RAJIV GANDHI UNIVERSITY OF HEALTH SCIENECES, BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / NAME OF THE CANDIDATE AND ADDRESS / Ms. JOLLY JOHNSON AGOLDFINCH COLLEGE OF NURSING
NO.150/24, KODIGEHALLI MAIN ROAD,
MARUTHI NAGAR, BANGALORE-560092
2 / NAME OF THE INSTITUTION / GOLDFINCH COLLEGE OF NURSING.
NO.150/24, KODIGEHALLI MAIN ROAD,
SAHAKARNAGAR POST, BANGALURU-560092
3 / COURSE OF THE STUDY AND THE SUBJECT / MSc NURSING
MEDICAL-SURGICAL NURSING
4 / DATE OF ADMISSION TO THE COURSE / 30-06-2012
5 / TITLE OF THE TOPIC / “A study to assess the effectiveness of structured teaching programme on knowledge regarding organized Crash Cart System among staff nurses working in selected hospitals at Bangalore”.
6.0 BRIEF RESUME OF INTENDED WORK
6.1 INTRODUCTION
“People who are always taking care of their health are like misers who are hoarding a treasure which they have never spirit enough to enjoy”.
~Laurence Sterne
Emergency Nursingis anursingspecialty in which nurse’s care for patients in the emergency or critical phase of theirillnessorinjury. In contrast to practically every other specialty of nursing, in which a patient arrives with adiagnosisapplied by aphysicianand the nurse must manage the patient's care according to that diagnosis, emergency nurses work with patients in whom a diagnosis has not yet been made and the cause of the problem is not known. Emergency nurses frequently contact patients in the emergency departmentbefore the patient sees a physician. In this situation, the nurse must be skilled at rapid, accuratephysical examination, early recognition of life-threatening illness or injury, the use of advanced monitoring and treatment equipment, and in some cases, the ordering of testing and medication according to "advance treatment guidelines" or "standing orders" set out by the hospital's emergency physician staff. Emergency nurses most frequently are employed in hospitalemergency departments, though they may also work in free-standing urgent care clinics2.
Crash cart is a specially designed trolley, used for transporting and dispensing medicines and equipments at the emergency site for participating in life saving measures. Crash carts are located in areas of patient care in case of a life-threatening occurrence. Physicians, nurses, pharmacists, and respiratory therapists must become familiar with the contents of this cart. It contains necessary equipments to handle an emergency. A crash cart is enabling healthcare providers to manage medical emergencies easily and confidently3.
The cart is characterized by being easily movable and readily accessible into all sides of the cart for quickly viewing and removing equipment and drugs during a crisis. The first cardiac crash cart was created at Bethany Medical Center in Kansas City, Kansas. One of the doctor’s fathers fabricated the first crash cart. It contained an Ambu bag, defibrillator paddles, a bed board and endo tracheal tubes. A crash cart or code cart (crash trolley in UK medical jargon) is a set of trays/drawers/shelves on wheels used in hospital emergency rooms for transportation and dispensing of emergency medication/equipment at site of medical/surgical emergency for life support protocols like Advanced Cardiac Life Support/Advance Life Support (ACLS/ALS), Pediatric Advanced life Support [PALS] to potentially save someone's life1.
The contents of a crash cart vary from hospital to hospital, but typically contain the tools and drugs needed to treat a person in or near cardiac arrest. These include but are not limited to:
- Monitor/defibrillators and suction devices
- Advanced Cardiac Life Support (ACLS) drugs such as Epinephrine, Atropine, Amiodarone, Lidocaine, Sodium bicarbonate, Dopamine, and Vasopressin
- First line drugs for treatment of common problems such as: Adenosine, Dextrose, Diazepam or Midazolam, Epinephrine, Naloxone, Nitroglycerin, and others
- Drugs for rapid sequence intubation: Succinylcholine or other paralytic agents like Pancoronoum , a sedative drugs such as Etomidate or Midazolam; endotracheal tubes and other intubating equipment
- Vascular access devices – Intra Venous(IV) Cannulae, Drip sets [Micro and Macro], IV fluids [Normal Saline(NS), Lactated Ringer(RL), Hydroxy ethyl starch
- Other drugs and equipment as chosen by the facility2.
