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PROFORMA FOR REGISTRATION OF
SUBJECTS FOR DISSERTATION
DISSERTATION PROPOSAL
“A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED
TEACHING PROGRAMME ON KNOWLEDGE OF STAFF NURSES
REGARDING HEMODIALYSIS IN SELECTED HOSPITALS AT
TUMKUR”.
SUBMITTED BY
Mr. CHELLIAH J
1ST YEAR M.Sc.NURSING
MEDICAL SURGICAL NURSING
SHRIDEVI COLLEGE OF NURSING
TUMKUR-06
2008-09
1
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA.
ANNEXURE-II
SYNOPSIS PROFORMA FOR REGISTRATION OF
SUBJECTS FOR DISSERTATION
1. NAME OF THE CANDIDATE
:
Mr. CHELLIAH J
1ST YEAR MSC (NURSING)
SHRIDEVI COLLEGE OF
NURSING,
LINGAPURA,SIRA ROAD,
TUMKUR.
2.
:
SHRIDEVI COLLEGE OF
NURSING
3. COURSE OF STUDY
AND SUBJECT
:
1ST YEAR MSC (Nursing)
MEDICAL SURGICAL NURSING
4. DATE OF ADMISSION
TO COURSE
:
14-06-2008
5. TITLE OF THE TOPIC
:
“A STUDY TO ASSESS THE
EFFECTIVENESS OF
STRUCTURED TEACHING
PROGRAMME ON KNOWLEDGE
OF STAFF NURSES REGARDING
HEMODIALYSIS IN SELECTED
HOSPITALS AT TUMKUR”.
NAME OF THE INSTITUTION
2
6. BRIEF RESUME OF INTENTED WORK
INTRODUCTION:Nurses must take on important contribution towards maintenance of health
in all aspects due to scientific changes in medical science and technology. Those
expanding responsibilities of nursing based on growing demands of more
knowledge and raise the need for critical evaluation of the educational programs
that prepares the nurses to entire in to the skillful nursing profession.
In 21st century the challenges for nurses will be translate scientific
knowledge base into innovative ways to provide nursing care for promoting and
maintaining health. It is anticipated from nursing diagnostic classification such a
pain, Oncology, Nephrology, Burn, cardiovascular and respiratory categories.
The majority of nurses 53.9% had very high level of educational needs
33.8% had high level and 12.3% had moderate level of educational needs1.
Nurses have been identified as being more enthusiastic in constantly
working in a hospitals nephrology nursing and renal dialysis is a highly
specialized field because the health team member are giving special care to fulfill
the basic needs such as elimination of waste from the blood products and to
maintain the electrolyte balance. The renal patients care being treated with HiTech equipments2.
Clinical nurse specialist competence produces confidence in their
capabilities and subsequent willingness to share their expertise with other so that
they were not the only “knowledge power brokers” on their unit or in their area of
specialization.3 Clinical nurse specialists deliver expert patient care i.e. based on
advancing nursing middles with clinical judgment. This will result of important
changes of specialization in nursing.4
Reflected that hemodialysis can not replace the metabolic and hormonal
functions of the kidneys fully. It can ease many of the symptoms of chronic kidney
disease. The yearly death rate of patients receiving maintenance dialysis has
increased to 22% patients feel positive about the dialysis because it makes them
feel better and keeps them active but there is often great ambivalence about it as
whether it is worth while or not and dependence on a machine is a reality and
some have dreams about being tied to the machine.5
Stated that no ”gold standard” is available to assess the compliance of
hemodialysis patients and methods to do so. There fore, it is difficult to assess how
many deaths are due to natural cause and how many are due to patient’s non
compliance with treatment.6
3
The clients who have end stage renal disease are at risk for anemia due to
decreased production of erythropoietin (EPO).Although EPO therapy augments red
blood cell production in these patients. It is also associated with increased viscosity
of the blood the there fore, increased heparin requirement. So the cloting time
must be observed of every patient.7
