"A STUDY TO EVALUATE THE EFFECTIVENESS OF PLANNED

TEACHING PROGRAMME ON THE KNOWLEDGE OF

RECORDING AND INTERPRETATION OF

ELECTROCARDIOGRAM(ECG) AMONG STAFF NURSES

WORKING IN SELECTED INTENSIVE CARE UNITS (I.C.U) OF

SELECTED HOSPITALS IN TUMKUR .”

PROFORMA FOR REGISTRATION OF SUBJECT FOR THE

DISSERTATION

SUBMITTED BY

NIDIGANTLA SUBRAHMANYAM

MEDICAL SURGICAL NURSING

2012-2013

SRI SIDDHARTHA COLLEGE OF NURSING

AGALKOTE, B.H. ROAD

TUMKUR

1

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT

FOR DISSERTATION

1 NAME OF THE CANDIDATE & ADDRESS

Mrs. N.SUBRAHMANYAM

I YEAR M.Sc NURSING

SRI SIDDHARTHA COLLEGE

OF NURSING, AGALKOTE,

TUMKUR

2 NAME OF THE INSTITUTION

SRI SIDDHARTHA COLLEGE

OF NURSING,B.H

ROAD,TUMKUR

3 COURSE OF THE

STUDY & SUBJECT

DEGREE OF MASTER OF

NURSING

MEDICAL SURGICAL NURSING

4 DATE OF ADMISSION 13-08-12

5 TITLE OF THE TOPIC "A STUDY EVALUATE THE EFFECTIVENESS OF PLANNED TEACHING PROGRAMME ON THE

KNOWLEDGE OF RECORDING AND

INTERPRETATION OF

ELECTROCARDIOGRAM(ECG)

AMONG STAFF NURSES WORKING IN

SELECTED INTENSIVE CARE UNITS

(I.C.U) OF SELECTED AREAS IN

TUMKUR DISTRICT"

2

6 BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION

“Cardiovascular disease (CVD) is the world's leading killer, accounting

for 17 million or 30 per cent of total global deaths in 2010.1 CVD alone accounts for

one-quarter of all deaths in low mortality low-income countries. Non-communicable

diseases such as cancers, neuropsychiatric and cardiovascular diseases now kill greater

numbers of people in the lower-income countries than they do in high-income

countries.2 While deaths from heart attacks have declined more than 50 per cent since

the 1960s in many industrialized countries, 80 per cent of global cardiovascular diseases

related deaths now occur in low and middle-income nations, which covers most countries

in Asia. In India in the past five decades, rates of coronary disease among urban

populations have risen from 4 per cent to 11 per cent.1

Introduced in 1902 by Einthoven, electrocardiography is the graphical display of

electrical potential differences of an electric field originating in the heart as recorded at

the body surface.3 As a record of electrical activity of the heart; it is a unique technology

that provides information not readily obtained by other methods. The procedure is safe,

simple, and reproducible; the record lends itself to serial studies; and the relative cost is

minimal.

There are numerous potential clinical uses of the 12-lead ECG. The ECG may reflect

changes associated with primary or secondary myocardial processes (e.g., those

associated with coronary artery disease, hypertension, cardiomyopathy, or infiltrative

disorders), metabolic and electrolyte abnormalities, and therapeutic or toxic effects of

drugs or devices Electrocardiography serves as the gold standard for the noninvasive

diagnosis of arrhythmias and conduction disturbances, and it occasionally is the only

marker for the presence of heart disease. As a research tool, it is used in long-term

3

population-based surveillance studies and in experimental trials of drugs with recognized

or potential cardiac effects.4

The technological development of powerful personal computers enabled the

development of extremely sophisticated signal processing algorithms, introducing

another dimension in the usefulness of ECG recordings. Analysis of RR intervals; QRS

and T-wave morphology, including late potentials; QT dispersion; and T-wave alternans

are currently being evaluated as prognostic markers in patients with structural heart

disease. In addition, transtelephonic monitoring of implanted devices has become a

standard technique of evaluating and following patients5.

Electrocardiograms are interpreted by Physicians and Nurses in many specialties,

including cardiology, internal medicine, family practice, and emergency medicine.

Interpretative skills vary among specialists .An adequate knowledge base should include

the ability to define, recognize, and understand the basic pathophysiology of certain

electrocardiographic abnormalities6.

Ensuring correct recording of ECG is imperative on the part of Nurses and technicians.

Because it helps the Physician and Nurse to correctly interpret recordings and take

appropriate measures. Operators recording ECGs should ensure that chest leads are

placed in the proper position and electrodes make good skin contact to minimize

artifacts. Incorrect placement of pericardial leads may lead to a false diagnosis of

infarction. The reversal of limb leads and the switching of precordial leads have been

well-documented to cause alterations in ECGs 7

Several studies have examined the accuracy of computer ECG interpretation programs

and have suggested that computer analysis cannot substitute for physician interpretation

of ECGs. A systematic study of computerized ECG interpretation performed in 1991

demonstrated that computer programs were 6.6% less accurate, on average, than

cardiologists at identifying ventricular hypertrophy and myocardial infarction (MI) 8.

4

Eectrocardiographic interpretation requires a basic knowledge of electrocardiographic

technology, cardiac anatomy, and cardiac physiology as well as the ability to recognize

diagnostic patterns on a 12-lead tracing

.Correctly recorded and interpreted ECGs will undoubtedly unearth the hidden changes

associated with primary or secondary myocardial processes, metabolic and electrolyte

abnormalities, and therapeutic or toxic effects of drugs or devices and aid the Physician

and the Nurse to intervene promptly and save many precious lives

6.2 Need for the study:

According to world health organization (WHO), at least twenty million people survive

heart attacks and strokes around the world every year; many require continuing costly

clinical care9.

British Heart Foundation’s 2009 statistics revealed Cardio Vascular Disease (CVD)

accounted for more than 276,000 deaths in the United Kingdom (UK) in 2009. Thirty-

nine percent of deaths are from CVD, and 36 percent of premature deaths in men and 27

percent in women are from CVD10

European Cardio Vascular statistics of 2008 showed that each year CVD causes over

4.85 million deaths in Europe and over 2.1 million deaths in the European Union (EU). It

causes nearly half of all deaths in Europe (51 percent) and in the EU (44 percent). It is

the main cause of death in women in all countries of Europe and is the main cause of

death in men in all countries except France and San Marino. It is the main cause of years

of life lost from early death in Europe and the EU – around a third of years of life lost are

due to CVD11

.

