RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BENGALURU, KARNATAKA.
PROFORMA FOR REGISTRATION OF
SUBJECT FOR DISSERTATION
1. NAME OF THE CANDIDATE : KARAN SINGH RATHORE
AND ADDRESS 1ST YEAR M.Sc. NURSING.
BRITE COLLEGE OF
NURSING,BENGALURU-91
2. NAME OF THE : BRITE COLLEGE OF
INSTITUTION NURSING,BENGALURU-91
3. COURSE OF STUDY & : 1ST YEAR M.Sc. NURSING
SUBJECT MEDICAL-SURGICAL
NURSING
4. DATE OF ADMISSION : 01 JUNE 2011
5. TITLE OF THE TOPIC : A STUDY TO EVALUATE
STRUCTURED TEACHING
PROGRAMME ON
KNOWLEDGE REGARDING
HEMODYNAMIC
MONITORING AMONG
STAFF NURSES AT
SELECTED HOSPITAL,
BENGALURU.
6. BRIEF RESUME OF THE INTENDED WORK INTRODUCTION
“Nurses are the heart of health” ~Donna Wilk Cardillo
Critically ill patients require continuous assessment of their cardiovascular system to diagnose and manage their complex medical conditions. This is most commonly achieved by the use of direct pressure monitoring systems, often referred to as hemodynamic monitoring.1
The word Hemodynamic monitoring refers to measurement of pressure, flow, and oxygenation of blood within the cardiovascular system. It includes both invasive and non invasive. Values commonly measured include systemic and pulmonary arterial pressure, central venous pressure, pulmonary capillary wedge pressure, cardiac output, and oxygen saturation of the haemoglobin of arterial and mixed venous blood.2
Hemodynamic studies provide wealth of information reflecting the earliest changes in the circulatory system that are not clinically detectable. Hemodynamic monitoring provides information about blood volume, fluid balance and how well the heart is pumping. Current technology allows measurement of right atrial pressure (CVP), pulmonary artery pressure during systole and diastole (reflecting right and left ventricular pressures), and pulmonary capillary wedge pressure (pcwp; an indirect indicator of left ventricular pressure).3
The nurse cares for the thermodynamically unstable patient as well as the equipment required to conduct hemodynamic monitoring. It is essential that the nurse must be able to interpret the data and make clinical decisions based on that data. The nurse must know how to detect and prevent complications of this clinical tool.4
6.1 NEED FOR THE STUDY
Nursing as a profession is now responsible to account for its competence and performance. This has been the birth of the language of outcomes. Outcome is a mechanism to evaluate the quality, improve effectiveness and link practices to professional accountability.5
Cardiac diseases and surgeries are relatively very complicated in treatment and monitoring which needs a thorough understanding of condition where it always require continuous assessment and diagnosis of the complex conditions. This can be achieved only by good and sound knowledge in Hemodynamic monitoring.1
Cardiovascular support of critically ill patients requires non-invasive and invasive monitoring of physiological indicators of cardiovascular function, including factors that affect cardiac performance (preload, after load, contractility, and heart rate) and the balance between oxygen supply and demand.6
The monitoring of cardio vascular physiology is tool, to titre interventions and to evaluate responses to the therapies instituted. For the result of Hemodynamic monitoring to be utilized effectively the nurse must have a solid foundation in understanding the technical and physiologic implications that can impact the values obtained.7
Hemodynamic monitoring offers critical insights into how a patient’s cardio vascular system is responding to acute physiologic stress. But if nurses do not have experience with it, they may find its language and equations daunting. A clear and skilful observation and monitoring can prevent many fatal complications in critically ill patient.8
In the present day nursing there is a wide variation in the quality of assessment, monitoring, and documentation of these parameters, due to range of factors including intra and inter-observer reliability, equipments malfunction and patients preparation. Education of nurses and other health workers in the physiological and technical rationale under pinning the collection of vital signs data, and the significance of alteration in findings remains an important challenge.9
Nurse acting in her capacity as a monitor ,observes a patient, she decides whether his actual state is deviated from his individual homeostatic limits, she determines what actions must be taken to reduce any difference that she observes between the actual and desired states on this basis of the decision . She may take actions by herself or transmit the information to physician. The author highlights the importance of observation and decision making capacity on the part of nurses for which they should have clear knowledge regarding the procedure of monitoring.10
Critical care nurses often care for critically ill patients who require hemodynamic monitoring. Nurses need an extensive knowledge base to understand the various technical and physiologic factors that may affect the accuracy of pressure measurements. Continued nursing research is needed to refine and guide the development of nursing practice standards in caring for patients who require hemodynamic monitoring. 11
The investigator also observed in certain situation which he had come across during his past clinical experiences at an intensive care unit that some of the intensive care unit nurses were unable to interpret the hemodynamic data with relevant client clinical condition which may in turn affect the health status of critically ill patients. The nurse is often placed in such a circumstances to keep up with the high technology and modernization of sophisticated equipments. So one can say that there is very much need and importance in improving the present knowledge and updating knowledge to the present day nursing around the world.
