B. P. Koirala Institute of Health Sciences, Dharan Nepal

APPLICATION FORMAT FOR RESEARCH GRANT

Section–A

1. Title of the research project:

Strengthening Knowledge and Practices Regarding Life Support Measures among the Nurses Working in

Emergency Unit of BPKIHS 2. Name and designation of:

a. Principal investigator:

Name:

Designation: Assistant Professor, Medical-Surgical Nursing Department

S.N. Name Designation Department

3. Expected duration of the proposal: 1 Year

4. Amount of grant in – aid asked RS. = 25,000/-

5. This is new project: Yes.

Declaration

1. I/we have read the terms and the terms and conditions of BPKIHS research grants, and agree to abide by them.

2. I/we agree to submit, within three months from the date of termination of the project, a report on the work done.

3. I/we agree to maintain a stock book for purchases made for he project. I/we shall submit the complete statement of account within three months of the termination of the project, and at any other time as required by the accounts section.

4. I/we agree to acknowledge the grant in any publication resulting from the project if it is approved for financial assistance.

5. I/we declare that no research grant is already available for the research project from any other source.

6. I/we declare that the project will be conducted as per the highest ethical standards applicable to animal/human experiments.

Signatures (with seal and date):

Principal Investigator Signature Date

Gayanand Mandal ………………………………………………………

Co-investigator Signature Date

Remarks form the HoD of the Principal Investigator:

Date: Signature & Seal of the HoD

Remarks for the HoD of the Co-investigator:

Section-C

Details of the research project

1. Title of the research project

Strengthening Knowledge and Practices Regarding Life Support Measures among the Nurses Working in Emergency Unit of BPKIHS

2. Objectives.

1. General Objectives: To find out the knowledge and practices regarding life support measures among the nurses working in emergency unit of BPKIHS.

Specific Objectives:

1. To find out the knowledge and practices regarding life support measures among the nurses working in emergency unit of BPKIHS.

2. To find out the association between selected demographic variables with

knowledge and practices. 3. To evaluate the effectiveness of education intervention on life support

measure among the nurses working in emergency unit of BPKIHS.

Null Hypothesis: There will be no difference in knowledge and practices about life support measures among the nurses working in emergency department after education intervention.

3. Summary of the research project. B P Koirala Institute of Health Sciences has 700 bedded tertiary care hospital having capacity of dealing with all kinds of emergency situation and disaster and polytrauma victim and is one of the tertiory level of health care in Nepal. Emergency unit may be thought of as having context (the demographics and characteristics of the kind of work they do), structure (the grouping of people and the allocation of responsibility through specialization, expertise, formalization, and some degree of centralization or decentralization), process (intra organizational relationships such as the flow of information and coordination), and outcomes (productivity, goal attainment, morale, and satisfaction of the members). Emergency nursing is that specialty within nursing that deals specifically with human responses to life-threatening problems. Emergency nurses account for an estimated 10 % of the total number of nurses working in the hospital setting. B P Koirala Institute of Health Sciences (BPKIHS) has 700 bedded tertiary care hospital .Research project is aimed at assessing the knowledge and practices regarding life support measures among the nurses working in emergency unit of BPKIHS. It will be hospital based pre-experimental research design conducted among the nurses working in emergency unit of BPKIHS.

4. Review of the literature pertaining to the project. A emergency nurse is responsible for ensuring that acutely and critically ill patients and their families receive optimal care. Critically ill patients are defined as those patients who are at high risk for actual or potential life-threatening health problems. The more critically ill the patient is, the more likely he or she is to be highly vulnerable, unstable and complex, thereby requiring intense and vigilant nursing care.1 High intensity fields of work, such as the airline industry and the military, already employ checklists to decrease errors of omission, improper implementation of procedures and protocols, and to decrease human error under stressful conditions. Examples include the prediction of successful weaning from mechanical ventilation in ICU patients, adherence to evidence-based best practices and in the improvement of patient safety in many clinical areas.1 As issues relating to patient care become increasingly complex and new technologies and treatments are introduced, emergency nurses will need to become ever more knowledgeable. 4 Nurses need to develop a thorough understanding of these modes including their effects on underlying respiratory physiology to be able to deliver safe and appropriate patient care.5 Emergency nurses work in a wide variety of settings, filling many roles. They are bedside clinicians, nurse educators, nurse researchers, nurse managers, clinical nurse specialists and nurse practitioners. 2 Much information is available on patients’ satisfaction and perceptions of quality of care, and some information is available on patients’ perceptions of physicians’ skills, little information is available on patients’ perceptions of nurses’ skills. 3 The defining characteristics of good nursing care investigation mostly involved the demeanor of the nurses: gentle, calm, courteous, kind, attentive, available, empathetic, and reassuring. Although researchers have described nurses’ attributes that patients consider when judging nursing quality and good nursing care in general, little is known of patients’ perceptions specifically of the skill of nurses. 4 Rapid advances in healthcare and technology have contributed to keeping more people out of the hospital. As issues relating to patient care become increasingly complex and new technologies and treatments are introduced, emergency and critical care nurses will need to become ever more knowledgeable. 4 An emergency unit is a specialized section of a hospital that provides comprehensive and continuous care for persons who are critically ill and who can benefit from treatment. The purpose of the emergency care unit is simple even though the practice is complex. Healthcare professionals who work in the emergency provide nursing care around the clock, intensive monitoring and treatment of patients seven days a week. 1