Heart and Stroke Foundation of Canada web site revealed that every seven minutes, a

5

Canadian dies of heart disease and stroke. CVD accounts for more deaths than any other

disease that is, 36 percent of male deaths and 38 percent of female deaths. It costs the

Canadian economy about $18.4 billion annually12

The World Health Organization (WHO) estimates that 60 per cent of the

world's cardiac patients will be Indian by 2010. Dr Timothy Gill, an Asia-Pacific

specialist with the International Obesity Task Force, a medical NGO that coordinates

with the WHO on obesity issues feels that of all Asians, South Asians have by far the

worst problems when it comes to heart disease Nearly 50 per cent of CVD-related deaths

in India occur below the age of 70, compared with just 22 per cent in the West. This

trend is particularly alarming because of its potential impact on one of Asia's fastest-

growing economies. In 2008, for example, India lost more than six times as many years

of economically productive life to cardiovascular disease than did the U.S., where most

of those killed by heart disease are above retirement age1.

In India it is estimated that at least 800,000 people die of heart attacks

every year. About 5 out In India it is estimated that at least 800,000 people die of heart

attacks every year. About 5 out of every 11 patients die after getting heart attacks, mostly

within 1 hour before medical aid can reach them 13

Coronary artery disease has progressively increased among urban Indians during the last

half a century and it affects people at younger age. India has the highest incidence of

CAD in the world and the incidence is expected to reach epidemic proportions in the

next few decades14.

The electrocardiogram (ECG) is one of the most widely used and useful investigations

in contemporary medicine. It is essential for the identification of disorders of the cardiac

rhythm, in various general conditions like head injury, poisoning, accidents, drowning,

surgical complications, electrolyte disturbance etc. But it is specifically useful for the

6

diagnosis of abnormalities of the heart such as Myocardial infarction (M.I), Coronary

artery disease etc Nurse working in an ICU is one of the most trained personnel who

possess specialized skills to provide care for these critically ill patients. Out of the many

procedures she performs, she is required to have a working knowledge on

electrocardiogram (ECG) i.e. correct recording and interpretation of ECG. She is in a

unique position to provide 12 lead ECG and initiate an appropriate response. Key

elements of 12 lead ECG interpretations and their application to established guidelines

are essential skills for nurses working in ICU’s frequented by patients with serious

problems15.

The investigators during their clinical experience in TUMKUR Hospital noticed

deficit in the levels of knowledge of recording and interpretation of ECG by nurses in

ICUs. In view of this need, the investigators strongly felt that every nurse working in the

ICU should have adequate knowledge on the recording and interpretation of ECG so that

precious lives could be saved. Planned teaching programme is a logical solution for this

problem and would greatly help these nurses to equip them in the correct recording and

interpretation of ECG.

6.3 REVIEW OF LITERATURE:

This chapter deals with review of literature which helps to gain an insight into

various aspects of the problem under study, its objectives, appropriate research design,

methods, instrument measures and techniques of data collection that may prove useful in

the proposed project.

The review of literature provides a basis for future investigations, justifies the need for

replication, throws light on the feasibility of the study, indicates constraints of data

collection and helps to relate findings of one study to another. It also helps to establish a

7

comprehensive body of scientific knowledge in a professional discipline from which

valid pertinent theories may be developed.16

In the present study, the research investigator has carried out different types of Literature

review at different stages of his research process and presented under the following

headings:

1. Studies supporting recording of electrocardiogram (ECG).

2. Studies supporting interpretation of electrocardiogram (ECG)

3. Studies supporting planned teaching programme

Studies supporting the recording of electrocardiogram

An observational study was done on a randomly selected sample of 185 patients in an

emergency setting on the appropriate recording of the electrocardiogram, it was found

that moving location of electrodes from the standard limb lead position to the trunk, by

placing the arm leads on the anterior ‘acromial region’ and the leg leads in the ‘anterior

superior iliac spine’ resulted in difference in amplitudes within 5% of the values of

standard recordings in 99.6 of all wave forms. It is prudent that a uniform approach for

placing the limb leads needs to be adopted with the provision that when a modification is

used for special reasons (patients with tremors), some information is entered on the ECG

record and included as part of the ECG’s interpretive

report 17

A Comparative study was done on a convenient sample of 184 patients in Kingston

hospital, New Jersey. The purpose of the study was to compare the proposed new method

using a 6-lead ECG BELT for precordial application to the standard 12 lead ECG method

to determine the level of agreement among automated interpretations. The results

indicated that BELT and standard automated interpretations disagreed significantly more

frequently than repeat standard recording automated interpretations of the cardiac

8

rhythm. The study suggested that the ECG BELT is not adequate for clinical application

in its current form 18

An Evaluative study was done on the usefulness of leads aVR and −aVR as well as on

the history of the frontal leads in electrocardiography. Results revealed that Lead aVR

and particularly, lead −aVR, provide useful information when systematically analyzed.

In addition, if lead −aVR is examined in its anatomically logical sequence, ie, aVL, I,

−aVR, II, aVF, and III, the frontal plane of the 12-lead ECG is more easily understood.

The study showed that ECG interpretation would be enhanced by displaying the limb

leads in an orderly arrangement that starts with lead aVL and ends with lead III, and

many ECG changes would be ideally displayed by a lead −aVR at 30° 19.

An evaluative study was done on one hundred forty-nine consecutive patients admitted to

neurology department of an University Hospital Geneva, Geneva, Switzerland with an

acute stroke or TIA. The purpose of the study was that 7-day ambulatory ECG

monitoring using an event-loop recording (ELR) device would detect otherwise occult

episodes of atrial fibrillation and flutter (AF) after acute stroke or transient ischemic

attack (TIA). The results revealed that Standard ECG identified AF in 2.7% of the cases

at admission (4/149 patients) and in 4.1% of remaining patients within 5 days (6/145).

