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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA, ANNEXURE-II PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION 1 2 NAME OF THE MRS. MANISHA A. BIJAPURKAR CANDIDATE AND K.L.E.S’ INSTITUTE OF NURSING SCIENCES, ADDRESS NEHRU NAGAR, BELGAUM-10 KARNATAKA NAME OF THE INSTITUTE K.L.E.S’ INSTITUTE OF NURSING SCIENCES, NEHRU NAGAR BELGAUM-10 KARNATAKA 3 COURSE OF THE STUDY AND SUBJECT M.Sc. NURSING 1st YEAR OBSTETRIC AND GYNAECOLOGICAL NURSING 4 DATE OF ADMISSION TO 15th MAY 2007 THE COURSE 5 TITLE OF THE TOPIC “EFFECTIVENESS INSTRUCTIONAL KNOWLEDGE AMONG OF NURSES OF A SELF MODULE ON OBSTETRIC DRUGS WORKING IN MATERNITY UNIT OF KLES PRABHAKAR KORE HOSPITAL & MRC, BELGAUM”. 1 6 BRIEF RESUME OF THE INTENDED WORK. 6.1 NEED FOR THE STUDY The midwife is recognized as a responsible and accountable professional who works in partnership with pregnant women to give the necessary support, care and advice during pregnancy, labour and the postpartum, period. This care includes preventive measures, the promotion of normal birth, the detection of complications in mother and child, accessing of medical or other appropriate assistance and the carrying out of emergency measures. It is true that midwifes are serving women, their babies and families, society and God. If it looks no different than the myth-based, damaging knowledge and practice of obstetrics, then it is not midwifery.1 Midwives who care for pregnant and laboring women are faced with an increasingly frequent use of pharmaceutical agents that facilitate initiation of labor (uterotropins), augment labor (uterotonics), or potentially stop labor (tocolytics). The choice of the drug, administration, side effects, and complications varies. Knowledge about uterine physiology helps the midwife to understand the action of these agents. Knowledge of the differences and similarities among oxytoxics, ergots, prostaglandins, and the various drugs used as tocolytics is essential for safe and effective care of women and their fetuses who may be exposed to these agents.2 All midwives bear a great responsibility when they administer drugs, as these may act not only upon the mother but also on the fetus during pregnancy and labour and on the baby in the early days of life.3 Medication administration is an activity that is prone to errors, in part because of the proliferation of new devices and new drug products. Medications are administered through a variety of routes, dosages, dosage forms and dosing regimens, adding variability. More over medication orders are changed frequently as pharmacists and medical specialists provide input into patient care based on changes in patient clinical status and the results of diagnostic tests.4 An article in American Journal of Maternal Child Nursing addresses the importance of the nursing role in the management of oxytocin during induction augmentation of labor. It highlights that nurses at the bedside of laboring women have 2 to make oxytocin titration decisions must be based on a sound knowledge of the pharmacologic properties of oxytocin, the physiology of uterine contractions, and the response of the woman and fetus to contractions. In addition, nurses must be aware of the standards and guidelines of care that govern their actions during induction / augmentation.5 A study was done at department of pediatrics, Johns Hopkins University, Baltimore, USA. The objective of the study was to synthesise peer reviewed knowledge on children’s medication errors and on recommendations to improve pediatric medication safety by a systematic literature review. Data were from Pubmed, Embase and Cinahl from 1st January 2000 to 30th April 2005, and 11 national entities that have disseminated recommendations to improve medications safety. From 358 articles identified 31 were included for data extraction. The definition of medication error was non-uniform across the studies. Dispensing and administering errors were the most poorly and non uniformly evaluated. Over all the distributional epidemiological estimates of the relative percentages of pediatric error types were: prescribing 3- 37%, dispensing 5 – 58%, administering, 72 – 75% and documentation 17 – 21%. 