain any knowledge that any challenges. proves their caring of their cerebral As regards dependence of children in palsy children. Also, illiterate mothers daily living activities, this study results were asking help from relative as son, showed that, the majority of them are husband, and sister to help them to completely dependent on mothers in understand every thing in handout. daily life activities. This result indicated The present study found that there was that mothers need assistance from significant difference between mothers' family members, and community knowledge and their occupation before services to provide care for their program. While after program there was children, and to teach them how to be no statically significance difference independent in care. Tourk,(2000) between mothers knowledge and their stated that, children with disabilities occupation which emphasizes the high need ample opportunities to solve effect of the program that near the level problems for themselves and to develop of knowledge between employee and a greater sense of independence rather housewives mothers. than dependence and a wide variety of On investigating mothers' practice and movement activities designed to break their level of education, their was a

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down the artificial limitation are that financial burden on the family expense. often build up around their disabilities. The current study, table (11) revealed The cerebral palsy affected children that there was positive highly have to get merciful support from the significant correlation between mothers' family members as well as from the total knowledge and total practice score teachers to achieve the optimum after program. These results mean that education to their potential and other the mothers' knowledge had an effect on skills. This helps them to achieve their their practice, as when mothers have a evergreen goal for the real independent satisfactory knowledge level regarding life without any support from anybody their children condition; this will else for his daily needs (www.Cerebral improve their practice regarding their PalsyTreating.com, 2010). daily care of their children with CP. Regarding problems facing mothers This explanation goes in the same line during caring of their children with with Ahmed, (2009) & Ali, (2008) who cerebral palsy, table ( 2), the present mentioned that when mothers provided study revealed that nearly more than with basic knowledge about children half of mothers' complains from condition, developmental prognosis and economical over loud, followed by various treatment approaches, will assist difficult transportations were a barrier them in practicing new and healthy for mothers in providing child care. behaviors. In addition to Afifi, (2006) Also no enough rehabilitation services who insist on the necessity of in the hospitals that they attend for availability of knowledge regarding receiving child care such as cerebral palsy, which help in managing occupational therapy. This result is CP children conditions. congruent with Afifi, (2006) who that The results showed that there were more than two third of mothers are positive highly significant correlation unsatisfied from follow up services due between the educational status of to many barrier such as insufficient mothers with total knowledge and total care, expenses and transportation of the practice scores after program, table (10) child. Price & Gwin(2008) added that this result proved that all mothers were the long course of cerebral palsy is a interested in how to gain any knowledge

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that proves their caring of their cerebral needs as well as influencing legislation palsy children. Also, illiterate mothers and policy to ensure improved access to were asking help from relative as son, services and local communities (Parkes husband, and sister to help them to et al 2010). understand everything in handout. The present study revealed that there The parent-reported quality of life for was significant improvement regarding children with cerebral palsy is participation and physical health item of associated strongly with impairment. quality of life after program, this may However, depending on the areas of life, due to care providing to children which the most severely impaired children (in enhance child health. These findings terms of motor functioning or were supported by Parkes et al (2010) intellectual ability) do not always have who mentioned that children with the poorest quality of; in the moods and cerebral palsy and severe co- emotions, self-perception, social impairments were significantly less acceptance, and school environment likely to experience higher levels of domains, less severely impaired participation in most areas of everyday children were more likely to have poor life when compared to children with quality of life (Arnaud et al., 2008). cerebral palsy and no severe co- Regarding physical wellbeing item of impairments. quality of life there were highly Health and social outcomes in children significant improvements in items who have cerebral palsy (CP) depend on related to child using their arm, legs, several factors, including the severity of way to sleep, and ability to use toileting the CP, medical interventions, and the after program compared with before child's environment. program. The children with mild cerebral palsy Participation is an important health had greater effects on their psychosocial outcome for children with cerebral well-being than would be predicted by palsy and should be incorporated in their functional disability. Functional routine clinical practice. Professionals measures were good at predicting the have a role to play both at the level of functional well-being but were weak at addressing individual child and family predicting the psychosocial arm of well-

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being (Pirpiris et al, 2006). self - concept compared with typically Pain is a frequent health problem and developing peers. has severe consequences both on the These results suggest that children with cerebral palsied children's QOL and CP do not have a lower Self-worth even their family (Tuzun, Guven, & Ekerl, though they may feel less competent in 2010). certain aspects of their self-concept. There was a significant negative effect Clinicians need to account for this when of pain on the QOL of subjects. The deciding on management strategies and pain also negatively affected parent's may need to educate parents and health personal time and caused limitations in professionals that a lower self-concept family activities (Tuzun, Guven, & may not necessarily be associated with a Eker, 2010). Pain was associated with diagnosis of CP (Shields et al., 2007). poor quality of life in the physical and Regarding mothers' happy, work psychological well-being and self- situation and financial situation as perception domains. Parents with higher aspect of social wellbeing domain of levels of stress were more likely to quality of life the present study revealed report poor quality of life in all that mothers felt severe sadness, and domains, which suggests that factors they indicated that after having a other than the severity of the child's disabled child, their social life, working impairment may influence the way in life, and family relationships were all which parents report quality of life affected. Families also have financial Arnaud et al., (2008). problems this is in agreement with Sen The present study that there was & Yurtsever (2007). So parents with a significant improvement regarding disabled child need support from emotional wellbeing and self-esteem professionals. Nurses have a vital role item of quality of life, this result in providing support for these families supported with Soyupek et al, (2010), Conclusion and disagreed with Russo et al, (2008) In the light of the study findings, it was who mentioned that children with CP concluded that, the mothers' knowledge experience reduced quality of life and and practice related to care provided to their children with CP was deficient as

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none of them had a pre – program booklets about cerebral palsy satisfactory knowledge or adequate which contain an action plan practice. The program succeeds in suitable for each child nature in improving the mothers' knowledge and order to facilitate improving their practice regarding CP. After three knowledge as they considered the months of implementation the program main member in children's care the mothers' knowledge and practice plan was decline but still higher than before - Mothers' wrong practice about the program regarding all items about caring of their children related to knowledge and practice. regularity of follow - up in As regards quality of life of children, by physiotherapy unit for the child comparing the result in the pre- and condition should be corrected post- program implementation, the through health teaching. result showed slightly improvement in - Nurses should play a key role in all dimensions of the quality of life; the health teaching and physical, psychological, social, and counseling mothers about care of

emotional post - program than their children with CP. pre -program. - Nurses in the physiotherapy clinic, Recommendation out patient clinic, and pediatrics The following are the main department should trained well recommendation: and supplied with information - Giving mother's handouts containing and training CP program as they the teaching program and use of are the main source of the illustrative materials help them to gain mothers' information during knowledge better. providing the child by needed - Teaching mothers different aspects of care. caring of their children having cerebral References palsy to improve their quality of life References

- Provide mothers of children with 1. Abdel Momen, A. Relation of cerebral palsy by updated Essential Fatty acids to Motor and pamphlets, posters and Arabic Cognitive abilities of Children

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suffering from Cerebral Palsy; Role Faculty of nursing, Alexandria of supplementation program, PhD University2008; 28. thesis, in childhood studies( Child 6-Anonymus. Definition and health & nutrition), Medical Studies classification of cerebral palsy. Department, Faculty of Medicine, Developmental medicine and child Ain Shams University. neurology 2007;49 (8): 8. 2004;11,12,29,30. 7-Arnaud, C., White-Koning, M., 2. Afifi, A. Needs and problems of Michelsen, S.I., Parkes, J., Parkinson, parents caring for their Cerebral K., Thyen, U., Beckung, E., Dickinson, Palsy Child, Master thesis, Faculty H. O., Fauconnier, J., Marcelli, M., of Nursing, Community health McManus, V.,& Colver, A Parent- nursing. Ain Shams University. reported quality of life of children 2006;1-7, 43, 63, 64,112-130. with cerebral palsy in Europe. 3. A Foundation of Hope for National Institute of Health and Children with Cerebral Palsy. ( Medical Research. 2008 March: 5th Annual cerebral Palsy 8-Avery, M. E., & First, R. Cerebral Conference. Eric P. Newman Palsy. In: Pediatric medicine. 2nd ed. Education Center, Washington Baltmore MD., Williams. 1997;807- University Medical Center, St. 810, 1450-1451. Louis. Washington University in 9-Ball,J. W. & Bindler, R.C.Child St. Louis.2009 health Nursing parenting with 4. Ahmed, S. A Home Care offered children& families. Pearson& prentice by Family Caregivers to Preschool Hall, New Jersey, United state. Children, suffering from 2006;1337, 1339, 1343. Hemiplegic Cerebral Palsy. Master 10-Elsayed, S., F. An Educational thesis. Cimmunity Health Nursing. Program for Caregivers of Children Faculty of Nursing. Cairo with Cerebral Palsy. Doctorate thesis. University. 2009; 95-104. Faculty of Nursing, Pediatric Nursing, 5. Ali, N. Needs of physically Ain Shams University2003; 115-120. handicapped adults in vocational 11-Favlo, D. Medical & Psychosocial rehabilitation center. Master thesis, Aspects on Chronic illness and

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Woodbine House, Inc, Bethesda, MD, Communications and Public Liaison. 800-843.2006 National Institutes of Health. Bethesda, 25-Mettleman, D. Infant Brain Injuries MD 20892.2010 and Cerebral Palsy. At 31-Parkes, J., McCullough, N., INJURYBOARD. 2009 Madden, A. Feb 24. To what extent do 26-Michael, H. L., Peter, L. R., children with cerebral palsy participate Dianne, J. R., & Robert, J. P.): in everyday life situations? Nursing- Developmental Medicine & Child Midwifery Research Unit, School of Neurology. Phiadelphia.2007;49: 225- Nursing & Midwifery, Queen's 231. University Belfast, Belfast, UK.2010 27-Mohamed, K. Assessment of 32-Pillitteri, A.: Maternal & Child Growth Pattern in Children with health care of the child health care and Cerebral Palsy using body Composition child bearing and child Rearing Analysis and Anthropometry. Master families. 5th ed. Lippincott, Williams & thesis. Faculty of Medicine. Ain Shams Wilkings,Philadelphia, London. 2007; University. 2008;13-19,27,32. 888, 894, 1548-1557. 28-Mohammed M.Nutritional 33-Pirpiris, M., Gates, P.E., Rehabilitation for Infants and Children McCarthy, J.J., D'Astous, J., with Cerebral Palsy having Feeding Tylkowksi, C., Sanders, J.O., Dorey, Difficulties. PhD thesis. Pediatric F.J., Ostendorff, S., Robles, G., nursing. Faculty of Nursing. Ain Shams Caron, C., & Otsuka, N.Y: Function University.2004; 118-126, 130. and well-being in ambulatory children 29-Moustafa, G. Community- Based with cerebral palsy. National Center for Rehabilitation (CBR), its impact on Biotechnology Information, U.S. Nahia Village. Giza governorate, Phd, National Library of Medicine 8600 Faculty of nursing, Community Health Rockville Pike, Bethesda MD, 20894 Nursing. Cairo Universaity.2002; 15, USA2006 17. 34-Price, D. & Gwin, J. : Pediatric 30-National Institute of Neurological Nursing an Introductory text. 10th ed. Disorders and Stroke. Cerebral Palsy: Sanders, Elsevier 2008;206-211. Hope Through Research. Office of 35-Russo, R.N., Goodwin, E.J.,

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Miller, M.D.Haan, E.A., Connell, T.M, USA2007 & Crotty, M: Self-esteem, self-concept, 39-Sen, E., & Yurtsever, S. and quality of life in children with Difficulties experienced by families

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University Rehabilitation Studies Unit, MersinUniversity School of Medicine University of Adelaide, Adelaide, South Research and Administration Hospital,

Australia.2008 Mersin, Turkey.2008; 12(4):238-52. 36-Shields, N., Loy, Y., Murdoch, A., 40- Taylor, F. National Institute of Taylor, N.F., Dodd, K.J.: Self-concept Neurological Disorders and Stroke of children with cerebral palsy (U.S.), Office of Science and Health compared with that of children without Reports. Cerebral palsy: hope through impairment. School of Physiotherapy, research. Bethesda, Md.:at: Faculty of Health Sciences, La Trobe http://www.ninds.nih.gov/disorders/cer University, Victoria, Australia. ebral_palsy/detail_cerebral_palsy.htm2

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37-Singapore,L.L.Cerebral palsy. 41-Thames Valley Children's Centre.

Available at Cerebral Palsy– htt\\www.Atricesphere.com\Article\Abo CausesandPrevalence".http://www.tvcc ut- cerebral palsy. Statistics by country .on.ca/gateway.php?id=167&cid 2007. for cerebral palsy.2008 42-The Center for Cerebral Palsy. 38- Soyupek, F., Aktepe, E., Savas, S., (2010): Cerebral Palsy. 106 Bradford & Askin, A. Do the self-concept and Street, Coolbinia WA 6050 post PO

quality of life decrease in CP patients? Box 61, Mount Lawley WA 6929 .2010 Focussing on the predictors of self- 43- Thorogood, C. Cerebral palsy. concept and quality of life. Department eMedicine specialties physical of Physical Medicine and Medicine and Rehabilitation. At www. Rehabilitation, Suleyman Demirel eMmedicine.com 2009 University, Isparta, Turkey. National 44-Tourk, H. Comparative study of Center for Biotechnology Information, physical care of mentally and U.S. National Library of Medicine. physically disabled and normal school- Rockville Pike, Bethesda MD, 20894 age children in Zagazig city.

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Unpublished Master Thesis. Faculty of Nursing. Cairo University. 2000 45-Tuzun,E.H., Guven,D.K., & Eker,L. Pain prevalence and its impact on the quality of life in a sample of Turkish children with cerebral palsy. Department of Physical Therapy and Rehabilitation, Faculty of Health Sciences, Başkent University 2010

Baglica, Ankara, Turkey.2005 46-United Cerebral Palsy. Press room: cerebral palsy- facts & figures. Accessed online,at:http://www.ucp.org/ucp_gener aldoc.cfm/1/9/37/37-37/447.2005 47-US Census Bureau, Population Estimates.: Statistics by Country for Cerebral Palsy. Incidence (annual) of

Cerebral Palsy. 2010 48-Waters, E., Davis, E., Boyd, R., Reddihough, D., Mackinnon, A., Graham, H.K., Lo, S. K., Wolfe, R., Stevenson, R., Bjornson, K., Blair, E., & Ravens-Sieberer, U. Cerebral Palsy Quality of Life Questionnaire for Children (CP QOL-Child) Manual. Melbourne: Deakin University.2006 49-WWW.Cerebral Palsy Treating. com

.Cerebral palsy.2010

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Knowledge of preparatory students working in Agriculture about work hazards Omima R. Rehap : Assistant lecturer of Community Health Nursing Faculty of Nursing , Tanta University Bassima E. Gowayed, Professor of Community Health Nursing Faculty of Nursing, Tanta University Ikbal F. El-shafie Professor of Community Health Nursing, Faculty of Nursing , Tanta University Amaal M. El-Zeftawy: Lecturer of Community Health nursing Faculty of Nursing , Tanta University

Abstract:- Child labor is alarmingly prevalent in Egypt .Child agricultural workers are at a greater risk than adult workers. Furthermore, occupational hazards and work conditions may have permanent effects on the growth and development of children. Several public health strategic interventions are required for effective prevention and control of child labor in agriculture. Aim of the study: to assess the knowledge of preparatory school students working in agriculture about work hazards. Material and Methods: this study was conducted in five preparatory governmental schools (including both sexes) at five villages affiliated to Kafer ELzayat city Gharbia Governorate, Egypt as a representative of rural environment. Tool: A structured questionnaire sheet was developed and used by the researcher; it included data regarding socio-demographic data related to the students, past working experience of the child, previous complaints, history of hazards, safety and protective measures and knowledge of students about agriculture work hazards. Results: most of the studied students' source of information was from their parents and family and the majority of studied students had poor total knowledge score regarding the agriculture hazards.