Holter disclosed AF in 5% of patients with a normal standard ECG (7/139 patients),

whereas ELR detected AF in 5.7% of patients with a normal standard ECG and normal

Holter (5/88 patients). The study concluded that ELR identified patients with AF, who

remained undetected with standard ECG and with Holter. ELR should, therefore, be

considered in every patient in whom a cardioembolic mechanism is suspected. 21

A randomized clinical trial on 174 patients in general practice was done in Amsterdam

Netherlands. The objective of the study was to test the diagnostic yield of Patient-

activated memo event recorders in diagnosing episodes of cardiac arrythmias in patients

with palpitations or light-headedness. The results revealed that there were fewer patients

9

without a diagnosis in the intervention group (17% vs. 38%; RR = 0.5, 95% CI 0.3 to

0.7) and more patients with a cardiac diagnosis (67% vs. 27%: RR 2.5, CI 1.8 to 3, 5).

More relevant cardiac arrhythmias were detected (22% vs 7%) with event recording than

with usual care (RR 3.2, 95% CI 1.5 to 6.8). The study concluded that the Patient-

activated loop recorders are feasible and effective diagnostic tools in patients with

palpitations or light-headedness in primary care22.

Studies supporting interpretation of electrocardiogram

A cluster randomized controlled trial on 14, 802 patients aged 65 or over was conducted

in 50 primary care centers in England. The purpose of the study was to assess whether

screening improves the detection of atrial fibrillation (cluster randomisation) and to

compare systematic and opportunistic screening. The results revealed the detection rate

of new cases of atrial fibrillation was 1.63% a year in the intervention practices and

1.04% in control practices. Systematic and opportunistic screening detected similar

numbers of new cases. The study concluded that Active screening for atrial fibrillation

detects additional cases over current practice. The preferred method of screening in

patients aged 65 or over in primary care is opportunistic pulse taking with follow-up

electrocardiography23

.

An experimental study was done on 117 persons consecutively admitted to a coronary

care unit in a community hospital, Toronto, Canada. The objective of the study was to

find out the usefulness of three additional electrocardiographic chest leads (V7, V8, and

V9) in the diagnosis of acute myocardial infarction. The results of the study revealed that

among the 46 (39%) with a proven acute myocardial infarction the electrocardiograms

(ECGs) of 9 (20%) showed ST-segment elevation or abnormal Q-waves, or both, in the

three additional leads. In six of the nine, such changes were associated with signs of

anterolateral or inferior wall infarction (in three each) on the standard 12-lead ECG. Thus

10

the study showed that additional chest leads are helpful in detecting myocardial injury of

necrosis in areas of the heart not properly reflected on the standard 12-lead ECG. this

study was performed to evaluate the sensitivity of ST-segment elevation of standard and

extended ECG leads in a cohort of patients with angiographically confirmed diagnosis of

AMI 25.

A Cohort study conducted on 47 patients with end stage renal failure undergoing

hemodialysis sessions with the objective to evaluate the responses of P-wave, R waves,

and host of other electrocardiogram (ECG) changes to the procedure. The results showed

after hemodialysis (HD), significant ECG changes precipitated by hemodialysis included

an increase in the P, QRS, mean, QRS duration, maximum P-wave duration,

measured in lead II. Lead II was the lead with the longest P-wave duration in 36 patients

(76.5%) 26.

An evaluative study on 2112 randomly selected standard 12-lead ECGs was done in

Nelson’s hospital, England. The purpose of this study is to determine the accuracy of

ECGC rhythm interpretation in a typical patient population. The results revealed that the

ECG-C correctly interpreted the rhythm in 1858 and incorrectly identified the rhythm in

254 (overallaccuracy, 88.0%). Sinus rhythm was correctly interpreted in 95.0% of the

ECGs (1666/1753) with this rhythm, whereas nonsinus rhythms were correctly

interpreted with an accuracy of only 53.5% (192/359) (P < .0001). Thus the study

concluded that ECG-C demonstrates frequent errors in the interpretation of non sinus

rhythms. In addition, incorrect rhythm interpretation by the ECG-C was frequently

further compounded by additional major inaccuracies. Expert over reading of the ECG

remains important in clinical settings with a high percentage of non sinus rhythms 27.

An evaluative study on the Value of Troponin-T Test in the Diagnosis of

11

Acute Myocardial Infarction was conducted at Dr. SN Medical College and associated

group of Hospitals in 156 patients of acute myocardial infarction reaching within 24

hours of onset of symptoms. Serial ECG changes were considered as gold standard for

the diagnosis of myocardial infarction. The results of the study revealed that, sensitivity

(64.7%) and specificity (71.4%) of troponin-T test was higher than CPK-MB (54.9% and

42.8%) and SGOT (31.3% and 57.0%) respectively. The study concluded that bedside

troponin-T test is highly sensitive and specific in the diagnosis of acute myocardial

infarction and can be used in emergency and ambulatory settings33.

An observational study on a randomized sample of 84 was done at All India Institute of

Medical Sciences. The objective of the study was to determine the role of ECG in the

recognition of Left septal fascicular block. The study concluded that Left septal

fascicular block is a polymorphic conduction defect which may explain some previously

inadequately understood electrocardiographic abnormalities34.

Studies supporting planned teaching programme:

A Pre experimental study was conducted on a purposive sample of 45 to assess the

effectiveness of structured teaching program on the knowledge and practice of hand

washing technique among food handlers at CMC, Ludhiana, and Punjab. A co- relational

approach was adopted to assess the knowledge and practice. Post-test scores of 83.1% in

knowledge and 92% in practice as against the pre-test scores of 44% in knowledge and

49.3 % in practice showed a remarkable gain in both areas thus proving the effectiveness

of structured teaching program35.

