INTRODUCTION:
Open
heart surgery is an important procedure which can solve many heart diseases.
The most important which are coronary artery bypass graft, repair or
replacement of the valves, repair the structural abnormalities of congenital or
acquired heart diseases, placement of a mechanical assistive device, and
transplantation of the heart. The Post-surgery stage is the most important
period for cardiac surgery patients. It features many of the complications such
as pneumonia, cardiovascular disease, neurological and kidney diseases, which
prolong hospitalization, increased costs and have a direct impact on the
probability of survival.1
Cardiac
surgeries Help patients to return their normal lives and improves the quality
of life for them. However, despite the positive therapeutic effects of open
heart surgery, it can cause some problems for patients, such as physical,
emotional and social problems for several months during the postoperative
period. Provide information of discharge after surgery is one of the most
common approaches to nursing. Patients should be given training in discharge
post open heart surgery with the purpose of reducing or eliminate physical and
emotional problems,2
The
aims of discharge education in hospital to give patients the necessary
information. The specific elements of information and criteria for cardiac
patient education are identified, and there are many guidelines or standards
for teaching patients with cardiovascular surgery for discharge. Usually the
cardiac surgery clinics create educational content for patients, focusing on
postoperative care, diet, exercise and rest, and implemented by nurses who play
a most important role in the teaching of patients in hospitals.3
Recent
developments have led to an increase in the success rate of coronary artery
bypass graft surgeries, but it does not reduce all psychological, physical and
social problems facing patients post discharge. The problems can happen during
the early period post discharge for several body systems such as the
circulatory system, respiratory system, the site of operation, nutrition, used
of drug, exercises, self-care, and pain control, shoulder, back, chest, or leg
pain, excretion, insomnia, nightmares, palpitations, weakness, fatigue, mood
swings, depression, loss of appetite.4
Planning
for discharge should begin from the time of patient's admission and be
coordinated by a multidisciplinary team, also the process of discharge planning
will be affected by physical and social circumstances of the individual in
addition to family conditions. It is significant to the patients who left
hospital with a clear plan for treatment, which is suitable to their condition,
the information including the drug therapy, exercises, lifestyle modifications,
and practical tips to get back to work and resume normal activity.5
Discharge
planning includes patient, caregivers and family, it purposes to ensure
continuity of care and to determine the different patients' needs, and have
been defined to be comprehensive not just focus on medical needs. Upon
discharge from the hospital, participator patient has a positive impact on
providing safe and secure care, which reduces the risk of readmission, increases
patient satisfaction, and enhances the patient's role within the organization.6
Educating
the patient and family is the responsibility of the nursing, which is one of
the most important aspects of patient preparation for discharge, and should
take place during the period of stay in the hospital and don't wait until the
last minute. Every day, patients must be educated about drugs, including
pain medication, forecasts about activity levels, diet, Sternal precautions,
and care for incisions, signs and symptoms of infection. Patients should be
involved in their care as much as they are able. Families should be
participated when possible, particularly family members who will take care of
patients at home.7
Discharge
planning has gained consideration as an approach to ensure the continuity of
high quality care for patients and decrease health care costs by preventing
long-term hospitalization and/or unnecessary readmission to the hospital.9
METHODOLOGY:
Design
of the Study:
A quasi-experimental design study is carried out
through the application of pre-test and post-test approach to the study and the
control groups, from the period of January 2nd, 2017 to, 1st of Jun 2018.
Setting of the Study:
The present study is carried out in surgical wards of
cardiac centers and hospitals in Baghdad city, including nurses who have been
working in the surgical wards of Ibn Al- Bitar specialized center for cardiac
surgery; Iraqi center for heart disease and Ibn al Nafees hospital.
A
sample of the Study:
A purposive (Nonprobability) sample of (58) nurses is
selected. The sample is divided into two groups; (29) nurses (study group) are
exposed to the instructional program and (29) nurses are not exposed to the
program, considered as the control group, the selection of nurses was randomly
chosen.
Instrument:
To evaluate the effectiveness of the instructional
program, the researcher was constructed the instrument, which consists of three
parts:
Part
I:
The demographic data which included the nurses’
characteristic, such as age, gender, marital status, level of education, years
of experience, ward years, training courses, number of training courses, type
of the training course and place of training course.