So therefore after the above information it’s a felt need to evaluate the adequacy of the existing knowledge regarding hemodynamic monitoring among staff nurses.
6.2 REVIEW OF LITERATURE
Review of literature is a critical summary of research on a topic of interest generally prepared to put a research problem in a proper context or to identify gaps and weakness on previous studies to justify a new investigation.12
A study was conducted on bridging the gap between hemodynamic and monitoring. It is the nurse who must be ever-vigilant and strive for excellence in invasive hemodynamic monitoring of critically ill patients as the caregiver who is with the patient 24 hours a day, 7 days a week. Effective hemodynamic monitoring starts with an understanding of the hemodynamic mechanisms that monitoring aims to measure. Then, measuring the hemodynamic mechanisms requires technical expertise to provide accurate parameters from the monitoring equipment. Nurses who couple knowledge of cardiovascular physiology, technical expertise, and thorough assessment and diagnosis of patient responses to hemodynamic instability and invasive monitoring bring the essence of holistic nursing care in hemodynamic monitoring. 13
A descriptive study was conducted on Hemodynamic monitoring and its practice over the past 30 years at North California among critically ill patients. Hemodynamic monitoring methods are of prime importance in diagnosis and management of critically ill patients therefore to ascertain whether nurses have enough knowledge a study was done in north California. The research which enrolled 200 nurses from 65 intensive care units, 170 nurses were eligible for analysis. The mean score of 63% was seen in over all 50 structured questionnaires. Study concluded that nurses had moderate knowledge on hemodynamic monitoring.14
A study was conducted on understanding advanced hemodynamic concepts. A 200 critical care nurses in 10 intensive care units at 4 hospitals were to complete structured questionnaire on hemodynamic concepts and a demographic data sheet. The data from 4 components scores ranged from 20% to 50% correct answers, with a mean of 35.7%. Later guide sheet was administered and then a statistical result were analysed and showed a minor differences in score. The research concluded that steady improvement in knowledge and that training programme will help nurses to gain knowledge in advanced monitoring methods and recommended that study should be replicated on a larger scale to improve the standards of practice in hemodynamic monitoring. The study suggests that a new source of information and understanding helps and provides opportunities for nurses to ensure optimum patient outcomes. 15
A study was conducted on the influence of patient complexity and nurses' experience on hemodynamic decision-making following cardiac surgery at Australia. The aim of this study was to describe variability of nurses' hemodynamic decision-making in the 2-hour period after cardiac surgery. Data were collected using continuous non-participant observation of clinical practice for a 2-hour period and follow-up interview. Purposive sampling was used to recruit 38 nurses for inclusion in the study. The quality of nurses' decision-making was influenced by interplay between the complexity of patients' hemodynamic presentations, nurses' levels of cardiac surgical intensive care experience, and the form of decision support provided by nursing colleagues. The findings revealed that staff resourcing decisions and postoperative patient management can be used to inform nurses' professional development and education.16
A study was conducted on expert critical care nurses' use of pulmonary artery pressure monitoring at Australia. Critical care nurses make numerous complex decisions during their day-to-day practice. General themes in previous decision-making studies have included the influence of knowledge and previous experience, the increasing complexity of decisions made and the change in decision-making processes used as the nurse progresses from a novice to an expert practitioner. Results indicated that pulmonary artery pressure monitoring was used to attain the concepts of preload, cardiac output and blood pressure. 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. The study concluded that expert critical care nurses process an immense amount of data in a short space of time. However, they may not use all available data. Evidence suggests not all nurses who practice in the field for a lengthy period reach the level of an expert.17
A study was conducted on Hemodynamic monitoring of patients undergone abdominal aortic surgery at North America. The data was collected from 40 ICU staff nurses. In which interview were carried out regarding the knowledge of post operative patient with aortic reconstructive surgery. This included 5 different categories of 60 questionnaires. Statistical analysis showed mean knowledge score of respondents was 40%, and range between (10 - 40), which showed a lack of knowledge in post operative treatment and managements of conditions. The study concluded that nurses have inadequate knowledge and there is a need for training programmes and educational programmes regarding cardiac equipments and its application in profession. 18
A study was conducted to Enhancing the accuracy of hemodynamic monitoring at Amsterdam. Assuring that critical care nurses have the skill and knowledge necessary to accurately utilize the many diagnostic monitoring functions available within critical care is essential for optimizing patient outcomes. This performance improvement project focused on the hemodynamic monitoring skills and knowledge level of the critical care nurses in both a cardiovascular and medical/surgical intensive care unit. A four-step progressive intervention strategy was initiated based on our pre-implementation assessment. Post-implementation measures demonstrated a substantial increase in the skill and knowledge level of the nurses.19
STATEMENT OF THE PROBLEM
“A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING HEMODYNAMIC MONITORING AMONG STAFF NURSES AT SELECTED HOSPITAL IN BANGALORE.”
