A study to assess learning need, knowledge and attitude of nurses regarding
tuberculosis care under RNTCP in two tertiary care tuberculosis institutions of
Delhi, India.
Anita Rani
Kansal1,
Rajinder Mahal2 D. Behera3, Rohit
Sarin4
1Nursing
Superintendent National Institute of TB & RD, Aurobindo,
Marg, New Delhi.
2Professor,
College of Nursing, M.D.O.C. Hospital, Ludhiana.
3Professor, Dept.
of Pulmonary Medicine, PGIMER, Chandigarh.
4Director,
National Institute of Tuberculosis and Respiratory Diseases, Aurobindo Marg, New Delhi
Corresponding Author Email: kansallrs@gmail.com
ABSTRACT
Background- India is high TB burden, high HIV burden
and high MDR TB burden country. Nurses are the backbone of any health care
delivery system. Nurse’s knowledge and attitude is crucial for achievement of
targets of TB control.
Objectives- To assess the learning needs, knowledge
and attitude of nurses for tuberculosis. To evaluate factors affecting knowledge
and attitude.
Methodology – Three different tools, one to assess
learning needs, second was knowledge questionnaire with six domains. and third attitude scale was used . Content validity and
reliability of all tools were established before data collection. Subjects were
400 nurses working in tertiary care TB institutions.
Results –20% nurses expressed that they knew about
category 4 treatment, its regimes and records and
reports related to RNTCP. Remaining 80% have expressed the desire to learn
these areas. About 30% nurses expressed that they have knowledge regarding
ACMS, regimens of treatment , diagnosis of
tuberculosis as per RNTCP guidelines. 50% nurses expressed that they have
learnt about history, etiology and pathphysiology,
side effects of ATT, categories of treatment and role of nurse for TB patient.
Mean knowledge score was 31.54 out of 50 (63.08%). Knowledge was
the lowest in the programmatic aspect of RNTCP domain (49.40%) followed by
prevention of TB (58%) drug resistant TB (63%),treatment of drug resistant TB
(63%) and basics of drug sensitive TB (73%). Demographic variables such as age,
gender, qualification, designation did not affect the total knowledge score but
source of learning, training and experience has affected the knowledge score.
Mean attitude score was 69.77±8.0. Demographic variables did not affect the
attitude score except qualification.
Conclusion – Though nurses had fairly good knowledge
regarding drug sensitive TB, they need to be updated for drug resistant TB.
KEY
WORDS: knowledge,
RNTCP (Revised National Tuberculosis Control Programme),
Tuberculosis (TB)..
INTRODUCTION:
India is high TB burden,
high HIV burden and high MDR TB burden.1 There are 8.6 million
incident cases of TB globally in year 2012 and about 1.30 million deaths2.
Studies have reported about incidence of MDR TB 2-3% in new cases and about 17%
in re-treatment cases.3
This leads to an absolute large no of MDR
tuberculosis cases owing to high Tuberculosis burden and large population
posing a challenge to meet the millennium development goal to halt and reverse
the incidence of TB by 2015. HIV has added another fuel in this epidemic.
An adequate preparation in terms of work force, drug supply, adequate laboratory network is needed4. To
achieve these targets right number of people, with right skill, in right places
and at right time are needed 5. India is preparing approximately
2.25 lakh nurses by various nursing institutions in
different cadres apart from already registered nurses 6.
OBJECTIVES:
To assess the learning needs, knowledge
and attitude of nurses regarding tuberculosis.
To identify factors affecting knowledge and
attitude.
MATERIALS
AND METHODS:
Setting – Present study was a cross sectional study
carried in two tertiary TB institutions in year 2010-2012.
Ethical issues- Ethical clearance was taken from the
institute’s ethical committee. Written consent was taken from all the
participants. Subject information sheet was given.
Sample- This present study was carried out among
400 nurses working in two tertiary care hospitals. 175 nurses from National
Institute of Tuberculosis and Respiratory diseases and 225 nurses from Rajan Babu Tuberculosis hospital. Subjects were selected using
purposive sampling technique who had atleast one year
of experience in care of tuberculosis patients.
Tools – Three different tools were used.
1. Learning Assessment Scale- This tool was
used to assess learning needs of nurses for tuberculosis under RNTCP as
expressed by them. It had 16 items related to tuberculosis care. Each item has
3point scale i.e. already know, need to know and need
elaboration.