Part II:
is
concerned the assessment of the nurses’ knowledge toward a patient discharge
planning program that consists of (7) domains:
1.
General information about
discharge planning (4) questions
2.
Discharge Follow-Up and Incisions
Care (11) questions
3.
Exercise program and activities
after discharge (8) questions
4.
Common health problems post
discharge (9) questions
5.
Medications post discharge (13)
questions
6.
Healthy nutrition (7) questions
7.
Risk factor modification (8)
questions
The knowledge test covers all domains and aspect for instructional
programs. For the purpose of the present study, the number of correct responses
of the knowledge questionnaire is used as the measure of the level of
knowledge. Each question is comprised of (4) alternatives.
Part III:
The
observational checklist was composed of seven domains and (52) items to assess
nurses' practices it was presented as follows
1.
General information about
discharge planning (2) items
2.
Discharge Follow-Up and Incisions
Care (8) items
3.
Exercise program and activities
after discharge (13) items
4.
Common health problems post
discharge 8) items
5.
Medications post discharge (8)
items
6.
Healthy nutrition (4) items
7.
Risk factor modification (9) items
The
Observational checklist of nurses' practices carried out during the morning and
night shift. The levels of scale which were scored as a total of three episodes
of events were observed for each respondent: practices as mean of data
collection (3) or (2) correct practices out of three episodes were rated as
always (l) corrected practices out of (3) episodes were rated as sometimes and
uncorrected practices were rated as never.
The
instructional program consisted of (4) session and were implemented over a
period of (4) weeks included knowledge and practice related discharge plan.
Validity:
The
content validity of the instructional program and the study instruments are
established through a panel of (16) experts.
Reliability of the
Knowledge and practice Items:
Test-retest
was used to determine reliability of the knowledge instrument, and Pearson
correlation coefficients are used which = (0.91), Reliability of the
observational checklist was determined through the use of the inter-observation
method. The reliability of the
coefficient was (r= 0.830).
Statistical Methods:
Data
have been analyzed through the use of Statistical Package for Social Science
(SPSS version 23 application).
The
table shows that the no significant association between age, gender, years of
experiences, ward years and training course with nurses' knowledge and
practices, while significant association between educational level with nurses'
knowledge and highly significant association with the nurses' practices of a
study group post-test when analyzed by one way ANOVA and independent sample
T-test.
DISCUSSION:
Analysis
of nurses' demographic characteristics ensures equivalence in both groups and
there is no significant difference between study and control groups, this
result of the study is accepted in the quasi-experimental study. According to
age of present study the results reported that the highest percentage in the
study and the control group were in the age group (20—24) years and mean age of
nurses in the study group is (29.17) and in the control group is (31.59). The
majority of nurses in the study group and the control group are female. And
married. These findings support through
studies to determine the nurses'
knowledge of cardiac setting and found
that a higher percentage of the nurses
are between the ages (20-27) years. 10,
11, 12. And similar to the results of the study to assess registered nurses’ CPR knowledge and skills found that the (86.3%) of the study sample were females and 13.7%
were males.(12)
Regarding the educational level, the findings show
that the most of nurses in the study and the control group were instituted,
this finding is supported by a study
which stated that a higher percentage of
the nurses in the cardiac unit were graduated from the nursing institute.
(14)
This
results comes along with a study found that the (62%) of the nurses were in the age group less than 25 years, and (90%)
were female. Concerning their educational level, 52% of the nurses held a
nursing diploma. (15)
Discussion
the years of experience, years of experience in surgical wards, training
course, number of training courses, types of training courses and place of the
training course of the study and control group:
In
related to years of experience the result shows that the more than half of the
study group were < 5 years, while less than half (37.9 %) of the control
group have < 5 years of experience. .The high percentage of the study group
and the control group were < 5 years. And they having a training course were
< 5 times. All their training inside of Iraq.
These
results confirmed by the study, which found that a higher percentage of the
sample in the study group and the control were between (1-3) years of
experience. Also indicated that both study and control groups were between
(1-3) years of experience in cardiac units; while (70%) of the sample in the
study group and (60%) of them in the control group have (1-2) training session.
(16)
This
result is consistent with studies (17 18) who stated that the most of the nurses had experienced
between (1–5) years. Most cardiac unit nurse, had experienced less than (5)
years. And most of the nurses had (1–2) training sessions concerning nursing
care of patients.