An evaluative study to identify the “effectiveness of a need based planned teaching

programme on care of infants for mothers in selected areas of Udupi district” was

conducted on a Purposive sampling size of 50 mothers. The study results revealed a

statistically significant difference between pre-test and post-test mean knowledge scores

12

that is (t (49) = 25.86, p<0.05) indicating a significant gain in knowledge. The study

concluded that a planned teaching programme on Care of infants was an effective

teaching strategy37

.A pre experimental study was done on the “Effectiveness of planned health education on

control and prevention of diarrhoea among mothers having children below five years at

selected rural areas, Tirupathi, Andhrapradesh”. The sample size was 100 mothers

selected by using convenient sampling technique. The mean post- test knowledge scores

of 7.27 in knowledge, and 12.53 in practice were higher than the mean pre-test

knowledge scores of 3.82 in knowledge and 6.21 in practice. Also the t - test scores of

14.43 in knowledge and 21.55 in practice showed significant improvement in the

knowledge on control & prevention of diarrhoea & hygienic health practices at P< 0.01

level38.

6.4 STATEMENT OF PROBLEM:

“A study to evaluate the effectiveness of planned teaching programme on the knowledge

of recording and interpretation of electrocardiogram (ECG) among staff nurses working

in selected Intensive Care Units (I.C.U) of selected hospitals in Tumkur..

13

6.5 OBJECTIVES OF THE STUDY:

1. To assess the level of knowledge of recording and interpretation of

electrocardiogram (ECG) among subjects.

2. To prepare and administer planned teaching programme on the recording and

interpretation of Electrocardiogram (ECG)

3. To evaluate the effectiveness of planned teaching programme in terms of gain in

knowledge scores.

4. To determine the association between pre-test and post test levels of knowledge

with elected demographic variables.

6.6 RESEARCH HYPOTHESIS:

. H1 :The mean post test scores of subjects exposed to PTP will be greater then their

mean pretest scores as measured by structured knowledge questionnaire at 0.05 level

of significance.

H2 : There will be a significant association between the pretest and post test scores

knowledge score and inselected demographic varibles

6.7 OPERATIONAL DEFINITIONS:

1. Effectiveness: Refers to determining the extent to which the information in the PTP

has achieved the desired effect as expressed by gain in knowledge score.

2. Planned teaching programme (PTP) :

Refers to a written material used for teaching which is prepared by researcher and

content validated by experts. It is intended to provide information / knowledge

regarding :

a. Anatomy and physiology of heart

b. Electrophysiology of the heart

14

c. Wave forms, intervals, segments and complexes of ECG

d. Analyzing ECG rhythm strip 3.

Knowledge:

Refers to the correct response of nurses to items on cognitive aspects of ECG and is

expressed in terms of knowledge score.

4. Level of knowledge - refers to the scores obtained on knowledge items of recording

and interpreting ECG and interpreted as good, average, and poor.

5. Recording - refers to the knowledge of applying leads and tracing the electrical

activity on the ECG paper.

6. Electrocardiogram (ECG): Refers to the pattern of electrical activity traced on

electrocardiographic paper.

7. Staff Nurses - Refers to registered nurses with a B.Sc (Nursing) or GNM

qualification, working in ICUs

8. Intensive Care Units - Refers to wards where critically ill patients are admitted for

receiving intensive nursing and medical care.

6.8 ASSUMPTIONS:

The study assume that Staff nurses working in ICU have some knowledge in recording

and interpreting ECG.

2. PTP is an effective teaching strategy.

6.9DELIMITATION: The study is delimited to nurses:

a. Working in selected hospitals in Tumakur

b. Who are posted to ICU on rotation duty, at the time of data collection and who are

willing to participate in the study

7. 0 MATERIALS AND METHODS OF THE STUDY:

7.1 SOURCE OF DATA:

15

Data will be collected from Staff Nurses from selected hospitals in

Tumakur

7.2 METHODS OF DATA COLLECTION:

1. RESEARCH DESIGN

The Research design for the study shall be Quasi experimental one group

pretest and post test design

2 .VARIABLES

-Dependent variables-Knowledge of staff nurses.

-Independent variable –Planned teaching program.

-Extraneous variable-Age,sex,marital status,education.

3.SETTINGS

The study will be conducted in selected hospital at Tumkur

4. POPULATION

The population for the study is staff nurse in selected hospitals at Tumkur

5.SAMPLE SIZE

50 Staff Nurse in selected hospitals at Tumkur

7.3CRITERIA FOR SELECTION OF SAMPLE:

Inclusion criteria: -

- Staff nurses working in selected ICUs (Medical, Surgical, Neurological along with

ICCU) selected hospital in Tumkur.

- Who are available during the data collection.

-Who can speak and understand English.

16

Exclusion criteria:

-Nurses on leave.

- Nurses who are in managerial posts. e.g. Floor supervisor

6. SAMPLING TECHNIQUES

Purpose sampling technique shall be used to select the sample .

7. TOOL FOR DATA COLLECTION

Structured Knowledge Questioner method

8.PLAN FOR DATA ANALYASIS

The data analysis shall be done through descriptive and inferential statistics like

frequency ,mean, meanpercentage ,paired ‘t’ test and ‘chisquare’test.

7.4 DOES THE STUDY REQUIRE ANY INTERVENTIONS TO BE

CONDUCT ON PATIENTS OR OTHER HUMAN OR ANIMALS?

No, the study does not require any interventions.

7.5.HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR

INSTITUTION?

Yes, informed consent will be obtained from the institution authorities and subjects.

Privacy ,confidentially and anonymity will be guarded .Scientific objectivity of the study will

be maintained with honesty and impartially.

17

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36. Saxena A. Cancer chemotherapy and its side effect management. The nursing

journal of India 2006 May ; 46(5): 109-110.

37. Erna JR. “Effectiveness of a need based planned teaching programme on care of

infants for mothers in selected areas of Udupi district” MAHE, Manipal.2004;

unpublished thesis

22

38. Kavitha K, “Effectiveness of planned health education on control and prevention

of diarrhoea among mothers having children below five years at selected rural

areas, Tirupathi, Andhrapradesh”. 2005; unpublished thesis

39. Krishna swami OR, Ranganatham M. Methodology of research in social sciences.

New Delhi: Himalaya publishing house; 1998.p132-9.

40. Salerno SM, Alguire PC, Waxman HS. Competency in interpretation of 12-lead

electrocardiograms: a summary and appraisal of published evidence.Ann Intern

Med 2003 May 6; 138(9):751-60.