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Conclusion and recommendations: The present study revealed that, the majority of studied students identified the elements of different agriculture hazards but had lack of knowledge regarding its health effects. It is recommended that the working children should receive full information and training from their employers about occupational hazards related to agricultural work. Such training should be conducted regularly and be understandable by children. Key words: Child labor, Egypt, knowledge

Introduction Children are the most important age opportunity to attend school, obligating group in all societies. Health status and them to leave school prematurely or health behavior of later life are laid requiring them to attempt to combine down at this stage. No one can deny school attendance with executively long their rights to grow and develop in a and heavy work (3,4).There are many healthy and normal manner, to benefit factors responsible for this problem. from social security including adequate These factors are mainly poverty, lack nutrition, adequate housing, recreation of education, unemployment, and and medical services, as well as to exploitation by lazy parents. Others receive education and be protected factors include school dropout, against all forms of neglect and maladjustment in the family, broken exploitation (1,2). family, death of parents and child of Child labor is a global problem that illegitimate pregnancy ( 5). appears to affect a major proportion of In Egypt the reasons given by child children in the developing world. The workers themselves in studies were International Labor Organization educational failure and a desire to learn defines child labor as work that deprives a profession for boys, where girls cited children of their childhood, their economic factors like a wish to earn potential and their dignity. It is also their own money or contribute to family harmful to The physical and mental income. Another reason is that parents development and interferes with their wish to keep their children occupied and schooling by depriving them from the off streets. Furthermore, many families

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think that sending their children to work have received little attention compared is acceptable. They view child labor as to child labor in manufacturing for child work only, not hazardous and as a export or children involved in way to learn a skill (6,7). commercial sexual exploitation (9). The International Labor Organization in Child agricultural workers may suffer 2002 estimated that nearly 250 million from considerable physical, biological, children were engaged in child labor chemical, and psychological hazards. around the world. The vast majority of Child agricultural workers frequently them 70 % were working in agriculture. work for long hours in scorching heat, Of the four most dangerous industries haul heavy loads of product, and (agriculture fishing, mining, exposed to toxic pesticides and suffer construction) agriculture has the highest high rates of injury from sharp knives morbidity and mortality rate (5). In Egypt and others dangers tools. Their work is it is difficult to gather accurate statistic harsh and violates their rights (10,11). The on child labor. In 2002 it was estimated employment of young children is a that over 2 million children were serious problem particularly in rural engaged in child labor from as young as areas where it is not unusual for the age of 4 years who work as street children to start work at the age of 5 to venders, domestic workers, agricultural 6 years. Finally child labor is used to laborers and factory workers. About 73 refer to anyone who is a child (under the % of the working children in Egypt are age of 18) who is working for payment employed in agriculture (8). and sometimes unpaid work (12) .Egypt According to the International Labor National low set appropriate limits on Organization's report in 2002 on child both the ages and hours at which labor, the number of children working children can work, and if enforced in agriculture is nearly ten times that of would help to protect children from children involved in factory work such abusive labor conditions (13). as garment manufacturing, carpet In Egypt, children represent a very large weaving and others industries. Yet, group of the Egyptian population despite the difficult nature of their pyramid. The population of Egypt, work, children working in agriculture (2008), is estimated to be 80 million

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inhabitants. The distribution of light industry (16-18,). Government population by age indicates that those studies in Egypt reveal that the below the age of 15 years represent percentage of working children is about 37.5% of the total population. higher in rural than urban areas. Egypt has a history of child labor Agriculture considered one of the most problems. Poverty has driven many hazardous occupations and also young children younger than the minimum ages are more likely to work in working age of 14, to join the labor agriculture. According to Human Right force. At the same time, it was difficult Watch in 2001, over one million to gather accurate statistic of the Egyptian children between the ages of 7 number of child work in Egypt. The and 12 years are hired each year to work annual activity report on 2007 stated to aid in controlling cotton leaf worm that the number of working children in (14,19,20). Egypt is estimated to be between 1.3 to Children work in farms especially in the 3 million. They are accepting the lowest cotton and rice farms during harvest wages and the hard and inhuman season, exposed to deadly pesticides, as working condition. Child labor in Egypt their bodies easily absorb these are divided between different sectors dangerous chemicals. The children in with the agricultural sector representing the cotton fields work for about 5 to 7 the highest percentage about 78%, in pounds per day and their ages vary from industrial sector, about 14.9%, in 7 to 15 years. They don't enjoy legal commercial 6%, and in the service protections, social insurance or official sector 1.14% (14,15). supervision (14,21). Most of the child In Egypt (2005), approximately 9.5 workers in Egypt are employed in percent of boys and 3.7 percent of girl's seasonable work in cotton fields, during ages 5 to 14 were working. A large the summer holiday months. The proportion of working children are Minister of Agriculture fails to uphold found in agricultural sector, where the legal minimum age of 12 for children are hired each year for the seasonable training. Each year over one cotton harvest. Children are also found million children between the ages of working on construction sites and in seven and twelve are hired by Egypt's

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agriculture cooperatives to take part in 54 percent work only in the summer cotton pest management. They work vocation (25). eleven hours a day, including a one to The future of a community is in the two hour break, seven days a week, far wellbeing of its children, so it becomes in excess of limits set by the Egyptian imperative for the health of the nation to child low (22,23). protect its children from premature Child workers also force routine beating labor which is a hazardous to their by their foramen as well as exposure to mental, physical, educational and heat and pesticides. These conditions spiritual development needs (26).The violates Egypt's obligation under the extraordinary numbers of children convention on the rights of the child, to working in agriculture, worldwide and protect children from ill treatment and the severe abuse they endure demand hazardous employment. They work that all governments, Non many hours that expand between Governments, community, parents and sunrise and sunset such as crop employers all cooperate together and gathering and looking after for animals. prioritize their working for protecting According to Human Rights Watch's child agriculture workers as a part of report in 2001, the children were their strategies to end child labor (27). exclusively recruited for the work The community health nurse can because they could be paid less than assume many roles while serving in adults, more easy going, obedient, and different community agencies. Thus, her had the appropriate height for removing preventive role can be provided damaged leaves(19,24). The National according to the three levels of Council for Childhood and Motherhood prevention; primary, secondary and (NCCM 2002) stated that working tertiary level of prevention (28).Finally children revenue makes up to 29 percent child labor especially in agriculture is a of his family income. About 73 percent phenomenon in rural areas which need of working children work in agriculture. to be studied from the community The NCCM survey stated that about health nurses. Thus, it is very important 81.5 percent of working children in to study the knowledge of the working Egypt are still enrolled in schools and students about work hazards in order to

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facilitate their role in dealing with using fish bowl draw to represent working condition, and workplace the study setting. hazards. - The schools selected in the study Aim of the Study were:- The aim of the study was to assess the 1-Kalip Ebiar Preparatory School in knowledge of preparatory school Kalip Ebiar village. students working in agriculture about 2-Gamal El Shafie preparatory school in work hazards. EL Naharia Village. Materials and Method 3-Nabil EL Daharawy preparatory Materials school in Ebiar village. Study design:- 4-Saad EL Hosary preparatory school in A cross sectional descriptive Sedema village. design was used in this study. 5-Kafer EL Maharoq preparatory school Setting: in Kafer EL Maharoq village. The study was conducted in five Sample:- preparatory governmental schools - The number of students working in (including both sexes) at five villages agriculture was estimated form each affiliated to Kafer ELzayat city, Gharbia school by asking the students in the Governorate, Egypt as a representative classes. The total number of students of rural environment. The villages were working in agriculture in the selected selected as follow: schools was 1338 students. They - A list of all villages with distributed in schools as follows:- preparatory schools in Kafer El -200 students in Kalip Ebiar Preparatory Zayat district was prepared by the School. researcher with the assistance from -233 students in Gamal El Shafie the Manager of the Educational preparatory school. Directorate in Kafer El Zayat. The -300 students in Kafer EL Maharoq number of villages was 28 villages. preparatory school - Accordingly, five villages with -150 students in Saad EL Hosary preparatory schools were selected preparatory school. by simple random sample technique

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-455 students in Nabil EL Daharawy reasons for initiating child work, preparatory school. working hours, rest periods, working - In each school a list was done of during studying and effects on study, students working in agriculture, it seasons of work, nature and tasks included their names, grades and performed by the working students. classes. -Previous complaints related to work - The total number of the students condition and work environment. included in the study was 510 - History of hazards faced during work students. From each school 102 -Safety and protective measures used students were selected by using by students to protect themselves and disproportionate stratified random reasons for not using safety and sample. protective measures. - Thirty four student were selected from Part (3) each grade (first, second and third) Knowledge of students about with simple random technique by agriculture work hazards which using fish bowl draw. included:- Tool of the study: 1-Physical hazards: These included: - A structured questionnaire sheet was exposure to heat (hot or cold), humidity, developed by the researcher in order to noise, and working during night. collect the necessary data. It included 2-Chemical hazards: These included:- the following parts:- exposure to dusts and straws from Part (1): crushing crops, exposure to fumes, Socio-demographic data related to the gases, exposure to pesticides and students, this included: - age, sex, grade, fertilizer. parents' education, parents' occupation, 3-Mechanical hazards: These family income, family size, housing included: - using different agriculture condition and numbers of rooms. machines, working long hours standing Part (2): or bending the head and the neck - Past working experience of the climbing trees for picking the crops, and students which included: age of experience in using agriculture starting work, working days per week, machines.

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1- Biological hazards: These Official permission was obtained included: - dealing with animals from the Educational Bureau in Kafer biting from mosquito and flies, El Zayat city to the head masters of eating fruits and vegetables each selected school for conducting directly without washing, dealing the study. with water canals in irrigation and 2- Developing the tool. using it in washing, dealing and -The structured questionnaire sheet was disposable of animal's excreta and developed based on the literature review breeding of rats in fields. (29-32). 2- Psychological hazards: These The tool was distributed to jury from included: - dealing with stressful nursing and medicine, fields to measure situation, abuse during work, its face and content validity and problems with others, accordingly modification was done. The unsatisfaction with working, jury consisted of three professors as forced labor, exposure to follows: - one professor from Faculty of emotional pressures and anxiety. Nursing, Tanta University, two 3- Personal hazards: These professors from Faculty of Medicine, included: - risk factors that Tanta University. increase the rate of hazards as 3- The Pilot study. young age, inexperience, physical A Pilot study was carried out before illness and fatigue, stress, careless embarking on the field work this was and misestimating the hazards. done on 20 preparatory school students Method working in agriculture. Those students 1- Obtaining approval. were excluded from the study sample.  Before conducting the study, a  The purpose of the pilot study was written permission letter was to test the reliability of the tool, obtained from the Faculty of clarity and organization and to Nursing to the Director of the determine the length of time needed Educational Bureau in Kafer EL- to collect the data from each Zayat city in order to attain an student accordingly modification approval to carry out the study. was done. In order to test the

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reliability of the tool, test – retest difficult or misunderstanding question was done .The pilot study to explain it. conducted twice, 2 weeks apart. -The average time needed for each The first test done and analyzed, its student to fill the sheet ranged from 20- results were 76.74% and the second 30 minute and the number of filled retest was 76.13%. sheet per day was about 18 -25 sheet. 4- The actual study. After the students filled the sheet the -The collection of data was done during researcher ensured that all questions the period from October to December were answered and asked the students to 2010. fill any missed question. -Data collection schedule was done by Limitation of the study: the researcher based on the free classes Nearly 20% of female students refused in the day for collecting the data. to participate into the study, fearing -The researcher was available in the from unknown consequences. Other schools three days /week from 9 am to1 students were selected randomly from pm. the list to fulfill the required number. -Data collection obtained from the students by the researcher in the Statistical analysis morning time. The researcher took 5 to 1-The knowledge of the studied 6 students from classes into the library students regarding agricultural work and distributed the questionnaire to hazards was analyzed and scored as them. follows:- The purpose of the study was explained Each correct item for each hazard was to the selected students. given one score and any wrong answer -Informed consent was obtained form was given zero, then the total score of the chosen students to participate into each hazard was calculated as follows:- the study before starting to fill the -Physical hazards score was17 points questionnaire sheet. -Chemical hazards score was 15 points -The researcher sat with the students, -Mechanical hazards score was13 explained the sheet and asked about any points -Biological hazards score was 21 points

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Psychological hazards score was 17 table shows that it ranged from 1-28 points with mean 6.46 ± 3.41 members. -Personal hazards score was 13 points Almost two thirds (65.88%) were living -Total score of all hazards was 96 with five to ten members. points Regarding the number of brothers & 2- The knowledge score of the studied sisters, the majority (87.65%) of the students regarding agricultural work studied students had less than five hazards had been classified into three brothers and sisters, with a mean 2.8 ± categories as follows:- 1.37. Nearly one third (33.9%) of the -Poor knowledge: < 50% of the total studied students were the first child in knowledge score the birth order , while nearly one quarter -Average knowledge: 50% - 65% of the (27.5% and 22.7% respectively) were total knowledge score the second and third birth order. The -High knowledge: > 65% of the total table shows that majority (91.4%) of the knowledge score studied students were living with their 3-The collected data was organized, parents. tabulated and statistical analyzed using As regard to fathers' education, it was SPSS software statistical computer observed that more than one quarter package version 16.For quantitative (29.6%) of them were either illiterates data, the range, mean, and standard or just read and write, while about deviation were calculated. 31.8% of them had basic education Results (primary & preparatory) and only Table (1) represents the socio- 15.3% of them were university demographic characteristic of the educated. studied students. The majority Regarding the fathers' occupation of the (72.75%) of the students were aged less studied students, more than one quarter than 15 years old, with a mean 13.85 ± (27.6% and 27.1%) of them were 1.13 years. Slightly less than three farmers and employees respectively. In quarters (73.9%) were males. relation to mothers' education nearly As regard to the number of persons half of them (48.8%) were either living with the students in the home the illiterates or just read and write. The

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majority (85.7%) of the studied .Among those who were affected by student's mothers were house wives. their work, 87.34% mentioned that they Regarding the family income per failed in study. month, it was observed that more than As regard to the reasons for working in half (61.0%) of the studied students agricultural work, it shows that (43.9%) mentioned that the income was just of the studied students reported to help sufficient, while only 21.2% mentioned their fathers' in the work and more than that income was insufficient. Three one quarter (27.5%) reported that to be quarters (75.4%) of the studied students independent. It is observed that two their source of income was from fathers' third (66.5%) of the studied students work. worked in their families fields while In relation to the type of house, it shows 16.9% and 16.7% of them were working that nearly half (47.8%) of the studied in relatives lands and paid from others students were owing a house. In relation respectively. The table shows that most to the number of rooms, the majority (70.18%) of the students who were (89.80%) of the studied students working at others fields (relatives or reported that they had less than 5 rooms paid) taking money, ranged between15- with mean 3.43± 0.986 rooms. 35 pound per day with mean Table (2) represents the distribution of 24.59±4.92. students past experience in agricultural As regard to the reasons for choosing work. It shows that more than half agricultural work. The table shows that (58.04%) of the studied students were nearly half (46.1%) of the studied working in agriculture before 10 years students, choose the agricultural work while about 41.96% started work from because it is their fathers' profession. 10 years or more .The mean age of The majority (72.2%) of the studied starting work was 8.79% ± 2.09 years. students reported working in picking The table shows that more than two crops .It shows that nearly half of the thirds (68%) of studied students didn't studied students (47.1%) only work work during school. the majority of the during summer & vocations while about studied students (84.5%) mentioned that nearly one third (32.5%) were working work had no effect on their study occasionally.

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As regard to the number of working students who were not wearing safety hours per day, It shows that (42.5%) of clothes reported that they were the studied students worked less than unavailable. Half (50.39%) of the four hours and about one third (35.5%) studied students reported that their of them worked more than 6 hours. The supervisors provided the safety clothes. entire studied students were taking a More than half (57.06%) of the studied rest period during the work, nearly half students reported that they were not of them (47.5%) were taking half an having enough money for purchasing hour while about one third (33.9%) protective clothes. were taking one hour during the day. Figure (1):- show the distribution of The table shows that three quarter studied students according to their (75.1%) of the studied students were responses regarding their sources of taking a weekend. information about agriculture The same table shows that more than hazards. It show that most of the one third (37.4%) of the studied studied students (69.80%) their source students had no complaint from of information from their parents and agricultural work, while nearly one family, while only 17.06% and14.90% quarter (26.7% and 23.7%) of them were from computers, internet and complained from fatigue, and beating agricultural supervisors respectively. &kicking respectively from their Table (3) shows the distribution of the supervisors or fathers. total score of knowledge for each As regard to the past hazards from agriculture hazards. Regarding the agricultural work, it was observed that different agriculture hazards the table 44.12% of the students exposed to past shows that the majority of studied hazards from the work. students had poor knowledge score In relation to wearing safety clothes, it regarding the different agriculture shows that nearly three quarter (74.5%) hazards. Only 6.3 % had average score of the students was wearing safety for both chemical and personal hazards. clothes, of them 54.21% were using a Table (4) and figure (2) represents hat, while 35.53% used gloves. Nearly the distribution of studied students two third (69.23%) of the studied according to the total score of

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knowledge of the agriculture hazards. 0.8% had average knowledge score, The table shows that the majority with mean 20.88 ± 9.1 and ranged (99.2%) of the studied students had between (0-56) from the total score of poor knowledge scores regarding the all hazards that had been 96 points. total agricultural hazards while only

Table (1):- Distribution of studied students accords to their Socio-demographic characteristics.

studied students Socio-Demographic characteristics (N=510) N % Age: < 15 years 371 72.75 ≥ 15 years 139 27.25 Mean ± SD 13.85 ± 1.13 Range 12 – 17 Sex: Male 377 73.9 Female 133 26.1 Number of persons lives with the students in home: < 5 119 23.33 5 – 10 336 65.88 > 10 55 10.78 Mean ± SD 6.46 ± 3.41 Range 1 – 28 Number of brothers & sisters: < 5 447 87.65 ≥ 5 63 12.35 Mean ± SD 2.8 ± 1.37 Range 0 – 8 Students' birth order: 1st 173 33.9 2nd 140 27.5 3rd 116 22.7 4th or more 81 15.9 The student lives with: The parents 466 91.4 Mother 41 8 Father 3 0.6 Fathers’ education: Read and write or illiterates 151 29.6 Basic education 162 31.8

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Secondary education 119 23.3 University education 78 15.3 Fathers’ occupation: Farmers 141 27.6 Farmer & anther work 71 13.9 Technical workers 94 18.4 Employees 138 27.1 Manual works 26 5.1 Not working 6 1.2 Others(retired or dead) 34 6.7 Mothers’ education: Read and write or illiterate 249 48.8 Basic education 118 23.2 Secondary education 104 20.4 University education 39 7.6 Mothers’ occupation: Housewife 437 85.7 Workers 24 4.7 Employee 38 7.5 Farmer 11 2.2 Family income per month Not sufficient 108 21.2 Sufficient 311 61.0 Sufficient and more 91 17.8 *Source of income Fathers‘ work 384 75.4 Mothers‘ work 19 3.7 Parents together 57 11.2 Parents & children 22 4.3 Children only 17 3.4 lands and properties 26 5.1 Aids and helpers 7 1.4 Type of house Owing a house 244 47.8 Rent flat 11 2.2 Shared house 34 6.7 Having a flat 221 43.3 Number of rooms: < 5 458 89.80 ≥ 5 52 10.20 Mean ± SD 3.43 ± 0.986 Range 1 – 8 * More than one answer was allowed.