6.2 NEED FOR THE STUDY
“Take care of your body with steadfast fidelity. The soul must see through these eyes alone, and if they are dim, the whole world is clouded”.
- Johann Wolfgang Von Goethe
A “Crash Cart” is a mobile, compact cart, equipped with various medical aid tools (used mainly for cardiac emergencies). The cart consists of items such as a defibrillator, medications, a suction pump, and other life-saving equipment. Each floor of the Detroit VA has a “Crash Cart” that is used only in the event of a Code Blue Emergency. These days, the Cart is very organized, but not too long ago, this was not the case3.
In past years, there have been various issues with efficiency and organization of the “Crash Carts”. The two main issues prior to its reinvention and revamping, were that (1) the materials on the cart were not easily found, and (2) there were no clear instructions on how to use critical items on the crash cart. There were also issues with over-stuffing of items, and the excessive shifting of various items when the cart was on the move, or even when the drawers of the cart were opened and shut. Knowing that the most critical aspects of the “Crash Cart” organization were time and access to materials, the Detroit VA’s Systems Redesign Team was asked to help. The team lives by what they call the “5 S’s”: Sort, Strengthen, Shine, Standardize, and Sustain. The Detroit VA’s Systems Redesign Team will take an issue or problem, break it down to its core elements, and then sort those elements. Once that is done, they figure out where exactly these elements can be improved upon, and become the most effective. Once that is developed, they then figure out how to organize it in the neatest and cleanest way. They then make the things they sorted, strengthened and shined, the more effective way of doing things, in other words, it becomes the new standard. Finally once the first “4 S’s” are complete, it comes down to simply sustaining that standard, as well as always striving to better it, improve upon it and update it4.
In collaboration with Renee Peterson, Assistant Chief of Nursing Services, the Detroit VA’s Systems Redesign Team revamped the cart to what it is today. They brought down the cumbersome number of 37 items to a more manageable 23. Using various bins within the medical drawers, the issue of sliding and the mixing up of various medical tools and medicine was addressed. They also made it significantly easier for the medical tools to be relocated by labeling where every single item goes directly on the cart. The cart is also loaded with various instruction books for first responders. Not only are the lives of clinicians made easier, but the improvements make for better care for our Veteran patients4.These improvements will make using the carts more effective, and more efficient. The Systems Redesign team says that when actually timed, nurses using the cart cut their action time drastically4.
Organizing a crash or code cart requires knowing the progression of the "Advanced Cardiac Life Support" process, established by the American Heart Association. Crash carts, found in most health care facilities, have five, seven or nine drawers containing supplies used when responding to a life-threatening emergency. Found in strategic locations throughout the hospital or health care facility, crash carts should be easily accessible to health care providers, inventoried, and restocked on a regular basis5.
The investigator had come across many incidents in his experience in nursing profession where many nurses were not having Knowledge regarding crash carts is very important that emergency nurses should develop the skills regarding organization, uses and care of crash carts in hospitals. Hence, from these instincts the investigator was motivated and planned for doing awareness programme with the help of a teaching material5.
6.3REVIEW OF LITERATURE
Review of literature for the present study is explained under the followingheadings,1)Literature related to knowledge of staff nurses on Crash cart trolley.
2)Literature related to self-instructional module.
3)Literature related to general information regarding Crash cart trolley.
- Literature related to knowledge of staff nurses on Crash cart trolley.