9.SIGNATURE OF THE CANDIDATE

10.REMARK OF THE GUIDE

11.NAME AND DESIGNATION OF GUIDE

Mrs.Ramai.p

Associate professor

Medical sugical nursing

12.SIGNATURE

23

13.CO GUIDE

14.SIGNATURE

15.HEAD OF THE DEPARTMENT

16.SIGNATURE

17.REMARKS OF PRINCIPAL

18.SIGNATURE

                                            "A STUDY TO EVALUATE 24

THE EFFECTIVENESS OF STRUCTURED TEACHING

PROGRAM ON KNOWLEDGE REGARDING PREVENTION

OF NOSOCOMIAL INFECTION AMONG STAFF NURSES

WORKING AT SELECTED HOSPITALS, TUMKUR ”

 

 

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

 

                                                             SUBMITTED BY

Mr. VITHAL

FIRST YEAR M.Sc NURSING

MEDICAL SURGICAL NURSING

2012-2014

 

 

 

 

SRI SIDDHARTHA COLLEGE OF NURSING , AGALKOTE ,

                                                             B .H ROAD,TUMKUR

 

 

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,25

BANGALORE,      KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

 

 

 

26

1              NAME OF THE CANDIDATE & 

ADDRESS

Mr. VITHAL SHANKAR

I YEAR M.Sc NURSING

SRI SIDDHARTHA COLLEGE

OF NURSING, AGALKOTE,

TUMKUR

2 NAME OF THE INSTITUTION SRI SIDDHARTHA COLLEGE OF NURSING,B.H 

ROAD,TUMKUR

3 COURSE OF THE STUDY & 

SUBJECT

DEGREE OF MASTER OF NURSING

MEDICAL SURGICAL NURSING

4 DATE OF ADMISSION 11-07-2012

5 TITLE OF THE TOPIC "A STUDY TO EVALUATE THE STRUCTYRED 

TEACHINGPROGRAM ON KNOWLEDGE 

REGARDING PREVENTION OF NOSOCOMIAL 

INFECTION  AMONG STAFF NURSES 

WORKING AT SELECTED 

HOSPITALS,TUMKUR”

 

 

6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION:-

                 Nosocomial infection is also called as 'Hospital  

Acquired-                               Infection’, it  is derived from the Greek 

word 'Nosocomeion' meaning hospital or hospitalization. It can 

be defined as an infection whose development is favoured by a 

hospital environment, such as one acquired by a patient during 

a hospital  visit or one developing among hospital staff. Such 

infections include fungal ,viral and bacterial infections and are 

aggravated by the reduced resistance of individual patients.1

Two factors contribute to the occurrence of nosocomial 

infections. First, concentration of virulent forms of different 

organisms in the hospital  and second is the presence of patients 

with anatomical and physiological defects.2

Nosocomial infections are important contributors for 

morbidity and mortality. They  became more important  public 

health problem with increasing economic and human impact 

27

because of increasing numbers and crowding of people, more 

frequent impaired immunity due to age, illness, treatments,  

new microorganisms, increasing bacterial resistance to 

antibiotics.3

Nosocomial infections occur worldwide and affect both 

developed and developing countries. Infections acquired in 

health care settings are a significant burden both for the patient 

and for public health. A prevalence survey conducted under the 

guidance of World Health Organisation in 55 hospitals of 14 

countries representing 4 World Health Organisation Regions 

Europe, Eastern Mediterranean, South-East Asia and Western 

Pacific has showed an  average of 8.7% of hospital patients had 

nosocomial infections. At any time, over 1.4 million people 

worldwide suffer from infectious complications acquired in 

hospital 4.

The most frequent nosocomial infections are infections are 

surgical wound, urinary tract infections and lower respiratory 

tract infections. Surgical site infections are the third most 

common nosocomial infections in surgical patients- accounting 

28

for about 24% of the total number of nosocomial infections .It’s 

rate has varied from a low of 2.5% to high of 41.9%.5

The effectiveness of infection control practices depends on 

nurse’s consciousness and consistency by using effective aseptic 

technique. It is human nature to forget key procedural steps, or 

when hurried, to take short cuts that break aseptic procedures.  

However, failure to comply with basic procedures places the 

client at risk for an infection that can seriously impair recovery 

or lead to death.6

The nurse follows certain principles and practices 

including standard precautions to prevent and control of 

infection and it spread. During daily routine care the nurse 

basic medical aseptic techniques to break the infection chain 

for example, use gloves and a mask during dressing to break the 

entry of pathogens. The term standard precaution applies to 

blood and body fluids, non-intact skin, mucous membranes from 

all clients.  The precautions will protect the client and provide 

protection of healthcare staff as directed by the occupational 

safety and health administration.7

29

   For Infection control,  nurse is responsible for the 

surveillance and analysis for hospital acquired infection; 

educating employees about infection control and ensuring the 

implementation of various infection control polices in the 

hospital.  Assessing environmental control through surveillance 

monitoring.  Conduct environmental  rounds in all  inpatient and 

outpatient care areas. Collect data on the incidence of selected 

device use in identified intensive care units. Participating in 

quality/performance improvement activities by assessing, 

monitoring, and measuring hospital acquired infections and 

evaluation outcomes on a continuous basis.8

 

Nurses play a pivotal role in preventing hospital-acquired infections (HAI), 

not only by ensuring that all aspects of their nursing practice is evidence 

based, but also through nursing research and patient education.  They 

instruct other nurses and health care staff on proper sanitation 

procedures.Nurses in all roles and settings can demonstrate leadership in 

infection prevention and control by using their knowledge, skill and 

judgment to initiate appropriate and immediate infection control 

procedure.9

30

 

 

 

 

 

 

 

 

 

 

 

6.2  NEED FOR THE STUDY :-

         Hospital-acquired infections add to functional  disabi l ity and 

emotional  stress of the patient and may,  in some cases,   lead to disabling 

conditions that  reduce the quality of  l ife.  Nosocomial   infections are also 

one of the leading causes of death5 .  The Centres for Disease Control  And 

Prevention has estimated roughly  1.7 mil l ion hospital-associated 

infections,   from all  types of bacteria   cause or contribute to 99,000 

deaths each year.10

         Nosocomial   infections occur  in about 5-10 percent  of 

hospital  admissions,  worldwide.   In India,  the nosocomial   infection rate is 