2. Knowledge Questionnaire- This tool had 50
multiple choice questions divided into six domains. Each right answer will
score one mark and no marks for wrong answer. The knowledge score of each
domain and total score was divided into 3 categories. Outstanding means
subjects who scored marks more than 80%. Category good was termed for those who
scored marks between 61-79%. Third category average was for the subjects who
scored marks less than 60%. As nurses need to understand and analyse patients problems using their knowledge so tool was
prepared on the basis of Benjamin Bloom theory of learning7. The
blue print of the knowledge questionnaire is as below in Table No 1.
3. Attitude Scale- Five point Likert scale was developed to evaluate the attitude of
nurses for tuberculosis and RNTCP as national programme.
This had 20 statements with five options ranging from strongly agree to
strongly disagree. Half of the Statements were positively worded and half were
negatively worded. Score ranges from 5 to 1 for positively worded statement
from strongly agree to strongly disagree and score ranged from 1 to 5 for
negatively worded statement from strongly agree to strongly disagree. So the
possible maximum score was 100 and minimum score was 20. As the score
increases, positive attitude increases.
Quality of tools
Content validity of
knowledge questionnaire and learning assessment scale was established by giving
it to ten experts, five RNTCP managers, five nurse
educators. Tool was evaluated for content, laungage, grammer. Each question was checked
and rated. Modifications were done as per comments and 100% content validity
was achieved. Attitude scale was reviewed by five RNTCP managers, three nurse
educators, one sociologist and one psychologist.
Reliability is capacity of
the knowledge questionnaire to measure what it intends to measure. It was
measured by test retest method.8
Learning assessment scale
(r= .79)
Knowledge questionnaire
reliability (r=.89)
Attitude Scale (r=.81)
Data collection- After taking written consent, data was collected
by self report method. Confidentiality was ensured. Subjects were told not to
write their names.
Statistical Analysis- Descriptive analysis was used. The
Chi-square and Exact test was used to compare knowledge and attitude with various
demographic variables and comparison of knowledge and attitude of nursing staff
of two tertiary hospital was also done. Correlation
was established between knowledge and attitude by Pearson correlation method.
Table
no: 1 Blue print of Knowledge
Questionnaire.
|
Number of
questions in each domain |
|||||||
|
Levels of
Knowledge |
Drug sensitive
TB |
Treatment of
Drug sensitive TB |
Drug resistant
TB |
Treatment of
Drug resistant TB |
Prevention of TB |
Programmatic
aspect of RNTCP |
Total |
|
Recall |
1 |
3 |
2 |
4 |
0 |
4 |
14 |
|
Understanding |
3 |
1 |
2 |
4 |
3 |
5 |
18 |
|
Applications` |
4 |
4 |
2 |
2 |
5 |
1 |
18 |
|
Total |
8 |
8 |
6 |
10 |
8 |
10 |
50 |
Findings
The results are descriptive and inferential according to the
objectives. Distribution of nursing staff as per demographic variables is shown
in Table 2.
Table No. 2 Frequency and
%age distribution of Nursing staff according to
Demographic variables
|
|
F |
Percent |
|
|
Gender |
Male |
59 |
14.8 |
|
Female |
341 |
85.3 |
|
|
Age |
20-30 |
97 |
24.3 |
|
31-40 |
162 |
40.5 |
|
|
41-50 |
109 |
27.3 |
|
|
51-60 |
32 |
8.0 |
|
|
Designation |
Staff Nurse |
349 |
87.3 |
|
Nursing. Sister |
51 |
12.8 |
|
|
Qualification |
GNM |
370 |
92.5 |
|
B. Sc. Nursing |
30 |
7.5 |
|
|
Experience |
1 to 10 year |
224 |
56.0 |
|
11 to 20 year |
112 |
28.0 |
|
|
21 to 30 year |
54 |
13.5 |
|
|
31 to 40 y-ear |
10 |
2.5 |
|
|
Place of work |
Hospital |
400 |
100.0 |
|
|
Outreach
facility |
nil |
0.0 |
|
Source |
Sensitization |
325 |
81.3 |
|
News Paper |
10 |
2.5 |
|
|
Colleagues |
12 |
3.0 |
|
|
T. V. |
11 |
2.8 |
|
|
Books and
Internet |
42 |
10.5 |
|
|
Sensitization
|
One |
120 |
30.0 |
|
Two |
31 |
7.8 |
|
|
More than Two |
56 |
14.0 |
|
|
None |
193 |
48.3 |
|
Out of 400 subjects, about 15% were male
and 85% were female. In age category, 24% were below the age of 30 years, 40%
in age group of 30- 40 years and rest 35% are above 40
years of age. 87%, of subjects were staff nurses and rest of the subjects was
nursing sisters. Majority of subject (92.5%) were having the qualification of General
Nursing Midwifery. Only 7.5% were with B. Sc. Nursing qualification. All subjects were working in hospital and
there was no staff nurse posted in outreach facility. About 48% of subject was
not exposed to any training selected to tuberculosis in entire span of working.