Regarding
the types of training, the result shows the majority of the nurses in the study
group and the control group were a participant in the theoretical training.
Discussion
effectiveness of the instructional program on nurses' knowledge concerning
patient discharge planning in pre and post-test:
The
data analysis (60 questions) including in seven domains of the nurses'
knowledge concerning patient discharge planning. The control group had
revealed that no significant differences between pre and post-tests of all
knowledge domains (General information, Follow up and wounds care, Exercise
program and daily activity, Common health problems, Medication, and Nutrition)
except (Risk factor modification domain). While the study group shows that
there are high significant differences between pre - post-tests of all
knowledge domains (general information, follow up and wounds care, Exercise
program and daily activity, common health problems and medication, nutrition
and risk factor modification)
These results confirmed by study to assess nurses'
knowledge working in thoracic surgery units and wards toward prevention,
complications of thoracic surgery found that
there were a high significant difference between nurses’ knowledge, at pre-test
and post-test for the study group, In addition, that there is a non-significant
difference between nurses’ knowledge at pre-test and post-test for the control
group.(19)
This
result comes along with a study to evaluate the effect of education on nurse’s knowledge about low cardiac output
syndrome and found there was a statistical difference in post-test from the
pretest. It reflects that educational intervention has improved nurse’s
knowledge.(20)
Discussion
effectiveness of instructional program on nurses' practices concerning patient
discharge planning in pre and post test:
The
effectiveness of instructional program to improve the practices of nurses who
work in surgical ward concerning discharge planning are clearly observed as
compared to the study group. The analysis of the data for observational
checklist revealed that the
implementation of the nursing education program for the study group had a
positive effect on nurses' practice. Furthermore;
the results confirmed that the highly significant differences between pre and
post of practice domains (Follow up and wounds care, Exercise program
and daily activity, Common health problems and Medication) and significant
differences of practice domains (General information, Nutrition and Risk
factor modification). While the results of the control group show that no significant
differences between pre and posttest of all practice domains (General
information, Follow up and Wounds care, Exercise program and Daily
activity, Common health problems and medication) except (nutrition and risk
factor modification). This result means that nurses' practices in the
study group are better than those in control group post implementing the
instructional program.
These results confirmed by study to examine the impact of structured teaching program
on knowledge and practices of staff nurses
about the incidence of intravenous
cannula complications found that there were no significant difference between nurses’
practices, at pre-test and post-test (p-value less than 0.05) for the control
group.(21), And confirmed by
study for evaluating the effectiveness of
nursing education program on the nurses practice toward cardiac rehabilitation
phase one found that the no significant differences for pretest between case
and control groups, and highly significant deference between pre and posttest
in the study group in overall main domains related to nurses' practice. (22)
Discussion
of the association between nurses' knowledge with demographical characteristic
and some variables:
The
results of present study established there is no significant association between
the nurses' knowledge of the study group with their age groups, gender, years
of experiences as a general, years of experiences in ward and training course
related to post-tests knowledge.
This
findings are supported with the result found by studies which stated that there
are non-significant relationship between
the age, gender, training course and years
in hospital experience with the
level of knowledge for nurses working at cardiac center.(23 24 25 26 27)
A
significant association in a study group
between the educational levels with nurses' knowledge in posttest. This result
supported by result of study shows that there was a significant relationship
between the nurses' knowledge with the educational level of the nurses (28),
and disagree with a study which found no significant association between
post-test knowledge scores and educational level.(29)
Discussion
of the relationship between nurses' practices with demographical characteristic
and some variables:
The
results of the present study established there is no significant association
between the nurses' practice of the study group with their age groups, gender,
years of experiences as a general, years of experiences in the ward and
training course related to post-tests. This result agrees with the studies
which showed no statistical significant difference between the nurses' age,
gender, years of experiences as a general, years of experiences and training
course with the practice level.(30 31 32)
The
findings of the current study show that the there is a high significant
association in a study group between the educational level with nurses
practice. Supports this findings through
the study to assess critical care nurses’
knowledge and practice they found that there were significant differences between nurses'
educational levels with their practice.(33). Alternatively, the present study finding contradicts
findings, which revealed that there was no significant association between
pre-test knowledge scores, pre-test practice scores and level of education
qualification.(34)
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= Mean, SD = standard deviation.