26 unique recommendations for strategies to reduce medication error were identified.6 According to the U.S. Supreme Court, the Fourth Amendment rights of 10 women were violated by a hospital that provided them prenatal care. The incidence of prenatal drug testing for criminal prosecution with or without a woman’s knowledge is increasing. Concurrently, funding and availability of drug treatment programs for pregnant women are declining. Nurses and physicians who act as advocates for the state rather than the patient damage the patient provider relationship and breach their ethical responsibility to the patient.7 Medication administration is one of the most time consuming aspects of nursing practice. Expertise in medication calculation and administration is essential to the treatment of all patients. However many nurses experience difficulty when calculating medications. In one study the result was 56.4% of nurses could not calculate medications correctly in 90% of the problems, suggesting the need for regular self testing of medication calculation skills. Continuing education programmes implemented for identified medication calculation errors influences nursing practice and patient outcome.8 3 During her experience of working in maternity ward, the investigator observed that though nurses have an important role in administering drugs they do not utilize their knowledge and just follow doctor’s orders. Thereby affecting their quality nursing care and giving opportunity for the occurrence of easily avoidable medication errors. Hence, the investigator decided to use self instructional module on obstetric drugs to increase nurses knowledge thereby improving quality nursing care and prevent occurrence of medication error, the outcome being a healthy mother and healthy baby. 6.2 REVIEW OF LITERATURE A diagnostic study was done in school of nursing, Sweden to assess the mathematical knowledge and skills in calculation and administration of drug dosage among Nurses, student Nurses and physicians. The main purpose of this study was to investigate if student nurses and registered nurses have adequate knowledge and skills in drug dosage calculation. The sample considered for the study was 545 experienced nurses and 197 student nurses. The result of the study showed that Nine out of the fourteen test items were solved accurately and no differences were found in the average performance between the two groups.9 An observational study was done in German on the cause of IV drug errors by nursing staff in hospital. The purpose of the study was to explore the cause of IV drug errors by nursing staff in hospital. The sample for the study were 22 nurses. The result showed that a total of 74 IV drugs errors were identified, while observing 161 preparations and 135 administrations. The conclusion of the study focused on training of nurses and providing guidelines by multidisciplinary team.10 A descriptive correlational study was done in Gold Coast Hospital, Australia to describe nurses’ assessment skills and knowledge related to the management of a patient with an epidural infusion and to explore relationships between these variables and the levels of education / clinical experience of the nurses. A convenience sample of surgical and obstetric unit registered nurses were involved. Data were collected via survey and observation, using instruments developed by the research team. The results of this study indicated that the nurses theoretical knowledge outweighed their clinical skill performance and clinical decision making. Education for nurses regarding the management of epidural infusions need to be comprehensive, context specific and have 4 the capacity to develop the nurse’s autonomous critical thinking and clinical decision making-skills. Strategies for this include self-directed learning packages best supplemented by demonstration of clinical skills and supervised practice.11 A structured program was developed and used by the clinical pharmacists in Abu Dhabi to identify the nursing knowledge on medication errors and other medication related safety issues. The sample for the study consisted of 370 in-patient nursing staff. Findings revealed differences