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Table (2):- Distribution of studied students accords to their past experience in agriculture work.

studied students Child past experience in agriculture work: (N=510) N % Age of starting agricultural work: < 10 years 296 58.04 ≥ 10 years 214 41.96 Mean ± SD 8.79 ± 2.09 Range 5 – 14 Working during school: Yes 163 32.0 No 347 68.0 Work effects on the study: Yes 79 15.5 No 431 84.5 If yes mention this effect: Failed in study 69 87.34 Fatigue 3 3.80 lose time 4 5.06 Un concentration 3 3.80 Reasons for working in agriculture: Help in family income 69 13.5 to expense on myself 35 6.9 Help the father in the work 224 43.9 according to parent desire 42 8.2 To be independent 140 27.5 Working in: family' s fields 339 66.5 relatives fields 86 16.9 Paid on others 85 16.7 Working with others or relatives, paid or not: paid 120 70.18 not paid 51 29.82 If you paid ,what daily allowance LE/day 24.59±4.92 Mean ± SD 15-35 Range Reasons of choosing working in agriculture: love it and appropriate to me 100 19.6 it is available to me 81 15.9 Because it's my father's profession 235 46.1 because my relative work in it 94 18.4

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Cont. Nature of work in the field: Picking crops 368 72.2 spraying pesticides 17 3.3 collecting worm from plant 70 13.7 Planting grains 55 10.8 Times of working in agriculture Daily during the year 39 7.6 During summer & vocations 240 47.1 At the time of picking crops only 65 12.7 According to occasions 166 32.5 Working hours during the day Less than 4 hours 217 42.5 from 4 to 6 hours 112 22.0 more than 6 hours 181 35.5 Taking rest period during the work Yes 510 100 No 0 0 If the answer is yes, the duration of rest period Half an hour 242 47.5 hour 173 33.9 more than hour 95 18.6 Taking a weekend Yes 383 75.1 No 127 24.9 Previous complaint or problem from agriculture work: Beating & kicking from supervisors or father 121 23.7 increasing working hours 32 6.3 Decreasing in money 30 5.9 fatigue 136 26.7 No complains or problems 191 37.4 Past hazards from agriculture work Yes 225 44.12 No 285 55.88

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Cont. Wearing safety clothes during work Yes 380 74.51 No 130 25.49 *If yes, what it is (more than one answer allowed) Gloves 135 35.53 Mask 34 8.94 Hat 206 54.21 plastic boots 45 11.84 If No, why you don't use: I dislike it 18 13.85 There is no hazard 13 10.00 There is no money 9 6.92 Unavailable 90 69.23 the supervisor(or father) provides these protective clothes Yes 257 50.39 No 253 49.61 Are you having enough money from your work that permits you to purchase protective clothes Yes 219 42.94 No 291 57.06 More than one answer was allowed 

Figure (1)):- Distribution of studied students according to their responses regarding their sources of information about agriculture hazards.

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Table (3:- Distribution of studied students accords to their total score of knowledge for each agriculture hazards.

Total score of student's Knowledge score knowledge related to High Average Poor agriculture hazards 65% & above 50%- <65% <50% N % N % N % Physical hazards 0 0.0% 6 1.2% 504 98.8% chemical hazards 12 2.4% 32 6.3% 466 91.4% Mechanical hazards 11 2.2% 19 3.7% 480 94.1% biological hazards 0 0.0% 1 0.2% 509 99.8% Psychological hazards 1 0.0% 7 1.4% 502 98.4% personal hazards 6 1.2% 32 6.3% 472 92.5%

Table (4):- Distribution of studied students accords to their total score of knowledge about agriculture hazards.

The sample ( n = 510 ) Total Knowledge score N %

High 65% & above 0 0%

Average 50% - <65% 4 0.8%

Poor <50% 506 99.2 %

Range 0 – 56

Mean ± SD 20.88 ± 9.12

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Figure (2):- Distribution of studied students accords to their total score of knowledge about agriculture hazards.

Discussion Child labor is a persistent problem agriculture perform hazardous labour throughout the world, especially in that can threaten their lives, health and developing countries. It is prevalent in general well-being (33-36). rural areas of those countries where Agricultural work is dangerous. poverty is widespread. Child labor is an Children are doing work that is important global issue associated with damaging their mental, physical and poverty, unbalanced economic growth, emotional development. Because inadequate educational opportunities, children's bodies and minds are still gender inequality, inadequate growing and developing, exposure to regulations to restrict child labor, and workplace hazards and risks can be lack of public awareness . One out of more devastating and long-lasting for six children in the world is involved in them (37-39). child labor, and nine out of ten children In (2002), The International Labor in rural areas are working in agriculture Organization estimated that nearly 250 or are involved in similar activities. million children engaged in child labor Many of the world‘s child laborers' in around the world, the vast majority (70

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percent) were working in agriculture. the national low in many countries Child agricultural workers, are exposed prohibit children from working before to toxic pesticides, and suffer high rates the age of fourteen, the present study of injury from sharp knives and other revealed that the majority of the dangerous tools. Their work is harsh, students' age was less than 15 years and violates their rights to health, (table1). This finding is in agreement education, and protection from work with Salem study (2004), in Mansoura that is hazardous or exploitative (5). The about the effect of agriculture work on work that children perform in the health status of preparatory school agriculture is often invisible and children, which reported that the unacknowledged because they assist majority of working children were their parents or relatives on the family under 15 years (42). Also Human Right farm or they undertake piecework or Watch (2002) reported that children work under a quota system on larger working in cotton pest in Egypt were farms or plantations, often as part of between the ages of seven and twelve migrant worker families (20). years (43). The International Labor Seeing vulnerable children risking their Office (2002), also reported that large lives and harming their health is proportion of working children were disturbing and painful to everyone. found in agricultural sector was aged Although child labor is globally between 5-15 years(44). recognized as a health problem, As regard to gender the present study researches into the health impacts of revealed that nearly three quarters were child labor in Egypt have been limited males and only one quarter were to some urban areas (40,41). Therefore the females (table1). This finding is in present study was initiated to study the agreement with different studies; knowledge of preparatory students Bureau of International Labor Affairs working in agriculture about work (2008), reported that child labor is more hazards in order to clarify the frequent among boys than girls (45). Kotb magnitude of the problem and grasp the et al. study about agricultural labor attention for necessary rapid solution. among school children in rural Assiut Although the Egyptian child low and (2011), revealed that male students are

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more involved in agricultural work than of child's labor on the health status in female students (60.2% versus 39.8%) Alexandria (1995), reported that most of (46). This finding could be explained by the working children were from large the norms of our society as females' families (49). Boer (2005), in the help their mothers in household Philippines stated that rural houses activities and do their homework. In stand closely together and are contrast a survey carried by ILO in 26 overpopulated with average family size countries (1997) on children at work, of eight to ten people (50). El-Gilany et reported that approximately three al., studies the epidemiology and quarters of girls compared to more than hazards of student labor in Mansoura two thirds of boys were engaged in (2007), stated that working students agricultural activities (47). The same were from large families (41). finding was also reported by a study The present study revealed that more done in Sudan (2001), which reported than one third of the studied students no sex differential, where females as were the first child in the birth order well as males were working mainly in while nearly one quarter was the second the traditional sector in agriculture (48). and third order (table1). This can be As regard to the number of persons explained that, parents may view that living with the students, the present the first child by taking part in study revealed that more than three agricultural work activities learn quarters of working students come from responsibility, reliability, work ethics, large families with five persons and new skills and coping with problems. more (table1). This may be attributed to This in contrast with Haggag study the nature of life in rural extended (1995), reported that most of the families which living together and also working children were the second or to the rising inflation and economic third order (49). Kotb et. al., study burden. This clarify the burden that (2011), also revealed that more than exists on parents of large family number half of the working children were from that lead them to employ their children. the second birth order or more (46). The same finding was reported by other In relation to mothers' education, the studies. Haggag study about the impact present study revealed that nearly half

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of them were either illiterates or read work before 10 years old. This finding and write, and the majority of the is below the minimum age (13) years in studied student mothers' occupation was seasonal agricultural work in Egyptian housewife (table1). This finding is in low (52,53). This may be explained by that agreement with Kotb et. al., study agriculture remains the primary (2011), who revealed that a greater occupation of adults in rural areas and percent of mothers fall in the illiterate fathers prefer to take their very young category and most of the student‘s children especially boys for gaining mothers were housewives (46). experience. Similar finding were Regarding the family income, the reported by Matter (2007), who stated present study revealed that more than that children started work from 6-14 half of the studied students mentioned years in Egypt, Itani (2009), reported that the income was just sufficient while that working children started work at an only 21.2% mentioned that income was early age from7-15 years , and El- insufficient and the majority of the Samman et. al., (2008), stated that studied students' source of income was majority of children started work at the from fathers' work (table1-4). This age of 8-9 years (14,51,54). finding is in agreement with different Regarding working during school, the studies; Matter study about child labor present study revealed that more than in Egypt: Scope and appropriate legal two thirds of studied students didn't responses (2007), Itani study about work during school. In relation to the child labor in Egypt (2009), and Bureau effect of work on study, the majority of of International Labor Affairs(2008), the students mentioned that there was who reported that most of the working no effect on their study .Among those children came from low income who reported that work affected their families and the source of their income study, the majority reported it in the was from fathers' work (14,45,51) . form of failure in the study (table 2). As regard to the students past This finding is in concomitant with experience in agricultural work (table Kotb et. al., (2011), study which stated 2), the present study revealed that more that student labor has a profound effect than half of the studied students started on education and achievement, as 63 %(

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out of 332 sample) of working students achievement of adolescent in Egypt failed in the previous year and 69% of (1998), indicated that for working working students successed with failure adolescent (10-19years), the most in some subjects. This was also important reason for work was to help corroborated with research conducted the family (without pay).This pattern is by UNICEF (2008), and its conclusion prevalent in rural areas (46,56). was that Labor often interferes with As regard to the reasons for choosing children's education(55). agricultural work, the results shows that As regard to the reasons for working in nearly half of the studied students, agricultural work, the present study choosing the agricultural work because revealed that slightly less than half of it's fathers' profession, and the majority the studied students reported that the of the studied students, their nature of main reason was to help their fathers' in work was picking crops .It also shows the work and nearly one quarter that nearly half of the studied students reported that their reason was to be were working during summer & dependent on themselves. The present vocations (table 2) .This finding is in results also stated that two thirds of the consistent with Itani study (2009),who studied students worked in their stated that most child workers in Egypt families own fields (table 2). This may were employed in seasonal work in be explained by that families don‘t want cotton fields and during summer to pay for outside help from other farm holiday months( 14). These findings were workers because all family including in consistent with other studies reported children work in the field. This finding by United State Department of Labor is in agreement with Kotb et. al., studies about the worst forms of child (2011), study who stated that the most labor in Egypt in 2007, 2006 and in important cause of the students‘ work 2005 (18,21,57). was helping their fathers in the work As regard to the working hours per day, and sharing in the family expenses and the result of the current study revealed about two thirds of the working children that less than half of the studied were unpaid. The survey on social , students worked less than four hours health status and educational and about one third of them worked

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more than 6 hours. The present study different body system (42). also revealed that the entire studied As regard to the past exposure to students were taking a rest period hazards from agricultural work, the during the work, nearly half of them result of the current study revealed that took half an hour (table 2). This finding almost one half of the students had past is in agreement with Kotb et. al., hazard from the work (table 2). Similar (2011), who stated that the majority finding was reported in Salem study (80%) of the working students worked (2004), where more than half of the not more than three hours (1to 3 hours working males were exposed to work per day) and about (75%) took a rest hazards (42). period of half an hour (46). In contrast of In relation to wearing safety clothes, the this, Mathews et al., (2003), found that result of the current study revealed that children worked about 12 hours per day nearly three quarter of the students wear (58). In 2002, a survey about child labor safety clothes and this was in the form in agriculture conducted by Human of hat for nearly half of them. More Rights Watch in developing countries than two thirds of the studied students revealed that the vast majority of who did not wear safety clothes working children worked between nine reported because they were unavailable and thirteen hours per day(59). (table 2). This finding can be explained The result of the current study revealed by that a hat is a cheap personal that more than one third of the studied protective device. In addition the students had no complain or problem working children have lack of from agricultural work, while nearly knowledge about expected hazards and one quarter of them complained from their effect on human health .This fatigue, and the same percentage highlight the need for educational complained of beating &kicking from training program about the importance their supervisors or fathers (table 2). In and quality of using personal protective contrast of this finding in Salem study devices. Salem study (2009), stated that (2004), found that all working children about 12.9%were using boot and except 1.3% reported one or more mentioned that safety equipments physical complaint affecting the designed for adults often doesn‘t fit

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children and were difficult for them to Furthermore, if they knew the hazards, handle (15). they had poor knowledge about its Work hazards affect children to greater effects. Lack of students' knowledge degree than adult, in some cases causing highlight the gaps of school curriculum irreversible harm to their physical regarding scientific information on development with serious consequences long-term health effects of child labour. for their futures. Thus young workers World Health Organization in studding are susceptible to all the dangers child labor and adolescent workers exposure faced by adults when placed in (2005), reported that two thirds of the the same environment. However, students lacked any knowledge or had children differ biologically from adults wrong ideas which probably reflect in their anatomical, physiological, and misconceptions of the general public psychological characteristics because of about ill-health-effects of work (68%) their process of growth and (62). By Contrast Ajayi (2004), in development. Therefore, exposure to studying rural children‘s knowledge of hazards that affect adults can affect hazards associated with farming in Oyo children much more strongly (60,61). State mentioned that 67.47% had a The present study revealed that most of moderate or average knowledge of the studied students their source of hazards associated with farming while information was from their parents and 20.08% had a high level of knowledge family and the majority of studied of hazards and dangers associated with students had poor knowledge score farming (63) . regarding the different agriculture Finally the present study revealed that hazards. The majority (99.2%) of them most of the studied students had poor also had poor knowledge scores knowledge score regarding the different regarding the total scores of agricultural agriculture hazards and their main hazards (figure 2 and table 3,4). This source of information was their parents can be explained by that there is lack of and families. This directs the lights health knowledge among parents and toward nurse's role toward improving family of the studied students regarding rural children and their families' agricultural health hazards. knowledge about the occupational

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health hazards especially agricultural regarding the different agriculture work. hazards. Most of the studied students Conclusion their main source of information was Based on the findings of the present from their parents and family. This study it can be concluded that most of revealed a lack of health knowledge of students working in agriculture were parents and families of the students males and were under fifteen years old. regarding the agricultural health The main reason for working in hazards. agricultural work was to help their Recommendations fathers' in the work and nearly one Based on the findings of the present quarter reported to be independent. study, the following are Furthermore, almost one half of the recommended:- studied students reported working only 1·Development of data base on child on summer and vocation for less than labor in agriculture, through four hours per day and about one third performing comprehensive of them worked more than 6 hours. epidemiological surveys to determine Nearly one quarter of the studied their number and nature of hazards, students complained from fatigue, and injuries or illnesses suffered by beating &kicking from their supervisors children. This should be used to plan or fathers. Nearly two thirds of the a protection measures and training studied students who were not wearing program. safety clothes reported that they were 2. Ensure that all working children unavailable. receive full information and training In addition, the majority of studied from their employers and health students identified the elements of workers about occupational hazards different agriculture hazards (physical, related to agricultural work. such chemical, mechanical, biological and training should be conducted psychological) but had lack of regularly and be understandable by knowledge regarding its health effects. children. Therefore, the majority of studied 3· Health education needs to be students had poor total knowledge score integrated with school curriculum to

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focus the attention of students about 4- International labor organization. the information on prevention of International programs of work related health hazards and elimination of child labor. USA: accidents. ILO Reports, 2008; 1-2. 4. Suitable protective equipments and 5- Rural employment team .Work clothes for children should be for eliminating child labor in provided by the employers, and agriculture. United Nation: Food children should be covered by and agricultural organization, medical and social insurance. 2010;1-6. 5. Community health nurses as health 6- Iskander L. Educating working professionals, social workers and all children. Cairo, Egypt: Al Aharms community sectors should ask for Weekly, 2006; issues No, 813. enforcing and applying existing laws 7- Assad R. The effect of child work on child labor which supervise and on school enrollment in Egypt. control child labor in agriculture Minnesata University; Economic through all means as community research forum for the Arab organizations and media. Counties, Humphrey Institute of 6. Community health nurses working in Public Affairs, 2001; 8 (2): 3-9. rural health units should receive 8- Mccurdy S and Carrol D. special training on agriculture hazard Agricultural injury. American References Journal of Industrial Medicine, 1- Ball J and Binder R. Child health 2000; 38:463. Nursing. United States: Reasons 9- Marlow D and Redding B. prentice Hall, 2006; 150-168. Pediatric Nursing .6th ed. New 2- Human Rights Watch. Failure to York: Elsevier / WB Sounders protect child from farm workers. Company, 2007; 3-20. United States: Human Rights 10- Marlenga B, Pickett W and Berg Watch reports, 2000; 1-4. R. Agricultural work activities 3- Fares J and Raju D. Child labor reported for children & Youth. across developing world. USA: North America: Journal of World Bank Report, 2007; 1-4.