31

alarming and is estimated at about 30-35 percent of all  hospital  

admissions.  Nosocomial   infections typical ly  affect  immunocompromised 

patients due to factors  l ike age, underlying diseases,  medical  or surgical  

treatments.  Aging of the population and increasingly aggressive medical  

and therapeutic interventions,   including implanted foreign bodies,  organ 

transplantations,  and xenotransplantation,  have created a plethora of 

vulnerable individuals.  Another important  factor  is  the poor state of 

government hospitals   in India.  The highest  infection rates are in 

intensive care unit   (ICU) patients.  Nosocomial   infection rates in adult  

and pediatric   ICUs are approximately  three times higher than other 

hospital  wards.   In these areas,  patients with invasive vascular  catheters 

and monitoring devices have more bloodstream infections due to 

coagulase-negative staphylococci.  11

A quasi experimental  study   conducted to evaluate the effect 

of an educational  training programme for 100 randomly selected hospital 

nurses on universal  precautions  in Chang Hospital   in China.  

Questionnaire  were administered to the 100 nurses prior to and four 

months after the training.  The result  showed that educational  training 

significantly   improved Chinese nurses knowledge,  practice and behaviors 

related to universal  precautions.  There was remain room for 

improvement in glove use and needle stick injury reporting.12 

 

32

             Nosocomial   infections are commonly transmitted when 

hospital  officials  become complacent and personnel  do not practice 

correct hygiene regularly.  Also,  increased use of outpatient treatment in 

recent decades means that a greater percentage of people who are 

hospital ized today are l ikely to be seriously  i l l  with more weakened 

immune systems than in the past.  Moreover,  some medical  procedures 

bypass the body's  natural  protective barriers.  Since medical  staff move 

from patient to patient,  the staff themselves serve as a means for 

spreading pathogens essentially,   the staff act as vectors.

                     Ayyat    AA   ,et al  (2000 )   conducted a study in Egypt     to 

assess the knowledge,  attitude and practice of staff and student  nurses .  

A questionnaire  is designed and distributed to al l  student nurses  in the 

school    and to all  staff nurses working in the hospital   .  They used Scoring 

system  for data analysis.  Result  showed the overall  scoring of 

Knowledge Attitude and Practice for the three items studied are below 

80%, which means that they real ly  need health education about these 

items   . .13

                   Prevention is better than cure .Nurses are working 24 hours  in 

hospital  with the patients .They are the caretakers of the patient.  During 

clinical  posting investigator  has personally  witnessed various patients 

who has acquired nosocomial   infections and associated complications.so 

as a future nurse the investigator  has felt  there is  need to educate staff 

nurses about nosocomial   infection and preventive measures .  This study 

33

would serve as a basel ine guide for further development and growth of 

nursing care and enhance the preventive strategies used to minimize 

nosocomial   infection for the patient or cl ient,  hospital  setting, and care 

giver  itself .

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   6.3 REVIEW OF LITERATURE:-

                               Review of  l iterature is  a key step of research process. 

A thorough literature review on prior research provides a foundation on 

which to base knowledge.  The review of  l iterature is  defined as a broad,  

34

comprehensive in depth,  systematic and critical  review of scholarly  

publications,  unpublished scholarly print materials,  audio-visual  

materials  and personal  communications.

                               Review of  l iterature can be  studied  in fol lowing 

three headings :

1. Studies     related to incidence and    prevalence of Nosocomial  

Infection.

 2. Studies     related  to prevention   of    Nosocomial   Infection.

3. Studies       related to Structured Teaching on prevention of Nosocomial  

Infections.  

1.. Studies   related to incidence and   prevalence of 

Nosocomial Infection. :-

                   Ambanna Gowda (2010)   conducted  a– Prospective study 

To study the prevalence of nosocomial   infections in the ICU. He selected 

total of 50 cases developing infection after 48 hours after admission into 

intensive care unit  and with detailed History,  physical  examination and 

required lab investigations.  Results  will  be analyzed statistical ly  among 

50 patients who had nosocomial   infections in the ICU, (14)28% had UTI,  

(11) 22% LRTI,  (10)20% CRBSI,  (8)16% Soft tissue infections & (7) 14% had 

Pneumonias.  Among 7 cases of Pneumonias 5 were associated with VAP. 

He concluded that:  NIs  is  seen worldwide but  is   less studied and are 

given less emphasis   in developing countries 14.  

35

     Jan Muhammad Shaik ,Et al(2008)   conducted an 

observational  study at Tertiary Care Hospital   ,  Pakistan,  on risk of 

acquiring infection in Intensive CareUnit.  They included 333 samples of 

above 16 years of age admitted  in ICU more than 48 hours and 

observed .result  showed that out of 333 patients 97 patients had 

acquired nosocomial   infection .the frequency of nosocomial   infection 

was 29.12 %.hence they concluded that patients admitted in ICU are 

more risk for acquiring nosocomial   infection than others.15

     Meena Agarwal  ,Et al   (2003) ,conducted a study Prospective 

study to determine the incidence of post  operative nosocomial   infection 

among neurological  patients  in post operative period at AI IMS.They 

included 2441 neurosurgical  post operative patients and excluded 

patients of pre operative infections ,  then analysed for one year .After 

study result  showed 7.3% of patients have got post operative nosocomial 

infection.16

2. Studies   related  to prevention  of  Nosocomial 

Infection:-

       SureshChandra Yadav et  al(2012)    conducted  a comparative 

study  is  to identify the need for using prophylactic antibiotic in clean and 

clean-contaminated surgeries,  to identify the prevalence of organisms in 

patients who are not given prophylactic antibiotics and to study whether 

presence of risk factors  increase the incidence of surgical  site  infection .  