in the knowledge of nurses about the causes and reporting of medication errors. There were statistically significant differences in responses across the participants years of experience and the current clinical working area. The participants responses improved significantly [57.4% ± 8.2, (95% CI: 56.6-58.2) vs.68.9 ± 10.3, (95% 67.8-69.9): p<0.05] pre and post questionnaire respectively. It shows that the clinical pharmacists structured program has improved knowledge of the in-patient12 A randomized control trial was done on the medication administration error rate among nurses of two hospitals (A and B) in Chicago. The objective of the study was to find the impact of dedicated medication nurses on the medication administration error rate. The sample for the study included 10 nurses who received a brief review course on safe medication use and were called “medicated nurses” and 15 “general nurses” who did not attended the course. A direct observation technique was used to record drug errors, process-variation errors and total errors. The result of the study showed that at both hospitals the combined total error rate was 15.7% for medication nurses and 14.9% for general nurses (p<0.84). comparing the 2 hospitals the total error rate for medication nurses at hospital B was significantly higher than it was at hospital A (19.7%vs 11.2%; p<0.04). At hospital A there was significantly lower error rate for medication nurses then for general nurses in the surgical units(p<0.01) but no significant differences in total errors comparing nurse types in the medical units (p<0.77). The study suggests that use of dedicated medication nurses does not reduce medication error rates.13 A pretest / post test study was done in Baltimore on the effectiveness of a Genetics Self Instructional Module for nurses involved in Egg donor screening. The objective of the study was to evaluate in increasing nurses knowledge of genetics. The sample for the study considered were 262 registered nurses involved in screening egg donor, but only 65 nurses completed the pretest as well as the post test. 22 page self instructional booklet on genetic risk assessment was given to the nurses after pretest. 5 The results showed significant increase of 20.8% in participant’s mean knowledge score on the post test (M=89.0%, SD=8.1%, RANGE = 67% - 100%) as compared with the pretest (M=69.0%, SD=12%, range = 42-92%) based on paired t test analysis (t=11.74, SE-0.426, P <0.001).14 6.3 STATEMENT OF THE PROBLEM “A study to evaluate the effectiveness of a self instructional module on knowledge of obstetric drugs among nurses working in Maternity Unit of KLES Prabhakar Kore Hospital & Medical Research Centre, Belgaum, Karnataka”. 6.4 OBJECTIVES OF THE STUDY 1. To identify the learning needs of nurses in relation to drugs used in maternity unit. 2. To assess the knowledge of obstetrics drugs among nurses. 3. To prepare and administer a self instructional module on obstetric drugs. 4. To evaluate the effectiveness of a self instructional module on the knowledge of selected obstetric drugs among nurses. 5. To find an association between knowledge of obstetric drugs among nurses and selected demographic variables. 6.5 OPERATIONAL DEFINITIONS :1. EVALUATE: Refers to statistical analysis, (descriptive and inferential) of knowledge of nurses in selected obstetrics drugs. 2. EFFECTIVENESS : Refers the extent to which the information in Self Instructional Module (SIM) has achieved the desired effect as measured by gain in post test knowledge scores. 3. SELF INSTRCTIONAL MODULE: Refers to an information booklet on obstetric drugs prepared by investigator and content validated by experts. It can be used by a learner without the presence of the teacher. It is designed to provide study information regarding use of obstetric drugs by nurses with regard to: 6 Pharmacological name Mode of action Dosage calculation Route of administration Indications and Contraindications Side effects Nurses responsibility Exercises 4. KNOWLEDGE : Refers to nurse’s appropriate response to items related to selected obstetric drugs as measure by a structured knowledge questionnaire. 