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agriculture's safety and health, U.S. Department of labor reports. 2001; 7: 241-252. 2007; 1-5. 11- Marlenga B, Pickett W and Berg 17- World Bank Surveys. Child R. Assignment of work involving Economic activity and school farm tractor to children. North attendance rates. Egypt, Unicef and America. Industrial medicine: UCW analysis of ILO Reports, 2001; 40: 15-22. 2007. 12- Dourdillon M. Child labor and 18- United State Department of labor education: A study from .Country Reports. Egypt: U.S. southeastern Zimbabwe. Journal of Department of labor Reports, 2006. social development 2000; 15 (2): 5- 19- U.N. Office for the coordination of 33. Humanitarian Affairs. Egypt: 13- One world guide. Child labor. children of the quarries. Integrated London: UEL University of East regional information Networks London, 2010; 1-7. (IRIN) Cairo, 2008;219-223 http://uk.oneworkld.net/guides/chil 20- International Labor dlabor. Organization. Harvest. Geneva: 14- Itani N. Child labor in Egypt. Bureau for worker's activities, Master thesis, Faculty of 2002; 1-5. Humanities, University of Southern 21- United State Department of Denmark. 2009;1-4. labor. 2004 Findings on the worst 15- Salem M. Impact of applying forms of child labor-Egypt. Egypt. safety measures on the occurrence U.S. department of labor reports, of agriculture hazards among 2005; 1-6. preparatory school pupils. Doctoral 22- Human Rights Watch. Underage thesis. Faculty of nursing, and unprotected: child labor in Alexandria University, 2009. Egypt's cotton fields. Egypt: HRW 16- Egypt- United States Department reports. 2001; 1-21. of labor .2006 Findings on the 23- Human Right Watch. Status of worst from of child labor. Egypt: child labor practice and minimum

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age for employment. Egypt: HRW http://www.dol.gov/esa/whod Reports, 2004; 76, 117; 421. /regs/compliance/child labor/ 20 24- Human Right Watch. Child labor pdf. laws grossly violated in Egypt. 31- Rogers B. Occupational and Egypt: HRW reports; 2001; 1-2. environmental Health Nursing. 2nd 25- The World Bank group in Egypt. ed. United States: Saunders, 2003; A future without child labor. 177-178. Middle East and North Africa: The 32- Kirkhorn S and Schenker M. World Bank group report, 2009. Human health effects of 26- International labor organization agricultural and illness. Journal of .What is child labor. United State; Public health, 2001; 1-16. International labor organization 33- International Labor reports, 2008. http://www.child Organization. Harvest. Geneva: labor. In Bureau for worker's activities, 27- Human Rights Watch. Child labor 2002; 1-5. in agriculture. New York: Human 34- Fassa A , Parker D , and Rights Watch reports, 2002; 1-4. Scanlon T .Child labour: A public 28- Watkins D, Cousins J and health perspective. United State: Whitehead D. Public health and Oxford University Press, 2010; 39- community nursing. 3rd ed. China: 42. Elsevier Limited, 2010; 230-717. 35- Human Right Watch. ILO 29- Levy B and Wegman D. members urged to take action on Occupational health: Recognizing child labor in agriculture. United and preventing work related States: HRW reports, 2002; 1-4. disease and injury. Philadelphia: 36- International Labor Lippincott Williams and Wilkins, Organization .Facts on child labor 2000; 689-748. .ILO (2004): At 30- Department of labor. Child website:www.ilo.org/childlabor. requirements in agricultural 37- Datta P. Pediatric Nursing. New occupation. United States: Fair Delhi: Jaypee Brothers, 2007; 30- labor standers Act, 2007;1-9 on 31.

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38- Smith C and Maurer A. 2002. Available http://hrw. Org/ Community / public health nursing: back grounder/ crop/back06/0 Health for families and population. 44- International labor office. A USA: Elsevier, 2005; 758. future without child labor Global 39- Hurst, P. Health and child labor in report under the follow up to ILO agriculture. Food Nutrition declaration on fundamental Bulletin, 2007; 28(2):364-371. principles and rights at work. 40- Kishk F, El-Masry A, Abd-Allah Switzerland: Geneva, International S. and Gaber H. Vulnerability of Labor conference 90th Session, working children to environmental 2002.1-35. health risks: a case study in a 45- Bureau of International Labor village in rural Egypt. Global Affairs. Study of child labor in Forum for Health Research, Haiti‘s agricultural sector: A study (Forum 8). Mexico city, Mexico, of Children in the rural centre 16-20 November 2004. department. Washington: Macro 41- El-Gilany A, Khalil A. and. El- International Inc, 2008; 1-147. Wehady, A. Epidemiology and 46- Kotb S, Mohamed A, Abdel hazards of student labor in Khalek E and Yones D. Mansoura, Egypt. Eastern Agricultural Labor among School Mediterranean Health Journal, Children in Rural Assiut. Egypt (2007); 13(2): 347-363. Life Science Journal, 2011; 8(2).1- 42- Salem N. The effect of agriculture 17 Available at:- work on the health status of http://www.lifesciencesite.com. preparatory school children. Master 47- Forastieri v .Children at work: degree in community health health and safety risks .Geneva: nursing .Faculty of Nursing. International Labor Organization, Alexandaria University. 2004. 2002; 5-7. 43- Human Right Watch. 48- Omar A. Workshop on the Backgrounder: child labor in analysis of poverty and its agriculture. HRW Word Report. determinants in the MENA Region. Northern Sudan: Economic

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Quality Nursing Care Versus Patient Satisfaction And Nurses Job Satisfaction In Zagazig University Hospitals

Manal Fauzy Eldaly : Quality coordinator, Ministry Of Health, Eglal Ahmed Abd-Elwahab Assistant Prof. of Nursing administration, Cairo University, Maha Abdeen Abdeen: Lecture of Nursing Administration, Faculty of Nursing, Zagazig University

Abstract: Quality of care is a right of all patients and responsibility of all nurses who deliver it. Quality is the effect of care on the individual and population. Effective improvement in quality of nursing performance should be reflected in better health, patient satisfaction and nurses‘ satisfaction. The aim of this study aimed to assess the level of job satisfaction among nurses, measure quality of work performed by study nurses and assess the patient satisfaction related to nursing care performance. Setting: the study carried out at new surgical hospital that affiliated to Zagazig university hospitals. The study sample: included (47) nurses and (1053) patients from different surgical wards at zagazig university hospital. Tools: three tools used to collect the necessary data; the questionnaire sheet to assess nurses job satisfaction factors, a patient‘ satisfaction questionnaire sheet and nurses‘ observational checklist to assess nurses performance for patient care. The results revealed that , most of nurses at surgical wards in new surgical hospital were satisfied in many factors when had the highest mean scores in relation to Salary , administration and management , work environment , relation at work , recognition , system of work , progress at work and work responsibilities factors . However, in relation to observed quality of nurses‘ performance the majority of nurses had an acceptable level in their practice on maintaining the patient rights factors, maintaining the elimination factors in the first and second 24 hours of

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Tanta Scientific Nursing Journal postoperative care. While, there were statistical significant relation between patient‘s education and their satisfaction with nurses‘ performance quality. Therefore, according to findings .Recommended that, developing a standard for surgical nursing care on Zagazig University Hospitals and it should be communicated to all healthcare providers to improve quality of care provided to patients, as reference for practice management and controlling Keys words: quality nursing care, patient satisfaction, nurses‘ satisfaction.

Introduction Quality of care emerged as a major perceptions of value that determines issue in health care and it will continue their satisfaction (Chunlaka, 2010). to be a crucial issue as the healthcare Satisfaction with healthcare service is a reform implemented (Zerwek and topic of wide interest to both people Claborn, 2006). Quality can be defined who work in organizations and people as the degree to which consumer who study it because it is important for progress toward desired outcomes all health professionals (Mc-Laughlin which established with guidance and and Kaluzuy , 2007 ) . support of healthcare providers Patient-centered care has become a (Suganthi & Samuel, 2005). In major concern of health care providers, addition, Evan and Lindsay (2005) patient satisfaction with nursing care defined quality as an overall experience became a pivotal indicator of the and satisfaction of patient with nursing quality of care provided in hospitals, services from the moment of admission and helping patients to adjust their until discharge. expectations of a cure is important step Nursing service quality refers to an in reducing the severity of the overall judgment of a particular service, condition. However, it is important to and there is a difference between provide patients with hope (Peterson, expected quality and perceived quality. 2005). Moreover, the nursing service quality is Therefore , consumer and patient's a critical component of patients' satisfaction has been used as index for

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Tanta Scientific Nursing Journal measuring quality of nursing care by number of positive outcomes, higher using the consumer or patient perceived quality life and less work- satisfaction questionnaire as a related stress. Chu & Lee (2010) found measurement tool reflects what the by recent studies that nurses were most patient thinks about the quality of stressed when their ability to practice nursing care they received and focus on quality nursing care was impeded. On patient's experiences about their total the other word , inappropriate care hospital stay (Kudo et al., 2006) . provided to patients contribute to high Moreover, in the recent years a high level of job stress and feelings of quality of care is the right of all frustration , inadequacy , self- doubt , patients, which require increasing the lowered self- esteem , irritability , level of quality in Egypt. A little hopelessness , depression and burnout concern started to be considered , there (Dorothy & Judith, 2010 ) . must be a large step to be moved Therefore, to produce effective and directly toward quality that meet or continuing quality improvement there exceed customers expectations which is should be a great interest to healthcare the ultimate goal of many healthcare providers; satisfaction with their work organization (American Hospital and belonging to work target , to Association., 2010) . achieve higher level of quality care and Furthermore, job satisfaction has higher level of their job satisfaction become a key concept within nursing ( Blumenthal , 2005 ) . work for the research in recent years. Aim of the study: This is largely due to the view that The study aimed to: nurses' job satisfaction has a wide Assess the quality of nursing care spread and significant implications for versus patient satisfaction and nurses‘ nurses, patient, hospitals and the job satisfaction in Zagazig University profession (Torninsk et al., 2005). Hospitals. While, Belegan (2006) believed largely Subject and methods: that job satisfaction linked with a The research design:

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A descriptive design was used. to the end of September 2007 are Research setting: included in the study . This study was conducted in surgical Tools for data collection: wards of new surgical hospital which Three different tools were used for data affiliated to Zagazig University Hospitals. collection in this study; the first tool is Subjects of the study: the questionnaire sheet for nurses' The study sample included two groups; satisfaction, the second tool is the namely staff nurses and patients. observation checklist of nurses' quality of The nurses group consisted of a performance, the third tool is the patient convenience sample of all nurses satisfaction questionnaire sheet. available in the above mentioned setting The first tool :Nurses' Satisfaction who accepted to participate in the study. Questionnaire: Nurses involved in the study had more The first part; entails the demographic than one year of experience. The total data such as age , qualification , years of number of nurses meeting this criteria experience , marital status, nursing care were 47 out of 50 nurses; because two assignment method and shift pattern. The nurses refused to participate in the study Second part was to assess nurses' and one of them didn't return the satisfaction factors .It was developed questionnaire .As regards to their based on the related literature qualification ; all nurses had a nursing (Mohamed, 2005 and El- Said, 2005 diploma .The patients group; all patients El- said, 2002 , Abd- Rabou, 2002) who were available and admitted to where the items were grouped under the hospital who their age group ranged from following dimensions: salary factors (13) one month to 78 years , fully conscious , items , administration and work system with varied duration of hospitalization , factors (24) items , Work environment all types of operation , with different factors (10) items , leadership and educational levels .The total sample was supervision factors (17) items, relation at (1052) patients admitted to surgical units work factor (10) items, recognition from at New Surgical Hospital from February other (8) items, progress and work

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Tanta Scientific Nursing Journal promotion factors (9) items, work itself items, pre- and post –operative care factors (6) items, job achievement factors which divided into (A) pre- operative (7) items, work responsibility (12) items . care(72) items, ( B ) post – operative care The scoring systems were on bases of ( first 24 hours after operation ) which (yes, sometimes and no). Yes scored (two included (62) items and (C) post- points, sometimes (one point) and no operative care (after 24 hours) which scored (zero). Then the nurses responses included(78),the general factors included; about job satisfaction factors were communication factors(14) items, categorized into three level of scores documentation factors(4), and which are; satisfied for (65 %) or more, to professionalism factors (10) .The scoring some extent from (60 – 65) and not system; responses could be done; either satisfied which less than (60 %). correctly (two points) or not correctly The second tool: The observation (scored one point) or not done (scored checklist for quality of nurses‘ zero point). There are three observations performance which developed based on done for each nurse in surgical ward review of related literature (Abd- Rabou where each observation taking from two , 2002, Abdeen , 2001, Said , 2000) as to three hours. Then, the total number of well as from previous experience with each response is summed and so on for nurses in clinical setting . Its purpose was the two other responses (done; correctly to assess quality of nurses' performance or not correctly and not done). After in the New Surgical Hospital. The first ending the recording process for all part includes the demographic observation checklist reposes the characteristics of nurses. The second part maximum scores, mean and standard of the observation checklist categorized deviation were calculated for quality of under (8) main dimensions which include nurses performance factors, the range ; the admission procedures (10) items , rates for all factors. Then, the p – value patient rights factors (10) items , were calculated between the observed assessment of psychological condition (3) quality of nurses performance and the items, health education to patient(5) nurses‘ age and experience for statistical

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Tanta Scientific Nursing Journal testing. estimating the time needed for filling the The third tool ; Patients' Satisfaction forms that ranged from 25- 40 minutes. Questionnaire: Regarding the observation checklist; (5) used as a components of quality of nurses are selected randomly from the nursing care . It was developed based on surgical wards in the New Surgical related literature review (Ibrahim, 1998, Hospital and observed to assess the Abd- Rabuo, 2002 and Gad, 2002) . Its applicability of the observation sheet. purpose was to investigate the patient' Field Work: satisfaction level as indicator of quality of This study was carried out during the nursing performance. period between February 2007 to the end The first part entails the demographic of February 2008 . The investigator met data about patients such as age, sex, the respondents individually during the marital status, education, length of stay three shifts to distribute the questionnaire and frequency of admission. or making the observations. During these The second part composed of questions meetings, the investigators explained the related to elements of : the surrounding purpose of the study, and assured to environment factors (6) items, patient respondents the anonymity of answers rights factors (6) items, health education and that information will be used only for factors(5) items, nursing performance (8) scientific research and will be items, social relation factors (5) items, confidential. Psychological condition and patient Administrative Design: safety factors (74) items . The scoring Formal approval was obtained through system is on the basis of (yes and no). official letters sent to directors of medical Yes were scored (one point) and no were and nursing departments at Zagazig scored (zero). University Hospitals explaining the aim Pilot Study: of the study and assuring confidently of A pilot study was conducted to assess informate and seeking their permission the tools clarity, to identify the obstacles, Statistical Design: applicability and test it. It has served in Data entry was done using computer and