he collected 100 cases admitted under two groups of 50 each: group A 

36

were given prophylactic antibiotic and group B were not given any such 

antibiotic and Al l  surgeries other than clean and clean-contaminated 

surgical  cases where excluded from the study. They got   Results  Out of 

50 patients  in group B who were not given prophylactic antibiotic,  6 

patients had more than one risk factor for development of SSI and both 

of them developed SSI .  Group A had 35 clean surgical  cases and 15 clean 

contaminated cases,  out of which none of them were  infected .17

   Kibret M et al (2010) conducted,  a cross-sectional  study on 

Antibiogram of nosocomial  urinary tract   infection at Ethiopia.  They 

selected 1254 patients for a year.  Their  Antimicrobial  susceptibil ity  tests 

were done using disc diffusion technique as per the standard of Kirby-

Bauer method and got result .  as Of the 1 254 patients,  118 (9.4%) 

developed nosocomial  UTIs.  Thus ,  they have concluded that 

catheterisation and preoperative antibiotic prophylaxis  were found to be 

risk factor for nosocomial   infection.18

   William & Water man (2001) conducted a study on effective 

hand washing with lotion or soap to remove nosocomial  bacteria 

pathogenesis  persisting on fingertip it   is  called  intra hospital  spread. 30 

seconds hand wash with a nonseptic lotion a study  in  l iver pool to 

examine the nurses'  practice when performing aseptic technique.  The 

data was collected through observations and formal  interview from 21 

trained nurses selected conveniently.  The result  showed reduced 

37

frequency of hand washing,  the transfer technique and maintaining the 

principles  of the glove technique required for procedures .19

 

 

 3. Studies     related to Structured Teaching on 

prevention of Nosocomial Infections:-

           Labeau SO et al(2010) .  conducted a survey study to assess 

the Nurses'  knowledge of evidence-based guidel ines for the prevention 

of surgical  site  infection at  Belgium(2009)by  development of an 

evaluation tool   .They developed a multiple-choice knowledge test  

concerning evidence-based Surgical  Site Infection prevention .sample 

was 809 ICU nurses .  Demographics   included were gender,   ICU 

experience,  number of  ICU beds,  and whether respondents  had obtained 

a specialized ICU qualification.  Based on the test results,  an item 

analysis  was performed.  They got result:  as nurses'  mean score on the 

knowledge test was 29%. Males were shown to have better scores .they 

concluded that Opportunities exist  to improve ICU nurses'  knowledge 

about Surgical  Site Infection prevention recommendations.  Current 

guidelines should support their ongoing training and education.20

                 Zoabi,Titler     .(2011)   conducted a study on Compliance of 

hospital  staff with guidel ines for the active surveil lance of methici l l in-

resistant  Staphylococcus aureus (MRSA) and its  impact on rates of 

38

nosocomial  MRSA bacteraemia at Nazareth,   Israel   ,  they assessed 

compliance with MRSA surveil lance guidel ines by assessing adherence to 

the screening protocol and reviewing medical  and nursing charts of 

patients colonized with MRSA, and observed hand hygiene opportunities 

among health care workers and colonized patients.  Rates of nosocomial  

MRSA bacteraemia and of adherence with hand hygiene among overal l  

hospital  staff were obtained from archived data for the period 2001-

2010 they .got result  as Only 32.4% of eligible patients were screened 

for MRSA carriage on admission,  and 69.9% of MRSA carriers did not 

receive any eradication treatment.  The mean rate of adherence to glove 

use among nurses and doctors was 69% and 31% respectively  (P<0.01) 

and to hand hygiene 59% and 41% respectively  (P<0.01).  The hospital  

overal l  rate of adherence to hand hygiene increased from 42.3% in 2005 

to 68.1% in 2010..21

   Yinnon AM, et al(2011)    conducted a study to Improving 

implementation of  infection control  guidelines to reduce nosocomial  

infection rates by using checklists  three hospitals  over the course of one 

year.  at-,  Jerusalem, Israel.  They used tools as checklists   , it   included 20 

subheadings (± 150 items).  Project nurses conducted rounds in the study 

(but  not control)  departments;  during each round ,the nurses selected 

15-20 items for observation,  marked the checkl ists  according to 

appropriateness  of observed behaviour and provided on-the-spot 

corrective education. Rates of adherence to the checkl ist,  antibiotic use,  

number of obtained and positive cultures,  and positive staff hand and 

39

patient environment  cultures were reported monthly as a report card to 

relevant personnel  and administrators.  The rate of nosocomial   infections 

was determined in the first and   last months .proved that the use of 

checklists  during the conduct of  infection control  rounds,  combined with 

monthly reports,  was associated with a significant  decrease in 

nosocomial   infections  in study departments .22

 

 

 

     

6.4 STATEMENT OF PROBLEM :-

 “A study to evaluate the effectiveness of structured teaching 

programme on knowledge regarding prevention of nosocomial   infection 

among staff nurses working at Selected hospitals,  Tumkur”

 6.5 OBJECTIVES OF THE STUDY:

1) To assess the knowledge of staff nurses regarding prevention 

of nosocomial   Infection.

2) To develop and conduct structured teaching programme for 

staff nurses on prevention of nosocomial   infection.

3) To evaluate the effectiveness of structured teaching 

programme by comparing pre-test  and post-test  knowledge scores.

40

4) To find the association between pre-test  knowledge scores 

with selected demographic  variables.

6.6 OPERATIONAL DEFINITIONS:

1. Structured teaching program: Refers to the systematically  

developed institutional  method and teaching aids for staff nurse.

2. Effectiveness:   It  refers to a measure of match between 

stated goals and their achievement.

3. Knowledge:      It refers to the correct response of nurses to items on preventive  aspects of nosocomial infection .

 

4.  Staff Nurse:   I t   refers  to the one who  is    registered nurses with a B.Sc Nursing or GNM qualification,

6.7 ASSUMPTIONS :-

 These are the statement taken for granted  or considered 

true, even though they have not been scientifically  tested.

1) Nurse may have some knowledge regarding prevention of 

Nosocomial           infection.

2) Structural  teaching programme will   improve the knowledge 

of student nurses regarding prevention of Nosocomial   Infection.

3)   Nurses may have interest to gain knowledge regarding 

prevention of Nosocomial   Infection.

6.8 HYPOTHESIS OF THE STUDY:

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H1 :-  There will  be significant  difference between mean pre and 

post test knowledge scores of staff  nurses regarding prevention of 

nosocomial   Infection.