6.3 Objectives of the Study
i. To assess the pre-existing knowledge regarding hemodynamic monitoring among staff nurses.
ii. To evaluate the effectiveness of structured teaching programme on knowledge regarding hemodynamic monitoring among staff nurses.
iii. To find the association between post test knowledge scores with selected demographic variables.
6.3.1 Hypothesis
H1-There will be a significant difference between pre test and post test knowledge scores on hemodynamic monitoring among staff nurses.
H2-There will be a significant association between post test knowledge score and selected demographic variables.
6.3.2 Variables
(a) Independent variable : Structured teaching programme regarding hemodynamic monitoring.
(b) Dependent variable : Knowledge of staff nurses on hemodynamic monitoring
(c) Attribute variables : Age, sex, educational qualification, area of working, years of experience, source of information underwent in-service education,
6.3.3 Operational Definitions
· Evaluate: Refers to the measurement of differences of knowledge of staff nurses regarding hemodynamic monitoring before and after structured teaching programme.
· Effectiveness: Gain in knowledge as determined by significant difference in pre test and post test knowledge scores.
· Knowledge: Refers to the correct response of the staff nurses to the items on structured knowledge questionnaire about hemodynamic monitoring.
· Staff nurses: Refers to registered nurses with GNM/B.Sc. (N) qualification, who are working in hospital.
· Hemodynamic monitoring: Refers to a systematic and methodological way of observing and recording the force generated by the blood within the vasculature that is associated with the movement of blood.
· Structured teaching programme: Refers to the systematically organized teaching plan on hemodynamic monitoring among staff nurses.
7. MATERIALS AND METHODS
7.1 Source of Data : Staff nurses working in selected hospital, Bangalore.
7.2 Method of Collection of Data
7.2.1 Definition of the study : Staff nurses who are registered in State Subject Nursing Council and working in selected hospital, Bangalore.
7.2.2 Inclusion and Exclusion Criteria
a) Inclusion Criteria : 1. Staff nurses who are present at the time of data collection
2. Staff nurses who are willing to participate in the study.
3. Staff nurses who are working in the OPD and general wards.
b) Exclusion Criteria : 1. Staff nurses who are sick or leave on the day of data collection
2. Staff nurses who had experience for more than 10 years. 3. Staff nurses who are working in the Intensive Care Unit.
7.2.3 Research approach : Experimental Approach
7.2.4 Research Design : One group pre test post test pre experimental design.
7.2.5 Setting : Selected hospital, Bangalore
7.2.6 Sampling Technique : Convenient sampling will be adopted to draw the samples.
7.2.7a) Sample Size : 50 staff nurses
b) Duration of the Study: 30 days
7.2.8 Tools of Research : Structured knowledge questionnaire will be used to collect data. The tool consists of 2 parts.
Part I - Demographic data Part II- The investigator will develop structured questionnaire on hemodynamic monitoring.
7.2.9 Collection of data : The investigator collects the data by administering structured knowledge questionnaire and conducts structured teaching programme on the same day, then after 7 days post test will be conducted with same structured knowledge questionnaire.