Patients cared for in emergency include those with severe trauma, major head injury or coma, respiratory and/or hemodynamic insufficiency, or failure of one or more organ systems and those with intensive monitoring needs following major surgery.

The medical needs of emergency patients are often complex, requiring of caregivers, who work under stressful conditions, a high degree of knowledge and skill. Despite the dedication and competency of emergency caregivers, mortality rates for critical care patients remain high, ranging from 10% to 20%.2 The emergency visit will provide treatment management, diagnosis, interventions, and individualized care for each patient recovering from severe illness. 3

Despite tremendous resource utilization, the majority of trauma patients can eventually return to varying degrees of functional daily living and independence due to better emergency management. A subgroup of severely injured elderly patients had a significantly higher mortality rate. However, elderly survivors that entered our rehabilitation facility fared as well as the younger patients.1

The main feature of emergency unit is the availability of triage system, disaster management system, continuous monitoring of the cardiac rhythm by electrocardiography. This allows early intervention with medication, cardio version or defibrillation, improving the prognosis. 4

5. Rational of the study.

There are no reliable statistics on basic and advanced life support measurses because no single agency collects information about how many people get CPR, how many do not get it who needs it, how many people are trained, etc. Brain Adenosine Triphosphate (ATP) is depleted after 4-6 min of no blood flow. It returns nearly to normal within 6 min of starting effective BLS. In clinical practice, the severity of the underlying cardiac disease is the major determining factor in the success or failure of life support measures attempts. Of those factors under control of the rescuers, poor outcomes are associated with long arrest time before BLS /ALS is begun, prolonged Ventricular Fibrillation (VF) without definitive therapy and inadequate coronary and cerebral perfusion during cardiac massage. Optimum outcome from VF is obtained only if BLS /ALS is begun within 3-5 min of arrest and defibrillation applied within 8 minutes.5

Several studies have shown the benefit on survival of immediate BLS/ALS, and the detrimental effect of delay before defibrillation. For every minute without BLS and ALS, survival from witnessed VF decreases by 7-10%. When bystander ALS is provided, the decline in survival is more gradual and averages 3-4%. Overall, bystander BLS and ALS doubles or triples survival from witnessed cardiac arrest.15 In cities, such as Seattle, where CPR training is widespread and defibrillation by emergency management system (EMS) personnel follows quickly, the survival rate is about 30%, but in cities such as New York, without these advantages, the survival rate is only 1-2%.9

Almost half of cardiac deaths occur in the hospital environment and nurses are the first responders. CPR is a critical component of BLS and ALS and the established first line of response to a cardiac arrest in the interim before defibrillation and advanced life support are available.24 Following cardiac arrest, effective BLS/ALS

enables enough oxygen to reach the brain to delay brain death and allows the heart to remain responsive to defibrillation attempts.9

Nurses work in a variety of clinical settings. Some of these areas involve care of patients with acute illness while others do not. No matter in which setting a nurse works, the possibility exists that he or she will participate in the resuscitation of a patient. When patients face a life-threatening event such as cardiopulmonary arrest, they rely on the competence and skills of the healthcare professionals. Because nurses are often the healthcare providers closest to the bedside and the first to respond to patient’s needs, their knowledge and skills need to be optimal and their performance proficient.16

Nurses have a two-fold role during a cardiac arrest. Firstly, they have a responsibility to provide BLS and ALS as a holding measure to ensure adequate circulation and perfusion of vital organs. Secondly, they participate in and often initiate ACLS measures, which aim to treat or reverse the cause of arrest.13