H2 :-  There will  be significant  association between pretest 

knowledge scores of staff  nurses with selected demographic  variables.

 

 

 

6.9 MATERIAL AND METHOD :-

7. 0 Source of Data :-

The data will  be collected from staff nurses of selected 

hospitals  at                Tumkur.

7.1 Methods of Data collection:

   Structured questionnaire   wil l  be prepared

1.Research Design :-  

Quasi  experimental  one group pre-test   post-test  research 

design .

 2. Variables:-

Dependent variables  -  performance in pre test and post 

test.

Independent variables  -  Structured teaching program.

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3 Setting of the study :-

 The study wil l  be conducted in selected  hospital  at  Tumkur.

4.Population :-  

The population for the study is staff nurses working in Selected 

hospital ,Tumkur.  

 

5. Data Collection Instrument :-

 Structural  knowledge questionnaire  wil l  be used for data 

collection.

6 .Sampling Techniques :-

        In this study Non Probabil ity  purposive sampling technique 

is  used    for the study.

   7. Sample Size :

 Sample consist  of 50 staff nurses.

 8. Criteria for sample collection :-

INCLUSIVE CRITERIA:  -  Study includes the staff nurses who are

   wil l ing to participate in the study.

 Present during the period of data collection.

EXCLUSIVE CRITERIA:  Study includes the student nurses who 

are

43

   Not wil l ing to participate in the study.

   Not present during the period of data collection.

 

 

 

9. Plan for data analysis:-

The data analysis  shall  be done through descriptive and 

inferential  statistics l ike frequency,  mean, mean percentage,  

paired”t”test  and“chi-square“test.

7.2 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR

INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR BRIEFLY? OTHER

HUMAN OR ANIMALS? IF SO, PLEASE DESCRIBE.

                                                                       “  No”

7.3 ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR

INSTITUTION ?

Yes,informed consent has been obtained from the  the 

concerned authorities and subjects.    Privacy,  confidentiality  and 

anonymity wil l  be guarded.  Scientific objectivity  of the study will  be 

maintained with honesty and impartially.

 

 

 

44

 

 

 

7.4 LIST OF REFRENCE:  

1.http://www.wikipedia.org.  

2.Phipps,Long,Woods  .  Shafer’s  Medical  Surgical  

Nursing .Seventh edition .  New Delhi     :B. I  Publications;1996.  164-65  .

3.Ducel  G. Les nouveaux risques infectieux.Futuribles; 1995, 

203:532.

4.Tikhomirov E.  WHO Programme for the Control  of Hospital  

Infections.  chemiotherapia;1987.  3:148–151.

5 Ponce-de-Leon S. The needs of developing countries and the 

resources required.  J Hosp Infect;  1991,18 (Supplement):376–381.  

6 Dider.  Hand hygiene and aseptic  in the emergency 

department.American journal  of   infection control;  vol-104; 2009. page-

170 to174.

7..Mangram, Alicia,  et.al ,  The center for disease control  and 

prevention.  Journal of  infection control;  2007. page-110.

                    8.  Jacqueline M.Smith . A journal of Infection Control Nurse; Nov3.; 

Calgary;2004.

9.  Mukerjee AK. Hospital  Acquired Infection Guidel ines for 

Control.  Government of  India;  New Delhi;    1992.

45

10.Klevens,R Monlna et al .Estimating health care associated 

infections and deaths in US hospitals.  Public health reports;  

122.2(2007);          160-166

11 Vasudha Mukherjee .Nosocomial   Infections in India:  

Assuming Dangerous Proportions.India ;   .  20 Jul 2001 

12.  Hung Jang,  Wang, Lin,  Ferrie Burgers.  A survey to 

determine knowledge of nurses in a clinical  setting  about universal  

precautions.China;  2002.

13.  Ayyat    AA   ,et al .  A kap study among staff and student 

nurses about infection control   ,J.Egypt soc parasitol   ;2000; 30(2).511-22.

14.Ambanna Gowda.A study on prevalence of 

nosocomial infections  in ICU.    abstract Rguhs.Bangalore.2010.

15.Jan Muhammad Shaik,Et  al.  Frequency,  pattern and etiology 

of nosocomial   infection in  intensive care unit  an experience at a tertiary 

care hospital .  J  Ayub Med Coll  Abbottabad Pakistan.  2008 ;Oct-

Dec;20(4):37-40.

 16 Meena Agarwal ,Et al.  The nursing journal of  India,  volume 

LXXXXIV,no.19.sept.   India 2003.  

17 Sureshchandra Yadav et al.  A comparative study of r isk 

factors and role of preoperative antibiotic prophylaxis   in prevention of 

surgical  site  infection .Bangalore RGUHS .2012. 

18.      Kibret  M,Abera B. Antimicrobial  susceptibility  patterns of 

E.coli  from cl inical  sources.  African health science;2011.  

46

19.Wil l iams and Watermen.  A study on aseptic technique at 

Liverpool.  American journal  of   infection    control.  August  ,  2001.1-7.  

20.Labeau SO et al   .  study to assess the Nurses'  knowledge of 

evidence-based guidel ines for the prevention of surgical  site  infection .  

Belgium. Worldviews Evidence Based Nursing.  2010 Mar;7(1):16-24.  

21.Zoabi et al,a  study on Compliance of hospital  staff with 

guidelines for the active survei l lance of methicil l in-resistant  

Staphylococcus aureus (MRSA) .Israil .  Medical  

Association.2011;13(12).740-44 

                           22.  Yinnon AM .  improving implementation of infection control guidelines 

to reduce    nosocomial infection rates . J Host infection.2012 ;81(3) 169-76.

 

 

 

 

 

 

 

 

 

 

 

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9.SIGNATURE OF THE CANDIDATE

 

 

10.REMARK OF THE GUIDE

 

 

 

11.NAME AND DESIGNATION OF GUIDE

Mrs. Ramai.p

Associate professor

Medical surgical nursing

13.CO GUIDE 

 

14.SIGNATURE 

 

15.HEAD OF THE DEPARTMENT

 

16.SIGNATURE   

17.REMARKS OF PRINCIPAL  

18.SIGNATURE

   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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