30% of subjects had received one training related to
tuberculosis though 81% had some form of sensitization towards tuberculosis.
Results of data collected from learning assessment scale are shown
in Table no. 3.
As the table indicates that only 20% nurses
expressed that they knew about category 4 treatment, its regimes and records
and reports related to RNTCP. Rest of 80% have expressed the desire to
learn these areas. About 30% nurses expressed that they have knowledge
regarding ACMS, regimes of treatment , diagnosis of
tuberculosis as per RNTCP guidelines. Rest of the 70% need to know and seeks
elaboration on these topics.50% nurses expressed that they have learnt about
history, etiology and pathphysiology, side effects of
ATT, categories of treatment and role of
nurse for TB patient. The rest of 50% expressed the desire to learn. Most of
the nurses i.e. 75% were comfortable with the topics of prevention of TB, types
of TB, ATT drugs and rest of 25% expressed the desire to learn.
Table No. 3 Frequency and percentage distribution of
nursing staff expressing their need for training in various domains.
|
S.No |
Domains of
Tuberculosis |
Already know |
Need to know |
Needs
elaboration |
|||
|
Count |
% |
Count |
% |
Count |
% |
||
|
1 |
History of TB |
215 |
53.8% |
122 |
30.5% |
63 |
15.8% |
|
2 |
Etiology of TB |
207 |
51.8% |
161 |
40.3% |
32 |
8.0% |
|
3 |
Patho physiology
of TB |
230 |
57.5% |
155 |
38.8% |
15 |
3.8% |
|
4 |
Prevention of TB |
302 |
75.5% |
76 |
19.0% |
22 |
5.5% |
|
5 |
Diagnosis of TB as per RNTCP |
125 |
31.3% |
208 |
52.0% |
67 |
16.8% |
|
6 |
Types of TB |
318 |
79.5% |
63 |
15.8% |
19 |
4.8% |
|
7 |
Anti
Tubercle Drugs |
291 |
72.8% |
81 |
20.3% |
28 |
7.0% |
|
8 |
Side effects
of Anti Tubercle Drugs |
189 |
47.3% |
156 |
39.0% |
55 |
13.8% |
|
9 |
Categories of treatment under RNTCP |
176 |
44.0% |
169 |
42.3% |
55 |
13.8% |
|
10 |
Regimes of
treatment |
123 |
30.8% |
214 |
53.5% |
63 |
15.8% |
|
11 |
Records
& Repots of RNTCP |
72 |
18.0% |
235 |
58.8% |
93 |
23.3% |
|
12 |
DOTS Plus
strategy |
158 |
39.5% |
195 |
48.8% |
47 |
11.8% |
|
13 |
Category 4
treatment |
82 |
20.5% |
267 |
66.8% |
51 |
12.8% |
|
14 |
Regimes of
category 4 treatment |
81 |
20.3% |
256 |
64.0% |
63 |
15.8% |
|
15 |
Advocacy, communication
& social mobilization |
111 |
27.8% |
223 |
55.8% |
66 |
16.5% |
|
16 |
Role of Nurse for TB patient |
232 |
58.0% |
117 |
29.3% |
51 |
12.8% |
Table No. 4 Mean score of various domains of knowledge
score.
|
Domains |
Mean |
Max Score |
% age |
Std. Deviation |
|
Basics of TB |
5.89 |
8 |
73.6% |
1.569 |
|
Treatment of
drug sensitive TB |
6.08 |
8 |
76% |
2.078 |
|
Drug Resistant
TB |
3.82 |
6 |
63% |
1.720 |
|
Treatment of
Drug Resistant TB |
6.15 |
10 |
61.5% |
2.724 |
|
Prevention of
TB |
4.66 |
8 |
58% |
1.682 |
|
Programmatic
aspect of RNTCP |
4.94 |
10 |
49.40% |
2.339 |
|
Knowledge
score |
31.54 |
50 |
63.08% |
9.485 |
Findings about knowledge and
attitude:
The mean knowledge score is 31.54 (63.08%) out of 50. The table no
4 shows that out of six domains of knowledge questionnaire mean score is least
in programmatic aspect of RNTCP domain (49.4%) and highest in the
treatment of drug sensitive TB (76%)
followed by basics of drug sensitive TB(73.6%). Mean score of knowledge in
basics of drug resistant TB (63%) and treatment of drug resistant TB (61.5%)
corresponds to the mean total knowledge score. The mean score in the domain of
prevention of TB was 58%.