A study was conducted on intensive care unit nursesknowledge of the Crash cart trolley. The investigator administered 31multiple choices question to 168 intensive care unit nurses from 15 institutions. Themean score was 57% correct. Although 90%of intensive care unit nurses correctlyidentify the equipmentsshould be measured, only 61% were able to measure it correctly, and answer to thispractical question varied. The results of the study indicated thatformal training, frequency and exposure to the Crash cart trolley and professional certificationin critical care correlated with better score on the questionnaire. Additional research is needed on a larger scale to validate these findings and determine if critical care nurses' knowledge of Crash cart trolley is sufficient to maintain quality standards of safety and optimal patient care.9
An article was published on assessment of critical care nurses' knowledge of the Crash cart arrangement. A 37-question multiple-choice examination that tested knowledge regarding the use of the Crash cart trolley was administered to a group of nurses, attending a national conference (New Orleans, LA), who preregistered for a hemodynamic workshop. Two-hundred sixteen nurses completed the questionnaire. The mean test score was 16.5 +/- 5.7 (48.5%). The study concluded that a wide variation in the understanding of the use of the Crash cart trolley exists among nurses using this device in the care of seriously ill patients. The results indicate that current teaching practices regarding the Crash cart trolley need to be re-evaluated and specific credentialing policies need to be considered.10An article was published on expert critical care nurses' use of Crash cart trolley. This paper reports one component of a study, which used a concept attainment framework to determine what data 8 expert critical care nurses in relation to Crash cart trolley used. In addition, participants used few clinical assessment attributes, but collected a large number of attributes, which they arranged around three to five central concepts and took a broad view of hemodynamic assessment. One participant did not display many of the decision-making features normally associated with an expert practitioner. In conclusion, expert critical care nurses process an immense amount of data in a short space of time. Evidence suggests not all nurses who practice in the field for a lengthy period reach the level of an expert.12
- Literature related to the effectiveness of structured teaching programme.
An evaluative study was conducted on the effectiveness of self-instructional module on selected drugs used in critical care units. The pre-test mean percentage knowledge of nurses was found to be less than 50 %( 49.92%).Findings of the study indicated that nurses were not adequately equipped with the knowledge on selected drugs. An increased knowledge score has obtained after the administration of self instructional module.14
3. Literature related to general information regarding Crash cart trolley.
A study was conducted on knowledge of Crash cart trolleyis a basic emergency medications oftenutilized to guide therapeutic interventions, especially in criticallyill patients. 391 criticalcare nurses practicing in various critical care specialtieswere invited to participate in the study. The response ratewas 17.4% (n = 68). Theparticipants were asked to complete an 18-item and total scores ranged from 11.1% to 61.1%.Literature on nurses’ knowledge of hemodynamic monitoringis limited, but several studies, published and unpublished,indicate a general knowledge deficit in use of crash cart trolley. Because of these research findings, in this article,we focus on areas of particular knowledge deficit related toessential Crash cart trolleyis a basic emergency medications .15
A descriptive study was conducted, in Finland, to assess theknowledge regarding use of crash cart trolley medication calculation skills of nurses and self-evaluation of nurses on it. The result shows that 70% nurses have sufficient skills and 95% of the nurses have mathematical skills. Moreover, 79% have sufficient knowledge on conversions, solution calculation (50%), tablet calculation (95%), weight calculation (77%), and infusion rate calculation (73%).The analysis revealed that the youngest nurses (20-29 years) have adequate skills, and where as the oldest (50-59 years) have less skill. According to above study Investigator concludes that the pharmacological skills of the nurses seemed to be inadequate.5
A qualitative study was conducted, in Australia, to explore nursing roles in crash cart trolley knowledge and nurse’s perception of related education, needed to prepare them for practice. The finding of the study shows that the, nurses have a limited understanding of crash cart trolley, and are dissatisfied with pre-registration teaching of the subject, but recognize the need for emergency knowledge in practice.4
6.4 STATEMENT OF THE PROBLEM
“A study to assess the effectiveness of structured teaching programme on knowledge regarding organized Crash Cart System among staff nurses working in selected hospitals at Bangalore”.