Membrane ruptures, clotting in coil, shunt and reduced blood flow through
the Dialyzer may necessitate termination of hemodialysis. The nurses needs to be
well prepared technically so that any problems arise they can be promptly
identified and steps taken to correct the situation.8
The nurses responsibilities for the hemodialysis patients are to maintain the
patency of the vascular access site and keep it free from infection, to monitor the
patient before, during, after treatment, to teach the patient and family about dialysis
treatment and often home treatment and to assist the patient and family to cope
with necessary life style changes and problems.9
6.1 NEED FOR THE STUDY:
Renal disease is growing rapidly in India because of the high prevalence
of diabetes and heart disease, which are the root causes of ESRD(End Stage of
Renal Disease).The mean age of ESRD patients in India is between 32 and 42
years, compared to 60 and 63 years in developed countries. Renal care issues in
India is widely accepted that kidney transplantation is the most effective form of
renal replacement therapy (RRT).However,transplant in india is severely curtailed
due to issues of possible exploitation, lack of donors and the absence of a strong
cadaver programme.Hence most patients who can afford it have to opt for dialysis
as the only possible option.10
Good hemodialysis treatment requires a meticulously clean atmosphere,
isolation of patients to prevent spread of infection, good water, trained technicians
and strict adherence to norms on dialyser and consumable reuse. In reality, there
is a large element of variation in hemodialysis practices from centers to centers. In
the absence of strong guidelines and legislations, several centers operate without
even a water purification system. As a result, inadequate removal of toxins and
high conversion rate of Hepatitis C infection after commencing hemodialysis were
found in many dialysis centers in India.10
India has a dual health care delivery system, with the economically less
advantaged patients visiting the state run hospitals and the more affluent
population generally patronizing hospitals in the private sector. State run hospitals
- where consultations are generally free and dialysis and transplant costs
subsidized –are overloaded with patients, with log waiting lists for starting dialysis
as well as for under going transplantation.State run facilities do not provide
maintenance hemodialysis for ESRD care, as most dialysis centers are
overwhelmed by patients with potentially reversible acute renal failure.11
4
The reported annual incidence from developing countries various from 34 to
240 per million population (pmp)1, which is in contrast to an incidence between 98
and 198pmp per year reported from ESRD registries maintained in the developed
countries. There is no reason to believe that the incidence of ESRD will be lower in
India.11
Nurses can help combat these feeling of helplessness by involving the
patient as much as possible in their health care decision, informing them of all
treatment options and placing an emphasis on self care.11
Some times nurses fail to adopt modern or recent nursing care for the
hemodialysis due to the lack of knowledge and ignorance for learning therefore,
the investigators is challenged to explore the knowledge level of staff nurses is
relation to hemodialysis with a view to develop a planned structured teaching.the
investigator during his training period and clinical experience observed. Lack of
desirable knowledge and any standardized protocols in the dialysis and related
units. So, the needs to develop a structured teaching programme on hemodialysis
was felt for nursing staffs in selected hospitals.12
6.2 REVIEW OF LITRERATURE:
The purpose of review of literature is to obtain comprehensive knowledge
base and in department of information from previous studies.