ALS is a practical skill and needs professional instruction followed up by a regular practice on a resuscitation manikin to gain and maintain full competency.9 The development of knowledge and skills is an essential component of professional development in nurses' career. Undoubtedly, the public expectation is high that nurses will be competent to perform BLS in the event of cardiac arrest. The issue of nurses' BLS knowledge and skills remain unexplored within the context of Nepal. Hence, for the most effective outcomes, hands-on training should be given by an expert. This will enable the person to perform BLS/ALS more safely and more effectively. Most organizations advocate regular retraining, in order to keep practice in the skills and to ensure that the person is up-to-date with the latest guidelines, which change periodically based on the outputs and governing bodies.9 The above facts made the investigators interested to study on this topic because BLS/ALS means life saving procedure. Hence, every nurses need to update their knowledge according to the current evidence-based guidelines.

1.3 Significance of the Study

• This study may be helpful to find out the training needs of the health workers. • The findings of the study may be helpful to provide the baseline data to plan

and implement similar type of educational package on ALS. • This study may be helpful for arranging refreshment courses/ in-service

education regarding ALS regularly for nursing personnel working at different areas of the hospital.

• This study may help/ save the life of public by nursing staff who are the first detector of cardiac arrest and the first receiver and provider of immediate BLS and further management which will ultimately help reduce the mortality rate of nation due to cardiac arrest.

1.4 Operational Definitions

1. 4.1 Knowledge

It denotes theoretical understanding of nurses regarding life supporting measures which includes definition of CPR and BLS,ALS , their purposes, indications , sequence , complications and termination of procedure. 1.4.2 Skills

Nurses’ performance to carry out sequence of BLS/ALS on Anne Manikin which includes assessment of the victim, maintaining of airway and breathing, chest compression and rescue breathing. 1.4.3 Nurses

Nurses having at least 3 years of education in Nursing course and working in emergency department of BPKIHS.

RESEARCH METHODOLOGY

3.1 Design of the Study

Pre-experimental (one group pre-test and post-test design)

O1 × O2

3.2 Research Setting Emergency unit of BPKIHS.

3.3 Sample

All the nurses who work in emergency unit and met the inclusion criteria.

3.5 Sample Size: All staff nurses working in emergency

3.6 Sampling Techniques

Samples will be selected by using Non-Probability Convenience Sampling

Technique.

3.7 Eligibility Criteria

3.7.1 Inclusion Criteria

• All nurses who are working in the emergency department of

BPKIHS.

• Nurses who have completed at least 3 years of formal Certificate

Nursing education.

3.7.2 Exclusion Criteria

• Those who are not willing to participate.

3.8 Research Instrument

A self-administered semi-structured questionnaire will be developed to assess the knowledge and skill regarding life Support measures as per the objective of the study. Resuscitation skills were observed and recorded on the observation checklist prepared by the investigators.

The tool consists of three parts:

Part I: It will consists of socio-demographic data of the nurses, including their training experiences and their exposure (witness, assistance and performance) to various life supporting measures during their nursing experience. Part II: It will consist of questions, which assess the knowledge of nurses on different aspects of Life Support measures. Part III It will be an observation checklist with criteria to evaluate skills of nurses regarding life supporting measures during resuscitation. The competence of the nurses will be determined by observing their performance with Anne Manikin.

3.9 Validity Content validity of instrument and the educational package will be established by seeking advises from review of literature and experts from Emergency department, Department of Anesthesia and Medical-surgical Nursing department. Necessary modifications will be done accordingly.

3.10 Pre-testing Pre-testing will be done in 10% of the total required sample , those who were included in the pre-testing will be excluded from the study.Necessary modifications were done accordingly.

3.11 Ethical Considerations Written permission will be obtained from College of Nursing and concerned department before the data collection. Informed (verbal) consent will be obtained from all the participants. Confidentiality will be maintained.

3.12 Data Collection Plan

Phase I

Pre-test phase: • Permission will be obtained from HOD Emergency , BPKIHS • Data i.e. knowledge and skill regarding Life Support measures will be

collected with the help of self-administered, semi-structured questionnaire. • Resuscitation skills will be measured using Anne Manikin. After completing

the questionnaire every participant will be requested to attempt resuscitation on Manikin. Ability was assessed by observation on a checklist.

Phase II Intervention phase:

• Circular will be sent to the concerned regarding the educational program by taking formal approval from HOD Emergency, BPKIHS.

• For educational package, participants will be divided into groups based on their availability and convenience, and the program will be conducted accordingly.