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Tanta Scientific Nursing Journal statistical analysis was done using comparison test, used for paired microstate statistical soft- package. Data comparison. were presented by using different statistic Pearson correlation coefficient indicates techniques for data analysis as following: the degree and direction of relationship (1) Descriptive statistics in the form of between two variables (correlation frequencies and percentage. (2) between observed satisfaction factors Quantitative variable were compared by total scores and staff nurse‘s using: Standard deviation, which is the performance). measure of standard deviation .Multiple Results: Table (1) Describe the socio- the functional method. However, most of demographic characteristics of nurses in nurses (70.2%) worked in rotating shift. the study sample .This table indicate that , Table (2) : Demonstrates that , nurses' less than half ( 46.8 %) of study satisfaction scores have been categorized subjects were in the age group ranged into " satisfied " with a score 60 % or from ( 21-30 ) years .While , the least more and " dissatisfied " with scores less percent than 60 % . The table clarifies that, (12.8 %) of study subjects were in the age nurses were dissatisfied in leadership group more than 30 years .According to and supervision factors and work qualification the table shows that, all the promotion factors of nurses‘ satisfaction staff nurses had diploma nurse (100%). In factors; The mean percent ( 59.4 % addition, regarding to years of experience and 58.9 % ) . While the nurses had the the highest percent (80.9 %) had five highest percent and be satisfied in the years or less. While, the least percent salary, administration and management, (4.3 %) had (11-15) years of experience work environment, relation at work, in nursing. In relation to marital status of recognition, system of work, progress at nurses, all of staff nurses had married work and work responsibilities factors. (100%). Regarding nursing care Table ( 3 ) : Clarifies that , there was a assignment methods this table indicates negative correlation between nurses‘ age that, the majority of nurses (87.1%) using and their observed quality of performance

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. But, this correlation was not statistically Table (6): describe the relation between significant ( P > 0.05 ) . education, diagnoses and patients‘ Table ( 4 ) : Shows that , there was a satisfaction factors. There were highly negative correlation between nurses‘ statistical significant differences between experience and their observed quality of education, diagnoses and patients‘ performance . But, this correlation was satisfaction factors. not statistically significant ( P > 0.05 ). Table (7) clarifies the correlation matrix Table (5): shows the distribution of among scores of patient satisfaction patient according to socio- demographic factors. As shown in table, there was characteristics. This table indicates that , highly statistically significant negative more than half ( 58.6 % ) of study correlation in the environmental, Patient subjects were in the department (C) . rights and performance factors of patient According to patients' age, the age group satisfaction (p < 0.001) .While, there was ranged from one month to 78 years. no statistical significant difference in the However, regarding to marital status of patient health education, social relation study subjects, around half of patients and patient safety and psychological (52.4 %) were married. As regard to factors. patients' gender more than two third (64.7 %) were female. According to educational level of patients, the highest percentage (38.1%) were for patients who able to read and write. Regarding to patients' types of surgery; about half (48.6 %) of study subjects had major surgery. However, the length of stay (hospitalization period) ranged from (1- 47) days and the majority of patients (91.6 %) had the first admission to hospital.

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Table (1) The percentage distribution of the study group according to their demographic characteristics ( n = 47 ) . Characteristics n = 47 NO. % * Age : - ≤ 20 19 40.4 -21 – 30 22 46.8 - > 30 6 12.8 * Qualification :-Diploma : 47 100.0 *Experience (Years) - ≤ 5 38 80.9 - 6 – 10 7 14.9 - 11 -15 2 4.3

*Marital status: - Single : 0 0 -Married : 47 100.0 *Nursing care assignment methods: 6 12.8 - Case method : - Functional method : 41 87.1 *Shift pattern : - Fixed shift 14 29.8 - Rotating shift 33 70.2

Table ( 2 ) : Level of nurses' satisfaction scores among the study subjects according to their perception ( n = 47 ) . Nurses satisfaction factors: Max. Scores Mean Total Mean (%) 1- Salaries . 26 15.6 60 2- Administration and 48 28.8 60 management . 3- Work environment . 20 12 60 4- Leadership and supervision . 34 20.2 59.4 5- Relation at work . 20 12 60 9.6 60 6- Recognition 16 (appreciation ) . 7- Work promotion . 18 10.6 58.9 8- System of work . 12 7.2 60 9- progress at work . 14 8.4 60 10- Work responsibilities 24 14.4 60

Table ( 3 ) : Correlation between the nurses’ age and observed quality of nurses performance factors in New Surgical Hospital ( n = 47 ) . The quality factors r P 1. Assessment of patient condition - 0.19 > 0.05 ( NS ) at admission : 2. Pre- operative care factors : - 0.16 > 0.05 ( NS ) 3.Post- operative care factors ( first - 0.09 > 0.05 ( NS ) 24 hours ) 4. Post- operative care factors ( - 0.04 > 0.05 ( NS )

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second 24 hours ): 5. Communication : - 0.21 > 0.05 ( NS ) 6. Documentation : - 0.07 > 0.05 ( NS ) 7. Professionalism : - 0.1 > 0.05 ( NS )

Table ( 4) : Correlation between the nurses’ experience and observed quality of nurses performance factors in New Surgical Hospital ( n = 47 ) .

The quality factors r P 1. Assessment of patient - 0.1 > 0.05 ( NS ) condition at admission : 2. Pre- operative care - 0.12 > 0.05 ( NS ) factors : 3.Post- operative care - 0.19 > 0.05 ( NS ) factors ( first 24 hours ) 4. Post- operative care - 0.06 > 0.05 ( NS ) factors ( second 24 hours ): 5. Communication : - 0.09 > 0.05 ( NS ) 6. Documentation : - 0.13 > 0.05 ( NS ) 7. Professionalism : - 0.18 > 0.05 ( NS )

Table ( 5) : The demographic characteristics of patients in New Surgical Hospital (n= 1052):

Characteristics NO. % Department :-Ward A : 143 13.6 -Ward B : 293 27.9 - Ward C : 616 58.6 Age : − ( X ± SD ) 30.4 ± 18.1 (Range) ( 0.1 –78 )

Marital status : -Married: 551 52.4 - Single 501 47.6 Gender : * Male 371 33.3 * Female 681 64.7 Education level : - Illiterate 210 20.0 -Read/ write 401 38.1 -Secondary 193 18.3 - High education 248 23.6 Types of surgery : * Major 511 48.6 * Moderate 108 10.4 * Minor 433 41.2 Length of stay : 30.2 ± 8.5 ( 1- 47 ) No. of admission: * 964 91.6 first admission: * Second admission : 88 8.4

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Table (6): The relation between patient characteristics and patients’ satisfaction factors in New Surgical Hospital at Zagazig university Hospitals (N = 1052): The factors Illiterate, SEC. High read education education F P − − − X ± SD X ± SD X ± SD

Education : 21.9+2.4 21.3+ 2.2 22.2 ±1.9 16.57 < 0.001 ( 15 – 28 ) ( 15 -27 ) ( 19 -27 )

Moderate Major Minor Diagnoses : 22.8 ±2 21.9 ± 2.4 21 ± 2.5 29.7 <0.001 ( 18 – 26 ) ( 15 – 28 ) ( 16 – 28 )

Table (7): Correlation matrix among scores of patients’ satisfaction factors in New Surgical Hospital at Zagazig University Hospitals: The factors : R P . Environmental factors: -0.45 < 0.001 HS * Patient rights factors : - 0.17 < 0.001 HS * Health education factors - 0.06 > 0.05 NS Performance factors : - 0.11 < 0.001 HS * Social relation factors : - 0.01 > 0.05 NS Patient psychological and - 0.4 > 0.05 NS safety factors :

References 1- Abd-elrhman, A. Assessment of ,2006; 35 ( 3 ) 531- 540 . implemented infection control program of 4- Coomber, B., & Barribal, L. Impact of nurses in zagazig fever hospital . job satisfaction components on the intent to Unpublished Master Thesis , Zagazig leave and turnout for hospital based nurse. University , Faculty of Nursing , Egypt International Journal of Nursing Studies , 44 2010. 2007;( 2 ) 297 – 314 . 2- Atchison, J. Perceived job satisfaction 5- El- said, M. Relationship between factors of nursing assistants employed in motivation and job satisfaction among Midwest nursing home . Retired from : nurses , Zagazig University , Unpublished www.Geriatricnurs.gov/morapro7/com.2008 Master Thesis , Faculty of Nursing , Egypt , 3- Bjork, I., & Samdal, G. Job satisfaction 2002;39 . in a resistance : A study of job satisfaction . 6-El- said, S. Development , Journal of Nursing Management Studies implementation and evaluation of an

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Tanta Scientific Nursing Journal educational program for nurses to assure registered nurses working in an acute quality care relevant to recording in Surgical hospital . Britishing Journal of Nursing , 11 ( wards at zagazig university hospitals . 4 ) 275- 280 . Unpublished Doctorate Thesis, Faculty of 15- Said, N. Performance effect of first line Nursing, Zagazig University, Egypt.2002 management functions on productivity of 7-El-said, K.Leadership styles hospital personnel . Unpublished Doctorate empowerment and job satisfaction among Thesis , Zagazig University , Faculty of nurses. Ain- Shams University, Unpublished nursing , Egypt , 2005;69, 72 . Master Thesis , Faculty of Nursing , Egypt , 16- Saleh, M.Nurses compliance to 2005;83 . standards of nursing care in performing 8- El-sebaay, f.Quality improvement in invasive procedures at Zagazig university medical units at Aexendria main hospital . hospitals . Unpublished Master Thesis , Alexendria University , Faculty of Nursing , Faculty of nursing , Zagazig university , Unpublished Doctorate Thesis , Egypt .2002 Egypt .2009 9-Ibrahim, H.Relationship between nurses‘ 17-Syptak, J., Marsland, D., Ulmer, D.,: job satisfaction and quality of their Job satisfaction : putting theory into practice performance in Abo-Kbier general Hospital . Family practice Management , 2009;6(9) : . Zagazig university Unpublished Master 18-26. Thesis, Faculty of Nursing, Egypt. 2009 18- Tantawy, N. Nurses knowledge and 10-Lu, H., Alison, E., & Barribal L., practice related to infection control in (2009): Job satisfaction among nurses: A operating room at Zagazig emergency literature review . International Journal of hospital . Unpublished Master Thesis , Nursing studies. Retired from: www. Zagazig University , Faculty of Nursing , Sciencedirect.com . Egypt 2000; 77- 85 . 11- Lundgren, S., Nordholm, l., & 19- Tantawy, N: Development of nursing Sengesten, K . Job satisfaction in relation to care standards for emergency surgical change to all RN staffing . Journal of patients . Unpublished Doctorate Thesis , Advanced Nursing ,2005; 13 ( 3 ) 322- 328 . faculty of Nursing , Ain-Shams University , 12- Mohamed , S: Relationship between job Egypt .2004 satisfaction and absenteeism among nurses . 20- Zakaria, A. The effect of Un-Published Master Thesis , Ain-Shams communication program on the performance University , Faculty of Nursing , 2002;10 . of nurses in surgical units at El- mansoura 13- Mostafa, H., ( 2004 ) : Leadership university hospital . Unpublished Doctorate styles and job satisfaction among nursing Thesis, Ain-shams University, Faculty of managers and faculty member . Ain- Shams Nursing, Egypt.2009 University Hospitals , Upublished Master Thesis , Faculty of Nursing , Egypt . 14- Price, M., ( 2008 ) : Job satisfaction of

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Development of Students' Assessment System to Conform Academic Standards at Faculty of Nursing Tanta University: A Case Study

Rahma Soliman Bahgat Dean and Prof. of Pediatric Nursing Faculty of Nursing, Tanta University Azza Fouad Mohammed El-Adham Principle Investigator the Implementation Manager of the Project Lecturer of Obstetrics and Gynecological Nursing, Faculty of Nursing, Tanta University

Project Abstract: The development of students' assessment system at Faculty of Nursing Tanta University is a challenging area in nursing education. This case study aimed at exploring students' evaluation system at Faculty of Nursing Tanta University Tanta Egypt and presents and highlights the background, methods key findings and outcomes from the project of "Development of Students' Assessment System to Conform Academic Standards at Faculty of Nursing Tanta University" in order to provide a model for change and development of nursing education. The presented project was one of the competitive projects of the "Program of Continuous Improvement and Qualification for Accreditation" of higher education in Egypt. The evaluation project was sponsored by the Egyptian Ministry of higher education and Tanta University. The project objectives included four components: development of Code of Practice for students' evaluation, adoption of standardized competency-based assessments, adoption of an electronic system for students' evaluation, and formation of a Question Bank. The project duration was 18 months that was extended 6 more months as a result of the circumstances encountered by the country during the implementation of the project. Introduction: The process of the project included Assurance Center Tanta University Branch. declarations and commitments of the Endorsement Letter of Tanta University university, the faculty, the dean, the confirmed its commitment to and role in the principle investigator, the University project "Development of Students' Project-Management-Unit Director Assessment System to Conform Academic (UPMUD), and the Manager of Quality Standards at Faculty of Nursing Tanta

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University" with the Program of Continuous the Faculty of Nursing Bylaw, reviewing Improvement and Qualification for relevant and recent literatures, developing Accreditation through participation in the standardized theoretical and clinical project by 40% (L.E 400,000 Egyptian examinations, formation of books, pounds in cash) for attainment of the project brochures, and posters including the objectives was conducted. The endorsement guidelines and the instructions of the new letter was printed on the official letterhead developed assessment methods, and of the (partner) institution and stamped with preparation of the infrastructure of OSCE the official stamp of the institution/PMU lab, the unit of electronic system for stamp. The Faculty of Nursing Tanta students' evaluation, the printing center of University developed two committees for the faculty, and the question bank lab. the purpose of this project (the management Additionally, workshops on the developed and the implementation committees / teams) students' assessment methods were and an organizational structure endorsement conducted for both students and staff letter of both committees confirmed their members. Data were collected through commitment to and role in the project was questionnaires, letters and interviews. conducted. Additionally, a list of the names, Findings suggest the benefits of the project positions, academic credentials, and to both the students as well as the teaching professional experiences of academic and staff. Both are able to identify and use the non-academic staff starting with the developed methods of students' assessment, members of the project management team, such as Objective Structured Clinical and followed by the participants involved in Evaluation, the objective exams (multiple the project implementation was involved in choice questions "M.C.Q.", true and false the project. The participants CV‘s were also questions "T & F", and the matching joined in an Annex. questions), the acquisition of skills to adopt The project methodology included many the electronic system for students' activities, such as meetings, development of evaluation, and to formulate a question bank tools for data collection, data collection, for the six scientific nursing departments at needs analysis, SWOT analysis, reviewing

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Tanta Scientific Nursing Journal the Faculty of Nursing Tanta University Assessment/Standardized Patient Egypt. Examination, Objective Assessment, & 1) The project basic data: Academic Standards/ Faculty Bylaw" Project Title: ―Development of Students' Institution: "Tanta University Faculty of Assessment to Conform Academic Nursing" Standards at Faculty of Nursing Tanta Project Partners:Tanta University and University" Program of Continuous Improvement and Project Acronym: "Multiple stations Qualification for Accreditation Examination/Clinical Skill Budget Information: A. Requested fund (from Program of Continuous Improvement and Qualification for Accreditation) (L.E) = 535000 B. Total co-financing from Tanta University (L.E) = 400000 C. Total co-finance from other partners (L.E) = 000000 Total Budget (Sum A + B + C): (L.E) = 935000 The following were the financial Project Size: Large constraints that had to stick for: Project duration: (18) Months + (6) Tanta University Institutional Co-financing Months extended due to the circumstances of the project was 40% and the "Program of encountered by the country at the time of Continuous Improvement and Qualification implementation of the project, started from for Accreditation 60%. October 2009 to September 2011.