1. Desai AA, et al. (2008)
conducted a study on to identifying best
practices in dialysis care: results of cognitive interviews and a national survey of
dialysis providers at department of medicine,California,USA.Because there is wide
variation in case-mix adjusted outcomes across dialysis facilities, it is possible that
top-performing facilities use practices not shared by others. We sough to catalogue
“best practice” that may account for interfacility variations in outcome. this
multidisciplinary
study
identified
through
systematic
review,coginitive
interviews,and a national “virtual focus group” of dialysis providers. the resulting
candidate practices were rank-ordered by perceived importance as determined by
mean RAND appropriateness scores from a national survey of
nephrologists,nurses,and opinion leaders. this study provides a “conceptual map”
of candidate dialysis best practices and highlights areas of general agreement and
disagreement. These findings can help the dialysis community think critically about
what may define “best practice” and provide targets for future research in quality
improvement.13
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2. Higgin M, et al. (2008) conducted a study about nurses knowledge and
practice of vascular access infection control in hemodialysis patients in the republic
of Ireland. A confidential self-completion questioner was sent to all 190 qualified
nurses employed in nine hemodialysis units. Which assessed knowledge and
behaviour in infection control? Although 92%of respondents reported that policies
had been developed by their units and 47% had received infection control
education in previous year, knowledge and adherence to best practice
demonstrated significant scope for improvement. The study recommended the
development of standard guidelines and regular reviews and update of policies.
System should also be developed to ensure a high level of compliace. 14
3. Rabetoy CP, et al. (2007) conducted a study about nephrology nurses
perspectives on difficult ethical issues and practice guideline for decision making.
nephrologists and nephrology nurses have straggled with the technological,
financial, and ethical concerns surrounding the life sustaining treatment of
hemodialysis for as long as this treatment as been available. One of the
overriding issues for the nephrology community has been appropriate utilization
of this technology and the appropriate restrain for prescribing dialysis. Since the
inception of dialysis, there has been discussion of guidelines for deciding who
should receive and who should not receive this therapy. In 2000, a guideline was
developed to assist in directing the care of patients. The knowledge and
acceptance of this guideline by nephrologists has been researched in the past.
however, there is no data of knowledge and acceptance of the guideline by
nephrology clinical nurses or nephrology practitioners. A survey was conducted
to begin to ascertain this information in order to better understand the
perspective of nephrology nurses.15
4. Barnett T.(2008) conducted a study on to examine the effectiveness of
a patient education programme on fluid compliance as assessed by interdialytic
weight gain, mean predialysis blood pressure and rate of fluid adherence. an
exploratory study was conducted in 2004-05 using a quasi-experimental, single
group design to examine the effectiveness of patient education on fluid
compliance in a dialysis centre located in a major teaching hospital in Kuala
Lumpur,Malasiya.twenty-six patients with in interdialytic weight gain of greater
than 2.5kg were identified as non-complaint and recruited to the study. the
intervention was carried out over a 2-months period. Nephrology nurses often
have long-term relationships with their patients and are ideally placed to provide
ongoing education and encouragement, especially for those experiencing
difficulties in adhering to fluid and dietary restrictions.16
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5. Gardner JK, et al. (2007) conducted a study about the relationship
between nurses perception of the hemodialysis unit work environment and nurse
turnover, patient satisfaction, and hospitalizations. A descriptive, co relational
design was used nurses level and facility level data were obtained. The sample
for nurses –level data consisted of 199 registered nurses in staff nurses roles in
56 dialysis facilities of national dialysis company. Study findings suggest that
nurses perceptions of the dialysis work environment are important for nurse and
patient outcome in dialysis settings. Further research is needed to explore the
predictive ability of the work environment for nurse and patient outcomes in
hemodialysis units.17
6. Sclauzero P. (2006) conducted a study about improvement of nursing
quality and outcome in intensive care patients acute kidney failure. to improve
this collaboration a questionnaire was circulated to the 122 ICU nurses in the
hospital to appraise their knowledge on acute renal failure (ARF).a refresher
course to update on ARF was than organized.colleagues interest in the initiative