• The total duration of educational programme will be one hour. • Lecture combined discussion and demonstration method will be used. • Power point will be used during lecture. • Hands-out regarding the Various Life Support Measures will be provided to

each of the participants at the end of the session. Phase III Post-test phase:

• Post-test data will be collected after two week of educational intervention from those respondents who participates in pre-test and intervention phase by using the same research instrument in the pre-test.

3.13 Data Analysis Plan • Data will be entered and analyzed on SPSS. • Descriptive statistics i.e. percentage, mean, mode, median, interquartile range

and standard deviation will be used to report findings of pre-test and post-test. • Inferential statistics i.e. McNemar Chi Square test, Wilcoxon Sign Rank test

and Spearman’s Rho Correlation coefficient will be used to find the significance of difference between the variables.

• Analyzed data will be presented in tables and figures.

APPENDIX B: DATA COLLECTION PROFORMA

Please tick and provide answers as you feel appropriate. This will remain confidential and will be used for the research purpose only.

Code no:

Ward:

Part- I: Socio-demographic information

1. Age of the participant………….. yrs 2. Level of Nursing course

a) Certificate Level b) Bachelor level (B.Sc./ BN)

3. Your present position: 4. Your professional experience:

a) 0-3 yrs c) 7-10 yrs b) 4-6 yrs d) more than 10 yrs

5. Have you ever had any in-service training on Basic and cardiac Life support measures? Yes/ No

a) If yes, when did you take the course and its duration? …………………………………………………………….

b) If no, do you want to have training on Basic and cardiac Life support measures in this institution? Yes/ No

6. Have you ever witnessed a cardiac arrest during your nursing experience? Yes/ No

a) If yes, how many times? …………….. 7. Have you ever assisted in a BLS or ALS measures during your nursing

experience? Yes/ No a) If yes, how many times? ……………..

8. Have you ever provided Basic Life Support during your nursing experience?

Yes/No a) If yes, how many times? …………….

9. Have you ever provided Advanced Life Support during your nursing experience? Yes/No

a) If yes, how many times? ……………. Part- II: Here are some statements. You are requested to tick the correct

answer. 1. a) Have you ever heard the word Cardiopulmonary Resuscitation (CPR)? Yes/No

b) If yes, what is it? .................. 2. a) Do you know the purposes of CPR? Yes/ No

b) If yes, what are they? ....................................... 3. What are the conditions in which you should start CPR? ............................... 4. a) Have you ever heard the word Basic Life Support (BLS)? Yes/ No b) If yes, what is it? …………………………………………………….

…………………………………………………... 5. a) Have you ever heard the word Advanced Life Support (ALS)? Yes/ No b) If yes, what is it? …………………………………………………….

…………………………………………………... 6. ABCs of resuscitation or BLS refers to: A: …………

B: ………… C: …………

7. To assess the responsiveness of the victim, you would a. Shout near the victim’s ear b. Shake gently c. Give a strong blow d. Shake gently and call the name

8. The “ARREST TIME” refers to: a) Time between the cardiac arrest and the institution of BLS

b) Time between the cardiac arrest and arrival to the hospital c) Time interval of chest compression d) Total time of resuscitation

9. How would you position victim prior to resuscitation?

a) In side-lying position on a flat surface b) In semi-fowlers position on a soft flat surface c) In prone position on a flat surface d) In supine position on a firm flat surface

10. In the unresponsive victim with no cervical injury, airway is opened by

a) Head tilt and chin lift maneuver b) Head tilt maneuver only c) Jaw thrust maneuver only d) By turning the head to the side

11. In case of cervical spine injury patient, airway is opened by

a) Head tilt and chin lift maneuver b) Head tilt only c) Jaw thrust maneuver only d) By turning the head to the side

12. Breathing is assessed by

a) Observing the chest movement b) Observing the chest movement and listening breath sound c) Observing the chest movement, listening to breath sound and feeling air on

cheek d) Feeling air on cheek

13. Assessment of breathing should be completed within

a) 5 sec c) 15 sec b) 10 sec d) 20 sec

14. Once cardiac arrest is confirmed what is done immediately?

a) Defibrillation b) Drugs c) Chest compression followed by rescue breath d) Rescue breath followed by chest compression

15. During chest compression, position of hands should be at the

a) Lower third of the sternum b) Centre of the chest c) Upper third of the sternum d) Lower half of the chest