5. NURSES: Refers to registered staff nurses with B.Sc. Nursing or GNM qualification, working in maternity unit of KLES Prabhakar Kore Hospital and Medical Research Centre, Belgaum. 6. SELECTED DEMOGRAPHIC VARIABLES: Refers to factors such as age, professional qualification, total years of experience, experience in maternity unit and inservice programme attended. 7. MATERNITY UNIT: Refers to the labour ward, antenatal ward, postnatal ward and where nurses are working to provide obstetric care. 8. SELECTED OBSTETRIC DRUGS: In this study obstetric drugs refers to the drugs used in labour unit which will be highlighted in the need assessment format by the nurses. 6.6 HYPOTHESES : 1. H1 The mean post test knowledge scores of subject exposed to Self Instruction Module will be significantly greater than the mean pre test knowledge scores at 0.05 level of significance. 2. H2 There will be statistically significant association between pretest knowledge scores and selected demographic variables at 0.05 level of significance. 7 6.7 ASSUMPTIONS : 1. Nurses working in maternity unit have some knowledge regarding selected obstetric drugs. 2. Self Instructional Module will increase knowledge of nurses on selected obstertric drugs. 6.8 DELIMITATIONS: This study is delimited to the nurses working in maternity unit of KLES Prabhakar Kore Hospital and MRC, Belgaum. 6.9 PROJECTED OUTCOME : The nurses will gain more knowledge about selected obstetric drugs and prevent medication errors. The study aims to provide Self Instructional Module as a easy reference to nurses working in maternity unit of KLES Prabhakar Kore Hospital & MRC, Belgaum, Karnataka. 7 MATERIALS AND METHOD 7.1 SOURCES OF DATA Primary Source: Nurses working in maternity unit of KLES Prabhakar Kore Hospital and MRC, Belgaum. Secondary Source : Review of literature collected from various journals, magazines, newspapers, books and internet. Research Approach: Evaluative Research design : One group pretest and post test design. Research setting: The study will be conducted in maternity unit of KLES Prabhakar Kore Hospital, Belgaum. Population: Nurses working in maternity unit. Sample size: 35 nurses 8 Inclusion criteria: Nurses 1. Having completed their B.Sc. Nursing or GNM Nursing qualification. 2. Working in maternity unit of KLES Prabhakar Kore Hospital & MRC, Belgaum. 3. Willing to participate. Exclusion criteria: Nurses 1. On managerial post 2. Not present during the time of data collection. 7.2 METHOD OF COLLECTION OF DATA. Sampling technique: Purposive sampling. Instrument: 1. Structured knowledge questionnaire to assess the knowledge. 2. The learning need assessment format. 3. Opinionnaire Section I: Items on selected demographic variables like age, professional qualification, total years of experience, experience in maternity unit and inservice education attended. Section II : Items on knowledge of nurses regarding selected obstetric drugs. Section III: Items on learning needs assessment format consisting of necessary desirable and not necessary alternatives. Section IV: Opinionnaire on acceptability Data Collection Method STEP I : The investigator will obtains permission from respective authority to conduct the study. STEP II: Selection of subjects (Nurses). 9 STEP III: Investigator introduces herself to the subject and explains about her aim, objectives and steps of the study and takes written consent to conduct the study. STEP IV: Conducts need assessment and prepare the Self Instructional Module. STEP V: Conducts pre test with a tool of structured knowledge questionnaire. STEP VI: Administer self instructional module regarding knowledge of selected obstetric drugs among nurses. STEP VII: Conducts post test by using structured knowledge questionnaire. STEP VIII: Analysis of collected data and interpretation. 7.3 Does the study require any interventions or investigations to be conducted? Yes ( Self Instructional Module). 7.4 Has ethical clearance been obtained from your institution? Yes. 7.5 Permission will be obtained from the authorities of KLES Prabhakar Kore Hospital and MRC, Belgaum. 