was elevated:66%of questionnaires were completed which include 88% of
nurses attending the course. the experience showed, through measurable
results, that team work is essential to collaborative nursing plans. The initiative
allowed improvement in the quality of nurses communication and was
accompanied with a significant reduction in short-term mortality rate of dialyzed
ARF patients. Deposit the limitations of this short period observation one year the
results are judged as useful. Collaboration ensures support for colleagues on
daily basis and during critical moments and can encourage appreciation of the
nursing profession.18
7. AI-Ghamdi SM. (2004) conducted a study on nurses knowledge and
practice in hemodialysis units: comparison between nurses in units with high and
low prevalence of hepatitis C Virus infection. This study has been conducted in a
questionnaire format to investigate the nurses knowledge about HCV and their
practice inside the hemodialysis units. Structured questionnaire distributed
among 36 nurses HCV infection in high prevalence units is probably related to
poor application of standard health precaution and that isolation does not prevent
spread of disease inside hemodialysis units. Improving the nurses: patient ratio
and encouraging the liberal use of gloves, together with well implemented polices
and practices, will result in a better control of HCV transmission in dialysis
units.19
8. Vinay Sakhuja et al. (2003) conducted a study on End-stage renal
disease in India and Pakistan: burden of disease and management issues. In the
absence of national registries, no reliable data are available on the incidence and
prevalence of end-stage renal disease (ESRD)in India and Pakistan. The
incidence of ESRD is likely to be higher than that reported from the developed
world, with chronic glomerulonephritis being the most common cause, accounting
for more than one third of patients, while diabetic nephropathy accounts for about
one fourth of all patients in India. Patients are generally younger at the time of
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detection of ESRD and two –thirds first see a nephrologists after they have
reached end stage. The vast majority of patients starting hemodialysis dies or
stop treatment because of cost constraints within the first three months and less
than 2% patients are started on ambulatory peritoneal dialysis. Preemptive
transplantation and use of generic cyclosporine can help bring down the cost of
treatment. Innovative and affordable health insurance police can also increase
the number of patients who receive effective treatment for ESRD in these two
countries.11
9. Deschenes D. (2002) conducted a study about an educational tool for
the care of the hemodialysis patients admitted to an acute care hospital. in the
hope of improving quality of care for hemodialysis patients. in Canada, the
prevalence of end stage renal disease is increasing by approximately 10%
annually to day, the hemodialysis patient is often older than previously, and may
well have multiple co morbidities resulting in hospital admission in a multitude of
settings.hemodialysis patients are not always admitted under the nephrology
service due to lack of beds or medical necessity. when patients are transferred
among the various hospital units, effective communication of knowledge and
expertise between nursing staff is essential for care of the hemodialysis patients
to be seamless.20
STATEMENT OF THE PROBLEM:
“A study to assess the effectiveness of structured teaching programme on
knowledge of staff nurses regarding hemodialysis in selected hospitals at
Tumkur”.
6.3 OBJECTIVES OF THE STUDY:
1. To assess the pre test knowledge of staff nurses regarding hemodialysis.
2. To assess the post test knowledge of staff nurses regarding hemodialysis.
3. To evaluate the effectiveness of structured teaching programme by
comparing the pre and post knowledge score.
4. To determine the association between the pre test knowledge score with
selected demographic variable on hemodialysis among staff nurses.
8
6.4. OPERATIONAL DEFINITION:
1. ASSESSMENT
: In this study it refers as organized, systematic
and Continuous process of collecting data from
staff nurses regarding hemodialysis.
2. EFFECTIVENESS
: In this study it refers to is the out come of the
structured Teaching programme on
hemodialysis,which is measurable in the terms of
improvement in staff nurses Knowledge score based
on given best on questionnaire.
3. STRUCTURED TEACHING ROGRAMME:
: In this study it refers as a systematically planned
and developed instructional programme designed
to improve the knowledge of the staff nurses
regarding hemodialysis.
4. KNOWLEDGE
.
5. STAFF NURSES
6. HEMODIALYSIS
: In this study it refers to the responses of staff
nurses to the questionnaire regarding hemodialysis.
: In this study it refers to a qualified person who has
completed a degree or diploma programme and
who is registered with nursing council to practice
nursing and presently working in a selected hospital
in Tumkur.