6.5. OBJECTIVES OF THE STUDY
1.To assess the pretest knowledge scores of Staff Nurses on Organized Crash cart system
2.To develop and implement structured teaching programme on Knowledge of Staff Nurses on Organized Crash cart system
3.To assess the effectiveness of structured teaching programme on knowledge of Staff Nurses on organized crash cart system in terms of posttest knowledge scores.
4.To find out the association between knowledge scores with their selected socio demographic data.
6.6. OPERATIONAL DEFINITIONS
1. Assess: It is the organized, systematic and continuous process of collecting data and the statistical measurement of knowledge regarding organized crash cart system by structured questionnaire.
2. Effectiveness:It refers to the feedback brought about by the nurses after structured teaching programmes. It is measured in terms of significant gains in the posttest.
3. Structured teaching programme: In this study, it is systematically developed programme with teaching aids, designed to impart knowledge, regarding organized crash cart system among staff nurses.
4. Knowledge: In this study, it refers to the awareness and understanding regarding organized crash cart system among staff nursesby structured questionnaire.
5. Crash cart: In this study, a crash cart is a trolley for storing life saving equipment and drugs in a hospital emergency room, Intensive care unit, clinics and other areas.
6. Staff nurses:In this study, Registered nurses are health care providers who provide patient care, training with a scope of practice.
7. Hospitals: It refers to an institution providing medical and surgical treatment and nursing care for sick and injured.
6.7. ASSUMPTION
- The nurses will not have adequate knowledge regarding organized crash cart system
- The nurses will be expressing their willingness to learn and understand about organized crash cart system
- The nurses will gain knowledge after the administration of intervention.
6.8. DELIMITATION
- The sample size was delimited to 60 staff nurses.
- The study period was delimited for 4 weeks.
- The sample was delimited to staff nurses who are presented in selected hospitals at Bangalore.
- The study was delimited to staff nurses present during the study.
6.9. HYPOTHESIS
H1∙ There is a significant difference in pre test and posttest knowledge of nurses.
H2∙ There is a significant association between then demographic characteristics and the posttest knowledge in nurses.
7.0 MATERIALS AND METHODS
7.1 SOURCES OF DATA
Research Design :Experimental, One group pre test and Post test
design
Setting of the study : selected hospitalsatBangalore
Population :staff nurses
Sampling technique :Simple random sampling technique
Sample size:Sample size will be 60
Sampling Criteria:
INCLUSION CRITERIA
Those who are willing to participate in the study.
Staff nurse, who know to speak, read and write in English or Kannada.
Staff nurses who completed GNM and BSc Nursing Course.
Available during the period of data collection
EXCLUSION CRITERIA
- Staff nurses those who are not available at the time of study
- Staff nurses who completed ANM, MSc and PhD in nursing.
7.2 METHODS OF DATA COLLECTION
After obtaining the permission from the concerned authorities, the investigator will introduce her/him to the study subjects and explains the purpose of study. The data will be collected by using structured questionnaire.
Description of the tool: Structured questionnaire
Tool-1
Part-A: Proforma for collecting demographic data
Part-B: Structured questionnaire to assess the knowledge of staff nurses on organized crash cart system
Tool-2: Structured teaching programme regarding organized crash cart system
Methods of Data analysis and interpretation
Pre and posttest scores of knowledge will be analyzed through the following technique.
Descriptive statistics: Mean, standard deviation, range and mean score percentage will be used to quantify the level of knowledge before and after structured teaching programme.
Inferential statistics: Paired t-test will be use to examine the effectiveness of structured teaching programme by comparing the pre- test and post- test score.
Chi-square test will be worked out to determine the association of socio-demographic factors of staff nurses with pre-test knowledge.
7.3Does the study require any investigation or intervention to be conducted on the patients or other human being or animals? If so, please describe briefly.