Mean score of the attitude scale was 69.77± 8.09 out of 100.
Findings about Demographic
factors affecting knowledge and attitude score.
The gender of nursing staff did not affect the knowledge score
neither in total nor in any of the domain. Designation did not affect the total
score and in other domains except in basics of drug resistance, here nursing
sisters had better knowledge than staff nurses (p=.007). Qualification also did
not make any change except in prevention domain where B.Sc
nurses showed more knowledge score with statistical significant difference with
nurses with GNM diploma course. Age could not affect the overall knowledge
score but in three domains significant differences are spotted. Young nurses
were more acquainted with basics of TB such as etiology, pathology,
transmission than the senior nurses. (p=.001) whereas senior nurses have better
knowledge in drug resistant TB and prevention of TB. This is explained that young
nurses have latest classroom teaching about etiology, pathology where as senior
nurses learnt from their practice. Source of information also affected the
total knowledge score. Nurses with experience in TB care have more knowledge in
all the domains of TB care except programmatic aspect of RNTCP than the less
experienced nurses. Nurses who had received training in tuberculosis has performed better in all domains and total score in
comparison to those who did not attend any training or update as expected.
In the attitude score, demographic variable age, gender,
designation, experience and training did not affect the score. Only
qualification has affected the attitude score. B.Sc
nurses have shown more positive attitude than their counterparts. (p=>.001).
Findings about comparison of
knowledge and attitude score between the subjects of two tertiary hospitals
As the subjects were from two tertiary care
hospitals 175 from National Institute of TB and RD and 225 from Rajan Babu TB Hospital. A comparison of knowledge score and
attitude score was done among the nursing staff of two hospitals. Though total
knowledge score did not vary significantly but nursing staff of LRSI showed
more score in domains basics of drug sensitive TB, basics of drug resistance TB,
treatment of drug resistant TB and RNTCP. There was no significant difference
in the attitude score of nursing staff of NITRD and RBTB.
DISCUSSION:
Nurses have shown interest in learning many aspects of TB in which
they are not very confident. Same can be interpreted from the learning
assessment scale and knowledge questionnaire. This positive attitude of nurses
to learn about TB under national programme can prove
to be an asset to TB programmes.
The present study showed mean knowledge score as 31.54 out of 50
marks which is just above average score in nursing
profession. This low score in domains of drug resistant TB and can be attributed to Multiple and extensive
drug resistant tuberculosis (MDR and XDR TB) which is new to nurses. Low score
in programmatic aspect of RNTCP can be explained as nurses are not involved
directly in programmatic aspect of RNTCP. Though this is taught during training
in nursing curriculum, but revisions in RNTCP is continuous process. Similar finding have been reported in post
graduate medical students in previous studies12.
Previous studies have also shown that nurses
knowledge regarding tuberculosis was inadequate especially in nursing staff of
general hospital as compared to nurses working in TB hospital10.
A Study was done
to evaluate knowledge regarding tuberculin testing,
correct technique was followed by 46%, reading the tuberculin test by 11%, and
interpretation by 7% only.9
Gender did not
affect the knowledge score, however age, experience, designation, qualification
and training did make a difference in some domains of knowledge score related
to tuberculosis care.
Previous studies at community have shown that ASHAs have shown
good knowledge, favorable attitude and practices regarding TB11.
CONCLUSION:
Nurses working in tertiary
care tuberculosis hospitals have better knowledge of drug sensitive TB than
drug resistant TB. Nurses have shown positive response about learning the new
concepts in drug resistant TB.
IMPLICATIONS
OF THE STUDY:
Nurses can be involved in tuberculosis control at all levels in
RNTCP. Tuberculosis is a social, cultural, medical disease and India being high
burden country need to utilize nursing potential to meet millennium development
goals for TB. Nurses have the training for holistic approach of care which is
needed for this disease.
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Received on 09.01.2014 Modified on 12.01.2014
Accepted on 14.01.2014 © A&V Publication all right reserved
Asian J. Nur. Edu. & Research 4(1): Jan.-March 2014; Page 30-34