16. While performing chest compression, the nurse exert pressure by placing

a) The fleshy part of a clenched fist by side extending the finger over the chest

b) The finger of one hand on the sternum and the finger of the other on top of them

c) The heels of each hand side by side on lower sternum d) The heels of the hand on the sternum and the heel of the other on top of it

interlocking the fingers

17. Depth of sternal compression for adult is a) 1.5-2 inch c) 0.5-1 inch b) 1-1.5 inch d) 2-2.5 inch

18. Sternal compression rate for adult is a) 80-100/min c) 70-90/min b) 60-80/min d) 60-90/min

19. During mouth to mouth ventilation, you should

a) Pinch the both nostrils with one hand and shield the victim’s mouth with the lips

b) Shield the victim’s nose and mouth with your lips c) Shield the victim’s mouth with your lips only d) Shield the victim’s nose with your mouth

20. Chest compression to ventilation ratio is

a) 15:2 c) 5:1 b) 30:2 d) 30:1

21. Ventilation rate for adult is

a) 20-22/min c) 16-18/min b) 10-12/min d) 15-20/min

22. What may be the commonest complication of chest compression?

a) Rib fractures c) Pneumothorax b) Hemothorax d) Fat embolism

23. When should we stop giving Basic Life Support? ..................................

…………………….. 24. Rearrange the following in the correct sequence.

a) Assess breathing b) Check for safe environment c) Start chest compression d) Check for unconsciousness e) Call for help f) Give Rescue Breath g) Clear Airway

25. The choice for VT/VF is

a. Manual Cardiopulmonary resuscitation b. Immediate Defibrillation c. Precordial Thumb d. Use of Inotrops

26. Best place to place the paddle of DF is

a. First paddle is placed on right side of chest just below the clavicle and second

on precordial region.

b. First paddle is placed on right side of chest just above the clavicle and second

on precordial region.

c. First paddle is placed on right side of chest just below the clavicle and second

on axillary line

d. First paddle is placed on right side of chest just below the clavicle and second

on left side below clavicle.

27. Paddle should be applied with the pressure equivalent to

a. 5 kg

b. 10 kg

c. 15 kg

d. 20 kg

28. Normal size of paddle for adult should be

a. 10 cm

b. 11 cm

c. 12 cm

d. 13 cm

29. Before pressing discharge botton call clear --- times

a) 2

b) 3

c) 4

d) 5

30. Most common drugs used during ALS are

a. Adernaline, atropine, Amidarone, lidocaine, sodabicarbinate, calcium

gluconate

b. Adernaline, atropine, Dpomaine and dobutamine

c. lidocaine, sodabicarbinate, calcium gluconate and broad spectrum antibiotics

d. lidocaine, sodabicarbinate, calcium gluconate

e. All emergency drugs

Part-III: Observation checklist

Nurses were observed skills regarding BLS in the Manikin in the following criteria

during their participation.

SCORES: Correct =3, Incorrect =2, Not performed =1

S.N Criteria 3 2 1 1. 2. 3. 4. 5. 6.

ASSESSMENT a) Shake and shout to the victim to assess responsiveness. AIRWAY a) Open mouth and check airway. CHEST COMPRESSION a) Rescuers’ position:

i Appropriate height or kneel by the side of the victim. ii Position of shoulder in relation to victim i.e.

vertically above with arms straight.

b) Correct hand position. i. Location on the center of the chest. ii. Place heel of one hand on top of other hand.

iii. Interlocking the fingers of hands.

c) Perform 30 chest compressions. d) Release of chest compression.

Release all the pressure on the chest without losing contact between hands and the sternum.

e) Rate of chest compression. While compressing the chest, count the compression as 1 and 2, and 3 and 4………… and so on.

RESCUE BREATHING a) Head tilt. b) Pinch the nostrils closed with thumb and index finger. c) Open the mouth and maintain the mouth seal tight. d) Give two slow (1 sec) breaths. COMPRESSION TO BREATHING RATIO

30:2 CORRECT SEQUENCE Assessment of the victim → Maintenance of the airway → Chest compression → Rescue breath

ORGANIZATION OF THE STUDY: (TIME SCHEDULE)

SN Activities Duration/Time

1. Literature review and finalization of the project 2 Months 2. Pre-testing and finalization of tool 1 Months 3. Data collection and education intervention 6 Months 4. Analysis of Data 1 Months 5. Report writing and Submission 2 Months ……………………….

1 Year

Section-D

Details of the Budget:

SN Item/particular Amount (in RS.)

1. Preparation and printing of tools : 1700 2.preparation of information booklet :6000 3.data collection : 3000 4computer data entry and analysis : 3000 5. Report writing : 3000 6. Binding photocopy :2000 7.inservice education /training session : 5000 8. Others : 1300

Grand Total: 25,000

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