2) Project Team: Table (1) indicate the number of staff involved in the project Category Number of Staff involved in the project I. Administrative Committee / Project Management Team Assistant Staff: 2 Teacher/lecturer/Assistant Professor: 6 Associate Professor: 1 Professor: 2 II. Implementation Committee / Project Implementation Team

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Assistant Staff: 10 Teacher/lecturer/Assistant Professor: 7 Associate Professor: 1 Professor: 1 Non-academic Staff: 6 Total number of academic and non-academic staff involved in 36 the Project:

3) Faculty / Institute Data: University: Tanta University Faculty/Institute: Faculty of Nursing The date of establishment of the Faculty: 1982

Table (2) Total number of the Faculty/Institute students for academic year: 2008/2009 First Second Third Fourth Total year year Year year 384 346 319 409 1458

Table (3) Total number of the postgraduate students for academic year: Diploma Master PhD Total 0 71 30 101

Table (4) Number of the staff members of the faculty: Prof. Assoc Prof. Lecture Total Number of the outside or leave 3 2 43 48 25

Table (5) Number of Assistance: Assistant Demonstrator Total Number of the outside or Lecturer leave 32 24 56 4

Table (6) The number of faculty administrators: Student Financial Other administrative Postgraduate Technicians affair management affairs 5 8 21 1 10

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Table (7) Educational programs granted by the faculty (undergraduate): SN Program Program courses 1 Bachelor Degree in Nursing Science 43 Total number of programs= 1 Total number of courses (unrepeated) = 43

Duration of the program: Four years + one year internship Program level (in the credit hour system): Not Applicable

Table (8) Educational programs granted by the faculty (postgraduate): ten programs SN Program Program courses 1 Medical Surgical Nursing Departments 8 2 Maternity and Gynecological Nursing 8 3 Pediatric Nursing 10 4 Psychiatric Nursing 7 5 Public Health Nursing 7 6 Nursing Service Administration 7 7 Critical Care Nursing 8 8 Geriatric Nursing 6 9 Nursing Education 8 10 AIDS Nursing 6 Total number of programs= 6 Total number of courses (unrepeated) = 74 List of scientific Departments: 1- Medical Surgical Nursing Departments 2- Maternity and Gynecological Nursing Departments 3- Pediatric Nursing Departments 4- Psychiatric Nursing Departments 5- Public Health Nursing Departments 6-Nursing Service Administration Departments

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Table (9) Ratio of the staff member to the students Ratio of the staff member to the students 1:32 Ratio of the staff member on-the-job to the students 1:64

Background: Faculty of Nursing, Tanta University is examination is beset with several problems. competing to achieve accreditation through Most of the methods used have proved to be implementation of the Quality Assurance deficient or defective in meeting the five System in nursing education. As most important criteria of objective development of students' evaluation system examination that ensure that standards of is one of the Quality Assurance System evaluation, standards of care for patients and requirements, the faculty is trying to adopt standards of practice for nurses are met. new objective methods of evaluation. So These criteria include: systematic, long as assessment of theoretical and clinical measurable, attainable applicable, valid and competence is of great importance when reliable, and tangible / time bounded evaluating the expected learning outcomes examination. Although marking should of nursing education, our faculty challenges depend only on student variability, patient in assessing both the theoretical and clinical and procedures variability and examiner competences. Although nursing educators variability significantly affect students' applied various methods in an attempt to scoring. The subjectivity involved may find an appropriate tool, including written reduce the marks awarded by different and oral exams, seminars, role play, group examiners for the same students' discussion short and long practical cases, yet performance. The marks awarded also the majority of examinations at the faculty reflect only the global performance of the are of the old traditional type. They are students and are not based on demonstration neither evidence-based nor community- of individual competencies and creativity. based nor performance-based assessment Problems in communication significantly methods. They are unreliable, invalid and affect the outcome. Attitudes are usually not non objective. The conventional clinical and tested at all by the conventional theoretical examination, and the student is questioned

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Tanta Scientific Nursing Journal only regarding the final conclusion. The was established. Staff members were trained final score indicating student' overall to effectively apply the new methods of performance gives no significant feedback to evaluation. Also students were trained on the student. The ability to examine a student those new methods before being and arrival at a conclusion is not observed implemented. The project plan and by the examiners/staff members. outcomes were monitored and evaluated. Additionally, the examination code of The project beneficiaries included: student practice (faculty evaluation bylaw) is not nurses, staff members, patients, families, developed/revised/ renewed to meet the hospitals, health care system, and the current academic nursing standards in community as a whole got benefit from nursing education and the program intended graduation of competent nurses that satisfy learning objectives/outcomes. Also, there is stakeholders' needs. The project importance no electronic system for student evaluation, included enhancement of the Faculty of and there is no question bank. As a result of Nursing and Tanta University national limitations involved in the evaluation system strategy of education development. The at the Faculty of Nursing Tanta University, project implementation helped the faculty to graduates are up to the level required. overcome the problems encountered in the Investigating the stakeholders‘ needs and previous examinations system; guarantee evaluation of the current graduates is continuous improvement as a step to meet unsatisfactory. Nurses are not competent and the requirements of the National do not satisfy and community needs. Accreditation Committee in Egypt; Scope: enhanced teaching and learning process; met Student Evaluation Project covered the the academic standards; met the faculty entire undergraduate as well as two of the mission and vision; graduate competent postgraduate nursing courses over a period professional nurses at national, regional, and of 18 months. The code of practice was international standards who will be able to structured, revised and approved by the provide evidence based nursing, culturally faculty council. Infrastructure and sensitive communication, ethical principles, modifications suitable for the new system awareness and responsiveness to health care

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Tanta Scientific Nursing Journal system, satisfy stakeholder's needs, and of the responsibilities of various boards and compete for excellent positions. committees which relate to this Code of Objectives: Practice were available at faculty student The project objectives were (1) development handbook and in a brochure for evaluation of examination code of practice (faculty rules, and at Tanta University website. (2) evaluation bylaw revision, renewal and Development of objective theoretical and approval of the examination items), (2) clinical examinations. (3) Adoption of development of objective theoretical and electronic system for student evaluation, and clinical examinations, (3) adoption of (4) Adoption of a question bank. The project electronic system for student evaluation, and supported a large number of the Faculty of (4) adoption of a question bank. The project Nursing Tanta University students of assumptions included: (1) Development of undergraduate nursing program of six objective summative and formative tools for nursing departments /specialties assessment of theoretical and clinical (Fundamental and Medical Surgical examinations that meet the academic Nursing, Maternity and Gynecological standards, (2) Solving problems encountered Nursing, Pediatric Nursing, Community by the present evaluation system. (3) Health Nursing, Psychiatric Nursing, and Attainment of one of the requirements of the Nursing Service Administration). National Accreditation Committee in Egypt. Additionally, the new developed student Description: assessment system was implemented on two The project included: (1) Development of courses of the post graduate nursing examination code of practice (faculty programs. The project period was 18 months evaluation bylaw revision and renewal). The extended 6 more months. code of practice described the conduct of Methodology and the faculty experience objective formative and summative with the project: assessment of the nursing courses of the Faculty of Nursing Tanta University faces undergraduate curriculum and of two several problems in students' evaluation courses of the postgraduate programs at the system. These include: the examination code Faculty of Nursing Tanta University. Details of practice (faculty evaluation bylaw) is not

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Tanta Scientific Nursing Journal developed to meet academic standards, bank [three months]. The project period was absence of objective theoretical and clinical 18 months extended 6 more months and examinations, there is no electronic system some of the activities were overlapped in the for student evaluation, and there is no timescale. question bank. The project included the Needs Analysis: following steps: (1) formation of assessment Faculty of Nursing Tanta University is committees [three months]; (2) preparation trying to achieve accreditation through of the infrastructure [six months]; (3) implementation of the Quality Assurance searching, and sourcing [three months]; (4) System in nursing education. Development development of the evaluation code of of students' evaluation system at Faculty of practice (review and renew of the faculty Nursing Tanta University is one of the evaluation bylaw, development of drafts, Quality Assurance System requirements. In assessment of opinions, development of this regard, assessment of theoretical and final version, approval from the faculty clinical competences is of great importance. council, and dissemination among different Assessment of students at Faculty of stakeholders [six months]; (5) development Nursing Tanta University did not measure of objective theoretical and clinical high levels of competencies, and creativity examination (conduction of thirty six in examinations. Graduates are not workshops for training of staff for the six professionally competent based on scientific nursing departments in the assessment of stakeholders' opinions. Faculty, development of drafts, assessment Stakeholders' opinions indicated that the of opinions, development of final versions present evaluation system is not evidence for the six nursing departments) [three base and the exams did not measure the months]; (6) development of an electronic actual performance of the students. Such system for student evaluation [six months]; limitations led to the disability of the (7) conduction of six meetings for training nursing graduates to meet the needs of the and examining students using the new patients and the market, and led to developed examination methods [three community dissatisfaction with the faculty months]; and (8) formation of a question graduates. Faculty of Nursing Tanta

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University is in need to use the most valid The opportunities included in the present and reliable methods of students' evaluation evaluation system were project fund and an in order to overcome the limitations opportunity to change and correct the encountered in its theoretical and clinical present evaluation system. examinations to become an integral The threats included in this project were component of the entire teaching and the resistance of the staff to implement the learning process, and to meet the community new developed evaluation system, refusal of needs. the staff to implement the new methods SWOT Analysis: adopted by the faculty, staff withdrawal The strengths included in the present from the project for different reasons e.g. evaluation system were supportive traveling abroad, and discontinuation of the administration of the faculty, variability in project fund, time and money limitations, staff experiences, and implementation of retardation in admission of a time/stage some objective examinations, e.g. Multiple report of the project, administrative barriers, Choice Questions (M.C.Q.) and change of the university presidents. In The weaknesses included in the present order to overcome the threats/risks, the evaluation system were subjectivity; following strategies were applied: The problems in communication; attitudes are stakeholders were involved in the project usually not tested; no significant feedback to activities; their opinions were assessed; the student; examination do not meet the further explanation were given for those program Intended Learning who ask for; handouts, poster, and a Objectives/Outcomes (ILOs); examinations portfolio were provided; thirty six do not measure competencies and creativity; workshops and six meetings were and the examinations do not measure the conducted; involvement of the faculty three domains of nursing education administration by attending and providing (knowledge, skills, and attitudes). On the regular reports about the project progress; other hand, there are some opportunities that and getting approval of the new developed will enhance the present evaluation system. students' assessment by the faculty council.

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Activity plan and implementation Structured theoretical and clinical The project specific objectives are: (1) examinations [six months] for the six develop /review/renew and approve the nursing departments and 2 post graduate faculty examination code of practice (faculty courses (conduction of thirty six workshops evaluation bylaw), (2) develop objective for training of staff, development of drafts, theoretical and clinical examinations, assessment of opinions, development of (3) adopt an electronic system for student final versions, training and examining evaluation, and (4) establish a question students using) the developed assessments bank. The project objectives attained [six months]. This output faced inability of through the following activities: staff members to use information (1) Available committees for conduction of technology, lack of staff and students' various project objectives and activities, e.g. cooperation, and lack of human and non a committee for reviewing and renewing the human resources. (5) Available electronic faculty evaluation bylaw, and a committee system for students' evaluation [three for constructing and reviewing months]. This output faced lack of resources examinations. This output faced staff in the term of place, money and people, and resistance and lack of cooperation [three staff and administrative resistance. (7) months]. (2) Preparation of the infrastructure Available question bank [three months] [six months]. This output faced by lack of included formative and summative resources in the term of place, money and examinations. This output faced by lack of people. (3) Available Code of Practice for resources and staff cooperation. The project students' evaluation (sourcing and searching, resources included human and non human review and renew of the faculty evaluation resources, such as personnel, money, bylaw, making drafts, assessment of physical environment, computers, printers, opinions, development of final version, photocopy machines, scanner, papers, approval from the faculty council, and manikins, video cameras, electronic machine dissemination among different stakeholders for students' assessment, and six OSCE [six months]. (4) Available of the Objective stations, etc.

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Logical Framework Matrix Specific Outputs/ Code Activities Objective(s) Outcomes 1.1.1. Invitation of staff for participation in the committees 1.1. Available 1.1.2. Conduction of 3 meetings for appointment of staff evaluation committees for various evaluation committees (1committee for for revision, and development of code of practice, electronic system, and renewal of faculty the question bank, and 6 committees for development of evaluation bylaw, and theoretical and clinical objective assessments for the 6 development of nursing departments). A subcommittee from the 6 (1) student assessments. committees will be assigned for preparation of the Development infrastructure needed for the various project objectives, of Code of e.g. OSCE stations I Practice for 1.2. Available new students' evaluation bylaw/code 1.2.1. Assessment of opinions regarding the present and evaluation. of practice with the new developed evaluation bylaw through details of the questionnaires responsibilities of 1.2.2. SWOT analysis various boards and 1.2.3. Searching and sourcing, development of drafts, committees which development of the final version of the new code of relate to this Code of practice, and approval by the faculty council Practice, 1.2.4. Dissemination through faculty student handbook documentation of and a brochure marks and grads, and other concepts 2.1. Available 2.1.1. Preparation of 6 OSCE stations for assessment of infrastructure suitable clinical competencies for the 6 nursing departments for the developed 2.1.2. preparation of a photocopy center equipped with students' clinical and necessary machines for safe exams printout theoretical 2.1.3. preparation of a suitable place fulfilling the assessments requirements for the question bank (2) Adoption 2.2.1. conduction of 6 workshops for training the staff of of the 6 nursing departments on the development of standardized objective assessments, criteria of examination paper, the 2.2. Trained staff on II competency- electronic system for students' evaluation, and the development of based categories and subcategories of examinations for the objective assessments assessments. question bank (pre test and post test will be done, and needs assessment) 2.3. Available 2.3.1. development of drafts for the 6 nursing objective summative departments and formative tools 2.3.2. assessment of opinions regarding the developed for students' tools assessment for 2.3.3. peer reviewing

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theoretical and clinical 2.3.4. development of final versions based on the competencies and obtained comments measure the ILOs of 2.3.5. Expert reviewing the faculty program and the courses. 2.41. orientation/training of students on the use of the 2.4. Trained students new developed assessments (OSCE and other methods) on the use of the new 2.4.2. routine assessment using the developed objective assessment methods. assessments 2.4.3. assessment of feedback

Logical Framework Matrix Specific Outputs/ Code Activities Objective(s) Outcomes 3.1. Available equipment needed 3.1.1. purchase of the electronic machine for for electronic system for students' (3) Adopt an students' assessment electronic evaluation III system for 3.2.1. Formulation of a portfolio that include 3.2. Available instructions on the students' staff members, students, and administrators assessment of students using the evaluation. directions on the use of the electronic system electronic system for students' evaluation 4.1. Available question bank that 4.1.1. Preparation of the infrastructure and include 6 categories and (4) development of drafts of templates and subcategories for assessing Formation of categories for each course/or department IV theoretical and clinical a Question 4.1.2. Development of final versions of the competencies that include Bank. templates for each department/ category and knowledge, understanding, skills, subcategories attitudes, and communication.