8. LIST OF REFERENCES 1. Midwifery Wikipedia, The free encyclopedia. [online] 2007 Aug. [cited 2007 Nov 13]; Available from: URL:http://www.en.wikipedia.org//wiki//midwifery 2. Payton RG, Mary C. Drugs and uterine motility. Journal of Obstetric, Gynecology and Neonatal Nursing [online] 1999 Nov [cited 2007 Nov 11]; 28(6);[628-37]. Available from: URL:http://www.blackwellsynergy.com/doi/obs/10.1111/i.15526909.1999.tb02172.x 3. Bennett VR, Brown LK. Myles Textbook for midwives. 12ed. Edenburgeh: Churchill Livingstone; 1998. p.675. 10 4. Nancy LG, Elizabeth F. The Impact of Dedicated Medications Nurses on the medication Adminsitration Error Rate. Arch Internmed [Online] 2003 Oct 27 [cited 2007 Nov 17]; 163: [2359-67]. Available From: URL:http://www.ncbi.nlm.gov/sites/entrez?cmd=Retrive&db=pubmed&list_uio ds=14581257 5. Clayworth, Suellen MN. The Nurses’ RoleDuring Oxytocin Administration. American Journal of Maternal child Nursing [online] 2000 Mar-Apr [cited 2007 Nov 11]; 25(2): [80-85]. Available From : URL:http//www.ncbi.nlm.gov/sites/entrez?cmd=Retrive&db=pubmed&list_uids =10748585&dopt=Abstract Plus 6. Miller MR, Robinson KA. Medication errors in peadiatric care. Quality and safety in health care [online] 2007 Dec [cited 2007 Nov 12]; 16:[116-26]. Available from: URL:http://qshc.bmj.com/cgi/content/abstract/16/2/116 7. Foley EM. Drug screening and criminal prosecution of pregnant women. Journal of obstetric, Gynecologic and Neonatal Nursing [online] 2002 Mar [cited 2007 Nov 11]; 31(2): [133-37] Available From : URL:http://www.blackwell.synergy.com/doi/abs/10.1111/j.15526909.2002.tb00032.x 8. Ashby DA. Medical Calculation skills of the medical-surgical Nurse. Med surg Nursing [online] 1997 Apr. [cited 2007 Nov 26] Available From : URL:http://qshc.bmj.com/cgi/content/full/16/2/116v/articlerender.Fegi?artid=10 7840 9. Kapborg. Calculation and Adminsitration of Drug Dosage by Swedish Nurses, student Nurses and Physicians. International Journal for Quality in Health Care [online] 1994 Nov [cited 2007 Nov 13]; 6(4): [389-95]. Available From: URL:http??intqhc.oxfordjournals.org/cgi/content.abtract/6/4/389 10. Taxis K, Barber N. Causes of intravenous medication errors observation of nurses in a German hospital. Journal of Public Health [online] 2004 Apr [cited 2007 Nov 12]; 12(2): [132-38]. Available From: URL:http://www.springerlink.com/content/5xyx4p2fp7whd6UF/ 11 11. Bird A, Wallis M. Nursing Knowledge and assessment skills in the management of patients receiving analgesia via epidural infusion. Journal of Advanced Nursing [online] 2002 Dec [cited 2007 20]; 40(5): [522-31]. Available From: URL:http://www.blackwell.synergy.com/doi/pdf/10.1046/j.13652648.2002.02409 12. Elnour AA, Ellahham NH. Raising the awareness of inpatient nursing staff about medication errors. Pharmacy world & science [online] 2007 Sept [cited 2007 Nov 20]; Available From: URL:http://www.springerlink.com/content/b26663547/w31735 13. Nancy LG, Elizabeth F. The Impact of Dedicated Medications Nurses on the medication Adminsitration Error Rate. Arch Internmed [Online] 2003 Oct 27 [cited 2007 Nov 17]; 163: [2359-67]. Available From: URL:http://www.ncbi.nlm.gov/sites/entrez?cmd=Retrive&db=pubmed&list_uio ds=14581262 14. Swank CO, Christianson CA. Effectiveness of a Genetics Self-Instructional module for Nurses Involved in Egg Donor screening. Journal of Advanced Nursing [online] 2006 [cited 2007 Nov7]; 54(2): [228-37]. Available From : URL:http://www.blackwell-synergy.com/doi/pdf/10.1111/;.15526909.2001.tb00008.x 12 9 SIGNATURE OF THE CANDIDATE 10 REMARKS OF THE GUIDE 11 11.1 NAME AND DESIGNATION OF GUIDE THE STUDY IS FEASIBLE AND OF GENUINE INTEREST OF THE STUDENT. Mrs.SUDHA A. RADDI M.Sc(OBG.N) M.Phil PROFESSOR & H.O.D DEPARTMENT OF OBSTETRICS & GYNAECOLOGICAL NURSING KLES INSTITUTE OF NURSING SCIENCES, NEHRU NAGAR, BELGAUM. 11.2 SIGNATURE Mrs. SANGEETA N. KHARDE MSc(OBG.N) PROFESSOR DEPARTMENT OF OBSTETRICS & GYNAECOLOGICAL NURSING KLES INSTITUTE OF NURSING SCIENCES, NEHRU NAGAR BELGAUM 11.3 CO-GUIDE 11.4 SIGNATURE 11.5 HEAD OF THE DEPARTMENT PROF. Mrs. SUDHA. A. RADDI MSc(OBG.N) H.O.D OBG NSG KLES INSTITUTE OF NURSING SCIENCES, NEHRU NAGAR, BELGAUM. 11.6 SIGNATURE 12 12.1 REMARKS OF THE CHAIRMAN & PRINCIPAL THIS TOPIC WAS DISCUSSED WITH THE MEMBERS OF THE RESEARCH COMMITTEE AND FINALISED. SHE IS PERMITTED TO CONDUCT THE STUDY. 12.2 SIGNATURE 13