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Feedback nursing care at the six nursing specialties Feedback of the students upon whom the of Faculty of Nursing Tanta University. (2) evaluations implemented were assessed to Students communicate effectively in a evaluate the pros and cons met with during culturally sensitive manner with the implementation. Community and patients. (3) Students acquire knowledge stakeholders feedback was assessed in and skills needed for effective patient care. order to ensure the benefit of the (4) Students use information technology implementation of the project. for the benefit of their patients. (5) Project Outputs/Outcomes: Students provide evidence based nursing. The project outcomes included availability (6) Students demonstrate professionalism, of objective summative and formative ethical principles, and an awareness of and tools for assessing theoretical and clinical responsiveness to the larger context of competencies that include knowledge and health care system. Graduation of understanding, skills and attitudes, meet competent nurses at national, regional, and community and labor market needs; and international standards. The outcomes also are transparent and fair, availability of involved available objective fair electronic examinations; available unit for evaluation examinations; available electronic assessment, ; existence of a evaluation committee for development, Question Bank, trained staff on the revision, renewal of faculty evaluation development of the new student bylaw, assessments; and students' assessment available developed code of practice for using the new developed tools and students' assessment (new evaluation methods, prevention of private classes, bylaw), available evaluation rules and evaluation committees will be available for ethics in documents. development, revision, and renewal of Dissemination and Sustainability: evaluation rules and examinations to meet The project dissemination through: (1) national, regional, and international Conduction and or participation in national standards, and dissemination of evaluation and international conferences and rules among students, staff, and workshops, seminar/round table discussion administrators. Additional project and meetings, and publication in faculty outcomes included: (1) students and student handbook, brochure, posters, graduates provide patients with competent books, and university web-site. The project

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Tanta Scientific Nursing Journal sustainability is influenced by three major Institutional sustainability through (1) groups of factors, and five important sub maintenance of the project equipment factors: (1) project design and (OSCE stations, manikins, electronic implementation factors: (a) the project system machine, computers, printers, outcomes modification over time, (b) the photocopy machine, lab top, and data "champion"/responsible committee show projector) and continue to use for present, (2) factors within the long-time; (2) regular revision and renewal organizational setting: (c) the project "fits" of the evaluation code of practice; (3) with the faculty mission and procedures, regular revision and renewal of the (d) perceived benefits to staff members developed students' assessment methods and/or clients, and (3) factors in the and procedures of both clinical and broader community: (e) stakeholders in theoretical components of the program of other organizations provide support. study; (4) maintenance of the project Important categories of indicators of the infrastructure, i.e. Question Bank and the project sustainability include: (1) printing center in place equipped with the maintenance of benefits achieved through necessary equipments; and (5) keeping the project, (2) level of institutionalization of project materials and documents in a well the project within the faculty and (3) conducted recording and reporting system. measures Sustainability at the policy level: include of capacity building in the recipient, i.e. quality control and monitoring, peer and staff members and their assistants, and the experts reviewing, recording and reporting students. system of activities, and inter- Program of The long-term perspective for project Continuous Improvement and results/outcomes includes financial Qualification for Accreditation project sustainability, and. sustainability at the coaching (auditing, monitoring, and policy level. reviewing). The overall project Financial sustainability of the project management implemented based on activities through: (1) allocation of an management structure and decision examination fee will be obtained, (2) making process. Management of the renting the project equipment for similar project used a scientific management agencies (nursing and health sciences), and approach for management of committees, (3) conduction of paid workshops. resources, activities, and evaluation

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Tanta Scientific Nursing Journal timeline, for planning, organizing, leading community needs. The project objectives and controlling the project teems, and were to: review and renew of the faculty activities. Critical thinking technique was evaluation bylaw; disseminate used for decision making to guide the examinations rules, adopt standardized project decisions, actions and beliefs theoretical and clinical competency-based through a rigorously and skillfully use of summative and formative tools, adopt an information, experience, observation and electronic system for students' evaluation; reasoning. For effective structure and establish a Question Bank. The project management of this project, role and implementation helps to overcome the responsibility of each member of the problems encountered by the previous project management team was identified. examinations system, and helps to meet Job classification, job descriptions, one of the requirements of the National understanding of interpersonal skills, Accreditation Committee in Egypt, and providing motivation, e.g. Financial meet the academic standards. The project rewards based on doing good job, special included: formation of various committees, compensation for overtime and extensive construction of various objective travel, and performance appraisal. Conflict assessments, preparation of the resolution by establishing priorities, good infrastructure (OSCE stations, the unit of planning, and consideration of specialties electronic system for students' evaluation, of individuals, and use of continuous and the question bank), training of staff formal and informal communication members, their assistants and students, and between team members examination entry for the question bank. Project summary: The new objective assessments met the Development of students' Assessment to psychometric and logistic assessment conform academic standards at Faculty of criteria in assessing many fundamental Nursing Tanta University constitutes a components of theoretical information and critical need for a systematic, measurable, clinical skills, as well as the transferable attainable/ applicable, valid/reliable, and skills not covered in other evaluations. The tangible / time bounded assessment. It is impact of realization of the present project important to avoid exam subjectivity, benefit students, staff members and their improve communication, graduate assistants, patients, health care sectors, and competent nurses, and satisfy the the community. Graduates of the Faculty

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Tanta Scientific Nursing Journal of Nursing will provide practical solutions, 3) Iain.R. Exploring approaches to innovate, create, deal with the clinical skills development in nursing technological advances, and conduct education. Nursing Times; 2009;105 outstanding scientific research to protect (3): 20-22. the community against health hazards at 4) The Egyptian Ministry of higher national, regional and international level. education. Code of the Bet Practices Graduates provide competent nursing care, for Students' Assessment in Higher

effective culturally sensitive Education. 1st draft. Revision 5. communication; use information 5) Frances M. Hill."Managing service technology and evidence based nursing, quality in higher education: the role of and demonstrate professionalism, ethical the student as primary consumer". principles, awareness of and Quality Assurance in Education, 1995; responsiveness to the health care system. 3(3): 10 – 21. References: 6) Conole,G. The Role of Evaluation in 1) El-Adham, A. et al. "Development of the Quality Assurance of eLearning. Students' Assessment System to Summer.Learning and Teaching in Conform Academic Standards at Action. 2004;3(1): 9 Faculty of Nursing Tanta University". 7) Susan M. Brookhart, Helena, MT. Project of Continuous Improvement Developing Measurement Theory for and Qualification for Accreditation" Classroom Assessment Susan M. of higher education in Egypt. The Brookhart, Helena, MT. Developing Egyptian Ministry of higher education Measurement Theory for Classroom and Tanta University Egypt 2009. Assessment. Purposes and Uses. 2) Mundt MH, Clark Procaccini M, and Winter Educational Measurement: Klemczak Wrona J. A Task Force Issues and Practice 2003. Model for Statewide Change in 8) NLN Board of Governors. Nursing Education Building Quality Transforming Nursing Education: and Safety. Journal of Professional Leading the Call to Reform. Nursing.Retrieved from Academic Progression in Nursing http://www.rwjf.org/en/research- Education A Leving Document from publications/find-rwjf-research.2013 the National League for Nursing 2011.

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9) Benner, P., Sutphen, M., Leonard, V., www.nln.org/newsreleases/tri-council. Day, L. Educating Nurses: A Call for 2010. RadicalTransformation.San. 15) Bruffee, Kenneth A. Collaborative Francisco, CA; Jossey-Bass2010. learning: Higher education, 10) Institute of Medicine. The Future of interdependence, and the authority of Nursing, Leading Change, Advancing knowledge.. Johns Hopkins University Health. Washington, DC:Author 2011. Press. Baltimore. 2002; 227-233. 11) Matthew W. Short, John A. Edwards, 16) Robert Wood Johnson Foundation. Madigan Army. Assessing Core Transforming Nursing Education to Competencies with an Objective Meet Emerging Health Care Needs. Structured Clinical Examination. The 2013. Route 1 and College Road East, ACGME Outcome Project: An P.O. Box 2316 Princeton, NJ 08543. Introduction.. Accreditation Council 17)Mundt MH, Clark Procaccini M, and for Graduate Medical Education. Klemczak Wrona J. A Task Force Model Review 2005 for Statewide Change in Nursing 12) National League for Nursing. Education Building Quality and Safety.. Academic/Professional Progression in Journal of Professional Nursing.Retrieved Nursing [Reflection and Dialogue. http://www.rwjf.org/en/research- Retrievedfrom publications/find-rwjf2013- www.nln.org/aboutnln/reflection_dial 18)Center for Teaching and Learning ogue/refl_dial_2.htm2007. Division of Academic Affairs. One 13) National League for Nursing. Hundred Methoss. The University of Outcomes and Competencies for North Carolina at Charlotte 2013. Graduates of Practical/ Vocational, 19)Jackson. S. 3 New Teaching Methods: Diploma, Associate Degree, Improve the Educational Process. 2012. Baccalaureate, Master‘s, Practice Learning. Learning Innovation. Doctorate, and Research Doctorate 20)South African Qualification Authority. Programs in Nursing. New York2010. Criteria and Guidelines for Assessment of 14) Tri-Council for Nursing. Educational NQF Registered Unit Standards and Advancement of Registered Nurses: A Qualifications. Policy document. Consensus Position. Retrieved from Directorate: Quality Assurance and Development. Waterkloof, Pretoria2001.

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21)Kou M. Objective Test Formats. How 22)Faculty of Nursing Tanta University. to Construct Objective Test Itens. Effect of The Education Bylaw. 2003. Objective Test Items on Teaching and Learning.The Gale Group, Inc. Retrieved from:http://www.education.com/reference/ article/objective-test-items/2010

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Influence of Intramuscular Dexamethasone on Labor Duration in primigravidas Fatma Ahmed AboRomia Azza Fouad Mohammed El-Adham Lecturer of Obstetric and Gynecological Nursing Faculty of Nursing, Tanta University Abstract The influence of intramuscular (IM) administration of dexamethasone on labor duration in primigravidas was assessed. An observational prospective case control design was used. Data collected from two Maternity and Child Healthcare Centers, over three months using a pre designed assessment tool conducted by the researchers.. The study sample was selected by purposive random sample technique. The sample consisted of 172 primigravidas women who had favorable cervix with a bishop score of 7 or greater, pregnancy duration of at least 37 weeks, a first trimester ultrasound, and a vertex presentation of a singleton fetus. Primigravidas with maternal systemic diseases, pre mature rupture of membranes (PROM), and vaginal bleeding were excluded. The sample was divided into two equal groups. The experimental group (86 primigravidas, 43 from each center) received an intramuscular injection of 8 mg (2ml) of dexamethasone, and the control group (86 primigravidas, 43 from each center) received a placebo of IM injection of 2 ml of saline. Data was analyzed using SPSS Version 17. Data results revealed that women received (IM) injection of dexamethasone had significantly shorter duration of the second stage of labor compared to those received IM injection of 2 ml of saline. However, no statistically significant differences were found between the studied groups regarding durations of the active / first and third stages of labor. The study recommended that intramuscular injection of dexamethasone is very important to shorten the length of the second stage of labor especially for primigravidas women to prevent unwanted complications. Introduction Although administrating corticosteroids is shown the importance of corticosteroid a suggested method to shorten labor secretion by the fetal adrenal glands on the duration, the role of these agents in the beginning of labor.(2) The findings of process of labor in women is not well these studies have led to the hypothesis understood.(1) Several animal studies have that corticosteroids also has an effect on

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Tanta Scientific Nursing Journal the duration of labor in primigravidas In this double-blind, randomized, placebo- women. Corticotrophin-releasing hormone controlled study, the effect of preoperative (CRH) has been identified in various organ administration of dexamethasone on systems, including the female reproductive postoperative vomiting and pain in women system. It is the principal regulator of the undergoing general anesthesia for major hypothalamic–pituitary–adrenal axis. gynecological surgery was evaluated. Circulating placental corticotrophin Dexamethasone was effective in reducing releasing hormone (CRH) is responsible the overall incidence of vomiting from, for the physiologic hypercortisolism of the and the influence of dexamethasone on latter half of pregnancy and plays a role in postoperative pain was minimal.(7) the onset of labor.(3,4,5) Dexamethasone is a corticosteroid with Administration of dexamethasone to strong antiinflammatory and prolonged pregnant women is now common practice effective strong antiemetic in patients if delivery before 34 weeks is expected. receiving cancer chemotherapy. It reduces Dexamethasone reduces the incidence of the incidence of postoperative vomiting respiratory distress syndrome in the new- and surgery-related side effects such as born, enhances the efficacy of neonatal delayed wound healing and increased surfactant therapy, and reduces the incidence of wound infection. The associated risk of intravascular cautious use of dexamethasone in surgical haemorrhage, and neonatal death. patients is recommended. Dexamethasone Conversely, some concerns exist about was administered orally, as well as adverse maternal effects of corticosteroid. intravenously (IV) as a post-operative The study revealed the effect of antiemitic. Studies revealed that for dexamethasone on human chorionic antiemesis, the minimum effective dose of gonadotrophin (HCG) concentrations and dexamethasone without discernible side suggested a direct inhibitory effect on effects is 2.5 mg. (8) placental hormone synthesis or secretion. Dexamethasone is corticosteroids used in Recommendations included the need for the management of preterm premature further studies to define the mechanism of rupture of membranes (PPROM) to action of dexamethasone on placental enhance fetal maturation and prevent HCG production.(6) obstetrical complication associated with high neonatal morbidity and mortality.

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Dexamethasone accelerates maturation of understand the benefits and limitations of fetal lungs, decrease number of neonates these medications. Obstetrics and with respiratory distress syndrome and gynecological nurses can contribute in the improves survival in preterm delivered enhancement or alteration of the health neonates. Optimal gestational age for use conditions involving the mother, the fetus, of dexamethasone therapy is 31 to 34 and the newborn, because the scope of weeks of gestation. Thus, the prenatal professional nursing practice is developed administration of corticosteroids had great and expanded to include and allow nurses valuable effect in conditions of PPROM. to implement a lot of clinical tasks and ( 9,10,11,12) techniques that were not employed in the Additionally, dexamethasone and past. Obstetrics and gynecological nurses lidocaine 1.5% solution are used in are key health care providers for axillary brachial plexus block as they childbearing women. They are significant prolong the duration of sensory and motor personnel and have important roles in the blockade. The optimal dose of prevention and control of morbidity and dexamethasone to be used for prolonged mortality risks of childbearing mothers, brachial plexus block as well as the such ad prolonged exhausting labor and its mechanism of this effect is not clear.(13) subsequent complications.(15) Dexamethasone is used in block Many studies show the probable effects of prolongation of local anaesthetics. corticosteroids on the labor process. Dexamethasone prolonged the action of Corticosteroids have been administered ropivacaine more than that of bupivacaine, intravenously, intramuscularly, and by the combined effect of dexamethasone and extra-amniotic infusion in various clinical either drug produced nearly the same 22 trials.(1,2,3,4) Consequently, it is very hour of analgesia. Large studies will be important for obstetrics and gynecological necessary to demonstrate the safety of nurses to find out the influence of dexamethasone for perineural use.(14) intramuscular injection of dexamethasone Medication used in women during labor on labor duration in primigravidas. and delivery, such as intramuscular Aim of the study injection of dexamethasone is The aim of the study was to determine the implemented by obstetrics and influence of intramuscular (IM) gynecological nurses. They should

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Tanta Scientific Nursing Journal administration of dexamethasone on groups of the study. Consequently, there duration of labor in primigravidas women. would be a 30% chance (power = .70) of Materials and Method: finding non-significant results, even if the Materials null hypothesis were false.(17) Subjects Study design were selected according to the following An experimental prospective case control inclusion criteria: being primigravidas, design to determine the influence of having favorable cervix with a bishop intramuscular (IM) administration of score of 7 or greater, pregnancy duration dexamethasone on duration of labor in of at least 37 weeks according to a reliable primigravidas women. date for the last menstrual period and a Setting first trimester ultrasound examination, The study was conducted at Segar and vertex presentation and singleton fetus. Kohafa Maternity and Child Healthcare The subjects' exclusion criteria comprised Centers at Tanta, Egypt. maternal systemic diseases, pre mature Sample rupture of membranes (PROM), and The study sample consisted of 172 vaginal bleeding. primigravidas women. They were selected Tool of the study by purposive sample random technique A pre designed assessment tool was and divided into two equal groups: the developed by the researchers and used to experimental and control group (86 collect the necessary data about the study primigravidas, 43 from each center), The sample. It included sociodemographic and sample size needed for each group can be clinical data, such as age in years, body determined by calculation or estimation of mass index (BME = weight / height2), the eta-squared ( 2 ), or based on gestational age, and the bishop score information from relevant studies or a pilot (assessment and calculation of the study. Sample size ratios differ according parameter/score of position, consistency, to the number of groups in the study. Thus, effacement, and dilatation of the cervix, for the current study, the approximate and the foetal station). sample size necessary to achieve a level of Methods power of 70% for  = .05 as a function of Permission to carry out the study was estimated population values of eta-squared obtained from the directors and the responsible specialists of the selected is (86) primigravidas in each of the two

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Tanta Scientific Nursing Journal settings after explanation of the aim of the by measuring their weight in kilograms study. Informed, oral consent was obtained and dividing it by the square of their from all primigravidas women who were height in meters. Bishop's Score invited and agreed to participate after calculation included assessment and explanation of the aim of the study. They calculation of the parameter/score of were informed of their voluntary to position, consistency, effacement, and participate and the right to refuse and of dilatation of the cervix, and the foetal the respect of their confidentiality. Before station. Parameter/score of cervix position embarking in the study a pilot study was ranged from (0 to 2) which means carried out on 8 primigravidas women (4 posterior, intermediate, and anterior from each center) to determine the respectively). The anterior position is applicability of the study. These better aligned with the uterus, and primigravidas were excluded from the therefore there is an increased likelihood actual data of the study. A total number of of spontaneous delivery. Parameter/score 172 primigravidas women were randomly of cervix consistency ranged from (0 to2) selected and divided into two equal which means firm, intermediate, and soft groups: the experimental group (86 respectively. When the cervix is less rigid, primigravidas, 43 from each center), and it allows for easier dilatation of the cervix the control group (86 primigravidas, 43 at term as in multigravida woman. from each center). Gynecological Parameter/score of cervical effacement are procedures were enrolled in this study. The (0-30%, 31-50%, 51-80%, and >80%) field work was carried out by the which ranged from (0-3). It measures the researchers within duration of three stretch already present in the cervix and is months. Once labor began the affected by individual variations and experimental group received an surgery. Parameter/score of cervical intramuscular injection of 8 mg (2ml) of dilatation are (0 cm, 1-2 cm, 3-4 cm, and dexamethasone, and the control group <5 cm) which ranged from (0-3). It is the received a placebo IM 2 ml of saline. diameter of the stretched cervix and it Data collection complements with effacement and is the Sociodemographic and clinical data (age in most important indicator of progression of years, body mass index (BME), gestational the first stage of labor. Parameters of fetal age, and the bishop score) were assessed station are (-3, -2, -1.0, +1, and +2) which by the researchers using the pre designed ranged from (0-4). It describes the position assessment tool. The Body Mass Index of the fetal head in relation to the ischial (BMI) of the primigravidas was estimated spines (negative numbers indicates that the

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Tanta Scientific Nursing Journal head is further inside above the ischial statistically significant differences between spines). It is palpated deeply inside the the two groups. posterior vagina (8-10 cm) as a bony Table (2) shows that the Comparison protrusion. The total Bishop Score is 14. A between the 2 groups regarding duration of total Bishop Score for childbearing woman the various stages of labor using Student t is considered favorable if the score is (7 or test had shown that women of the <7). Additionally, all women were experimental group who received an subjected to full history taking, abdominal intramuscular (IM) injection of 8 mg (2ml) examination, assessment of fundal level dexamethasone had significantly shorter and auscultation of fetal heart sounds. duration of the second stage of labor, the Statistical analysis data results were statistically significant at tatistical analysis of the collected data was 0.05% (P = 0.001) than the control group computed using SPSS versions 17 under who received a placebo IM 2 ml of saline the platform of Microsoft Windows 7. once Labor begins. However, no Continuous data were expressed in the statistically significant differences were form of mean ± SD, while categorical data found between the studied groups were expressed in the form of count and regarding durations of the active/first and percent. Comparison of continuous data third stages of labor was performed utilizing student t test, Table (3) illustrated the Correlation while categorical data were done using between durations of the three stages of Chi-square test. Relation between labor and the basic data (age in years,body variables was investigated using Pearson's mass index (BME), gestational age, and correlation coefficient. (P value less than the bishop score) revealed that a 0.05) was considered statistically statistically significant relation at 0.05% significant. existed between the subjects' BMI, Results gestational age, Bishop Score, and the Table (1) shows that Intramuscular (IM) duration of the first stage of labor injection of 8 mg (2ml) dexamethasone (P=0.005, 0.01, and . 0.03) respectively On was applied to the experimental group and the other hand, there was a statistically a placebo IM injection of 2 ml saline was significant relation between the subjects' applied to the control group once labor age and the duration of the second stage of begins. Data were analyzed on age in labor (P= 0.01). years, body mass index (BME), gestational age, and the bishop score. Comparison between the studied groups There were no

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Table-1 Comparison between the basic findings in the studied groups Socio- Student t test Dexamethasone Control group demographic and group (n=86) (n=86) T p clinical variables Age (Years) 18.6 ± 1.4 18.8 ± 1.7 -0.67 0.5 BMI (Kg/m2) 27.0 ± 3.3 26.4 ± 2.7 0.93 0.35 Gestational age 38.2 ± 1.0 38.5 ± 1.1 -1.1 0.27 Bishop score 7.7 ± 0.7 7.9 ± 0.8 -1.2 0.2

Table-2 Comparison between the studied groups regarding duration of the various stages of labor Duration of labor Dexamethasone Control group Student t test group (n=86) (n=86) T P 1st stage duration 3.6 ± 0.7 3.8 ± 0.8 0.81 0.15 2nd stage duration 17.9 ± 3.5 22.4 ± 8.6 -3.4 0.001* 3rd stage duration 6.9 ± 1.9 7.0 ± 1.8 0.53 0.71

Table-3 Correlation between 1st. 2nd, and 3rd stages of labor duration and the basic data Socio-demographic 1st stage 2nd stage 3rd stage and clinical duration duration duration variables r P R P r p Age (Years) 0.11 0.12 0.19 0.01* 0.05 0.32

BMI (Kg/m2) 0.19 0.005* 0.14 0.09 -0.11 0.07 Gestational age 0.17 0.01* 0.1 0.11 0.07 0.83 Bishop score -0.18 0.03* 0.08 0.78 0.05 0.56

Discussion In the present study, comparison between Kashanian et al.(18) reported on the extra- the studied groups regarding duration of amniotic infusion of a saline solution the various stages of labor had shown that mixed with dexamethasone through a the dexamethasone group had significantly Foley catheter whose balloon was filled shorter duration of the second stage of with 15 mL of water, and concluded that labor when compared with the control the procedure could shorten the duration of group. These are in line with the labor without significant maternal or fetal conclusions of Barkai et al.(1,2,17) who risk. Thus, the present study provides found that inducing labor by means of an high-level evidence of direct relevance for extra-amniotic infusion of corticosteroids clinical practice, because the use of through an intracervical Foley balloon dexamethasone on labor of primigravidas catheter reduced the time between will reduce the risk of prolonged labor and induction of labor and delivery. Also,

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Tanta Scientific Nursing Journal delivery and prevent the consequent dexamethasone on placental HCG complications. production. Ziaei et al.(19) examined the effect of Furthermore, Kashanian et al.(18) evaluated intramuscular administered of the effect of dexamethasone corticosteroids on the labor process using a administration on labor duration. In this randomized, controlled study on 66 controlled trial on 122 nulliparous women women with gestational age of 41 weeks with a full-term pregnancy and a Bishop and over and favorable cervix (bishop score of 7 or greater were randomly score > or = 7). The study group (n = 32) assigned to receive a single 8-mg dose received 10 mg of dexamethasone of dexamethasone or placebo 6 hours phosphate intramuscularly in two doses at before initiation of labor induction. The an interval of 12 hours, and the day after authors found that the duration of the the enrolling administration intravenous second stage of labor was also shorter in oxytocin was given. The control group (n the dexamethasone group. The effect of = 33) received only intravenous oxytocin dexamethasone on labor duration had 24 hours after enrolling. The number of many explanations. It has been shown that patients to enter the active phase of labor glucocorticoids induce the synthesis of was significantly higher in the study group surfactant protein in human fetal than in the control group (n = 33 [100%] membranes, and suggested that surfactant vs n = 29 [87.9%], p < 0.039). The mean protein induced prostaglandin E2 synthesis time interval between induction of labor in chorionic trophoblasts—thus playing a and the active phase was significantly role in the initiation of parturition.(20,21) shorter in the study group than in the Glucocorticoids are normally circulating control group (1.7 +/- 1.5 hours vs 4 +/- stress hormones; however, in the initiation 1.7, P < 0.0001), and the mean of oxytocin of labor, a stressful situation, their dose was significantly lower in the study expression is regulated by placentally group (1.15 +/- 1.5 u vs 4.16 +/- 2.5 u, P < derived corticotrophin-releasing hormone 0.0001). The study confirmed that (CRH).(20) Other studies have suggested a induction of labor with the use of role for this hormone on the initiation of intramuscularly injected dexamethasone active contractions of uterus (22), and also a phosphate reduced the time interval role for maternal stress hormones. (23) between the induction of labor and the In the present study, there was a active phase. This is in line with the statistically significant direct correlation present study, because the use of between first stage duration and maternal dexamethasone enhanced and shortened BMI. This is in accordance with Norman the second stage of labor. et al.(24) who found that the first stage of On the other hand, the present study labor for obese women is of longer contradicts with Ogueh1 et al. (6) who duration and has a slower progression until explained the effect of dexamethasone on 6 cm than the non-obese cohorts, even HCG concentrations and suggests that it after adjusting for potential confounding has a direct inhibitory effect on placental factors. In addition, the current study hormone synthesis or secretion. The found a statistically significant correlation authors recommended further studies to between gestational age and first stage define the mechanism of action of duration. This is in harmony with the

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Tanta Scientific Nursing Journal findings of Cheng et al.(25) who reported gestational age, and duration of the second that women with first stage duration stage of labor. In primigravidas, under the greater than the 95th percentile had age of 20 years, the second stage of labor significantly higher frequency of was significantly shorter compared to gestational ages more than 41 weeks when women aged over 40 years, and compared with other groups. Also, our significantly shorter compared to women study found a statistically significant between the age of 20 and 40 years. inverse correlation between duration of the Gestational age at delivery was 1st stage of labor and bishop score. This significantly shorter in women aged over finds support in the study of Strobel et 40 years compared to those under the age al.(26) who concluded that Bishop score in of 20 years as well as to those between 20 a significant predictor of duration of labor. and 40 years of age. Age was positively Regarding the association between the correlated to the duration of the second second stage duration and the demographic stage of labor and negatively correlated to and clinical parameters, the present study the gestation age at delivery. In found a statistically significant direct multigravidas, age was negatively correlation between duration of the second correlated to the gestational age at stage and maternal age. This is in delivery. In primigravidas, maternal age accordance with Papadias et al.(27) who was positively correlated with the duration found that in primigravidas, maternal age of the second stage of labor. On the was positively correlated with contrary, gestational age at delivery was the duration of the second stage of labor. negatively correlated with maternal age. In Gomes et al.(28) also revealed that the multigravidas, a negative correlation consistent increase in the average age at between maternal age and gestational age pregnancy may exacerbate the main causes at delivery was statistically significant. of death, raising concerns for the future Gomes et al.(29) also revealed that the and prompting the need for emergency consistent increase in the average age at facilities nearby maternities. pregnancy may exacerbate the main causes Canavan et al.(10) made a study on preterm of death, raising concerns for the future premature rupture of membranes and prompting the need for emergency (PPROM) that occur in 3% of pregnancies facilities nearby maternities. and responsible for one third of all preterm Limitations births. The study confirmed that treatment The study had the following limitations: using antibiotic and corticosteroid therapy inclusion of a small number of health care has the strongest evidence for improving facilities, and a small sample size. neonatal outcome is gestational age- Conclusions dependent and influences local neonatal The present study concluded that IM intensive-care unit (NICU) survival administration of dexamethasone statistics according to the U.S. influences the duration of the second stage Preventative Task Force of labor in primigravidas women, as it recommendations.(27) resulted in significant shortening of the Papadias et al.(28) revealed that there is a second stage of labor. This is of great statistically significant relationship value particularly in primigravidas where between parity, maternal age at delivery,

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Tanta Scientific Nursing Journal the long duration of labor is exhausting plasma human chorionic and troublesome. gonadotrophin, oestradiol and Recommendations progesterone. Human Reproduction, This study provides high-level evidence of 1998 ; 14( 2):303-306. direct relevance for clinical practice. 7- Liu. K., Liu. C.C., and Chia. Y.Y. Dexamethasone can be used consistently Effect of dexamethasone on in primigravidas women to enhance the postoperative emesis and pain. Br. J. second stage of labor. Further assessments Anaesth. 1998; 80 (1): 85-86. should be conducted to find out the 8- Liu. k, Hsu. C.C, and Chia.Y.Y. The association between other maternal and Effective Dose of Dexamethasone for fetal sociodemographic and clinical data Antiemesis after Major Gynecological and dexamethasone administration. Surgery. the International Anesthesia References Research Society, 2013 1- Kavanagh J, Kelly AJ, Thomas J. 9- Vidaeff A.C, and Ramin S.M. Corticosteroids for cervical ripening Antenatal corticosteroids after preterm and induction of labor. Cochrane premature rupture of membranes. Clin Database Syst Rev 2006 Obstet Gynecol. 2011;54(2):337-43. (2):CD003100. 10- Canavan T.P, Simhan H.N, and Caritis 2- Kavanagh J, Kelly AJ, Thomas J. S. An evidence-based approach to the Corticosteroids for induction of labor. evaluation and treatment of premature Cochrane Database Syst Rev rupture of membranes: Part II. Obstet 2001;(2):CD003100. Gynecol Surv. 2004 Sep;59(9):678- 3- McAuliffe F, Grimes H, Morrison JJ. 89. Fetal cortisol in relation to labour, 11- Grgić G, Fatusić Z, and Bogdanović intrapartum events and mode of G. [Stimulation of fetal lung delivery. J Obstet Gynaecol maturation with dexamethasone in 2004;24(2):129—32. unexpected premature labor]. Med 4- Kalantaridou S, Makrigiannakis A, Arh. 2003;57(5-6):291-4. Zoumakis E, Chrousos GP. Peripheral 12- Pattinson RC. A meta-analysis of the corticotrophin-releasing hormone is use of corticosteroids in pregnancies produced in the immune and complicated by preterm premature reproductive systems: actions, rupture of membranes. S Afr Med J. potential roles and clinical 1999 Aug;89(8):870-3. implications. Front Biosci 13- Movafegh. A, Razazian. M, 2007;12:572—80. Hajimaohamadi. F, and Meysamie. A 5- Lindsay JR, Nieman LK. The Dexamethasone Added to Lidocaine hypothalamic–pituitary–adrenal axis Prolongs Axillary Brachial Plexus in pregnancy: challenges in disease Blockade. Anesthesia and Analgesia detection and treatment. Endocr Rev the Gold Standard in Anesthesiology 2005;26(6):775—99. IARS. The International Anesthesia 6- Ogueh. O., Jones. J., Mitchell .H., & J. Research Society. 2013. Print ISSN: Alaghband-Zadeh. J.A., and Johnson 0003-2999 M.R.. Effect of antenatal 14- Cummings. C., Napierkowski. D.E., dexamethasone therapy on maternal Sanchez.P., Kurz. A., Dalton. E.J.,

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Brems. J.J., and Sessler.I.D. Effect of stress. Arch Dis Child Fetal Neonatal dexamethasone on the duration of Ed 2004;89(1):F29—32. interscalene nerve blocks with 22- Pike. I.L. Maternal stress and fetal ropivacaine or bupivacaine. Br. J. responses: evolutionary perspectives Anaesth. 2011; 107 (3): 446-453. on preterm delivery. Am J Hum Biol 15- Daly, W. M. and Carnwell, R. Nursing 2005;17(1): 55—65. roles and levels of practice: a 23- Norman SM, Tuuli MG, Odibo AO, framework for differentiating between Caughey AB, Roehl KA, Cahill AG. elementary, specialist and advancing The effects of obesity on the first nursing practice. Journal of Clinical stage of labor. Obstet Gynecol. Nursing2003;12: 158– 2012;120(1):130-5. 167.doi: 10.1046/j.13652702.2003. 24- Cheng YW, Delaney SS, Hopkins Polit, D.F., & Hungler, B.P. Nursing LM, Caughey AB. The association Research Principles and Methods, 6th between the length of first stage of edition, Lippincott, Philadelphia, labor, mode of delivery, and perinatal Neew York, Baltimore.1999 outcomes in women undergoing 16- Barkai G, Cohen SB, Kees S, Lusky induction of labor. Am J Obstet A, Margalit V, Mashiach S, Schiff E. Gynecol. 2009 ;201(5):477.e1-7. Induction of labor with use of a Foley 25- Strobel E, Sladkevicius P, Rovas L, catheter and extraamniotic De Smet F, Karlsson ED, Valentin L. corticosteroids. Am J Obstet Gynecol Bishop score and ultrasound 1997;177(5): 1145—8. assessment of the cervix for prediction 17- Kashanian M, Dadkhah F, Mokhtari F of time to onset of labor and time to (b). Effect of intramuscular delivery in prolonged pregnancy. administration of dexamethasone on Ultrasound Obstet Gynecol. the duration of labor. Int J Gynaecol 2006;28(3):298-305. Obstet. 2008 ;102(3):259-62. 26- Yyonne W. Cheng, Linda M. 18- Ziaei S, Rosebehani N, Kazeminejad Hopkins, and Aaron B. Caughey. How A, Zafarghandi S.The effects of long is too long: Does a prolonged intramuscular administration of second stage of labor in nulliparous corticosteroids on the induction of women affect maternal and neonatal parturitionJ Perinat Med. outcomes? Original Research Article. 2003;31(2):134-9.. American Journal of Obstetrics and 19- Sun K, Brockman D, Campos B, Gynecology, Volume 191, Issue 3, Pitzer B, Myatt L. Induction of September 2004;933-938 surfactant protein A expression by 27- Papadias K, Christopoulos P, cortisol facilitates prostaglandin Deligeoroglou E, Vitoratos N, synthesis in human chorionic Makrakis E, Kaltapanidou P, Tsoukas trophoblasts. J Clin Endocrinol Metab A, Creatsas G. Maternal age and the 2006;91(12):4988—94. duration of the second stage of labor. 20- Vitoratos N, Papatheodorou DC, Ann N Y Acad Sci. 2006;1092:414-7. Kalantaridou SN, Mastorakos G. 28- Gomes M.C, Maria T. Ventura M. T, ―Reproductive‖ corticotropin- Nunes R.S How many maternal deaths releasing hormone. Ann N Y Acad Sci are there in Portugal? Journal of 2006;1092:310—8. Maternal-Fetal and Neonatal 21- Gitau R, Fisk NM, Glover V. Human Medicine. 2012 ;25, (10):1975-1979 fetal and maternal corticotrophin releasing hormone responses to acute

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