: In this study it refers to hemodialysis an artificial
membrane (usually made of cellulose based or
synthetic materials) is used as the semi permeable
membrane and is in contact with the patients blood
which allows the movement of fluid and molecules
across the semi permeable membrane to correct
fluid and electrolyte imbalance and to remove waste
products in renal failure and treat drugs over dose.
6.5 RESEARCH HYPOTHESES:
H1
: There will be a significant differences between pre and
post test knowledge score on hemodialysis among staff
nurses.
9
6.6 ASSUMPTIONS:
1.
knowledge of staff nurses on hemodialysis is influence by different
socio demographic variable like age, professional qualification,
professional experiences, working area, in service education,
exposure to hemodialysis
2.
Structure teaching programme will enhance the knowledge of staff
nurses regarding hemodialysis.
6.7. DELIMITATIONS OF THE STUDY:
1.
This study will be limited to the staff nurses working in nephrology
Unit ,intensive care unit, medical wards at selected hospitals in
Tumkur.
2.
Sample size is limited to 60 staff nurses .
6.8. PILOT STUDY:
Pilot study will be conducted with eight samples the purpose of
pilot study is find out the feasibility of conducting study and design on plan
of statistical analysis.
6.9. VARIABLES:
Variables are the concepts at various levels of abstraction that are
entered, manipulated and collected in a study.
 Dependent variables: knowledge level of staff nurses
regarding hemodialysis
 Independent variables: Structure teaching programme.

Demographic variables: Age, professional qualification,
professional experiences, working area, in service
education, exposure to hemodialysis.
7. MATERIAL AND METHOD:
One group pre and post test will be used This study is designed to
assess the effectiveness structured teaching programme on knowledge of
staff nurses regarding hemodialysis.
10
7.1. SOURCE OF DATA:
The data will be collected from staff nurses working in nephrology
unit, intensive care unit, medical wards at selected hospitals in Tumkur.
7.1.1. RESEARCH DESIGN:
Experimental design-One group pre and post test design.
7.1.2. RESEARCH APPROACH:
An evaluative research approach will be used.
7.1.3. RESEARCH SETTNG:
The study will be conducted in nephrology unit, intensive care unit,
medical wards at selected hospitals in Tumkur.
7.1.4. POPULATION:
The target population of the study will be staff nurses working in
nephrology unit, intensive care unit, medical wards at selected hospitals in
Tumkur.
7.2. METHOD OF DATA COLLECTION:
The data collection procedure will be carried for a period of 3
months.The study will be conducted after obtaining permission from the
concerned authorities
Part I: It deals with demographic data of the staff nurses such as
age, professional experience, professional qualification,
training institute, working areas, in service education,
exposure to hemodialysis.
Part II: It deals with multiple choice questions about hemodialysis.
such as definition, principles, vascular access, infections,
dialyzer and dialysate, complications, procedure and nursing
care.
7.2.1 SAMPLING PROCEDURE:
Purposive sampling technique will be used.
11
7.2.2 SAMPLE SIZE:
The sample size consists of 40 staff nurses working in nephrology
unit, intensive care unit, medical wards at selected hospitals in Tumkur.
CRITERIA FOR SAMPLE SELECTION:
7.2.3. INCLUSIVE CRITERIA:
1. Staff nurses who all are working in nephrology unit, intensive
care unit, medical wards at selected hospitals in Tumkur.
2. Staff nurses who are willing to participate in this study.
7.2.4. EXCLUSIVE CRITERIA:
1. Staff nurses who are not willing to participate in this study.
2. Staff nurses who are not available at the time of data collection.
7.2.5. INSTRUMENT:
A structured interview questionnaire schedule will be used to
assess the knowledge of staff nurses regarding hemodialysis.
7.2.6. PLAN FOR DATA ANALYSIS:
The pre and post test scores of knowledge on hemodialysis will be
assessed through following statistical techniques.
1. Descriptive statistics:
 Mean standard divations range and mean score of the subjects will
be used to quantify the level of knowledge before and after
structured teaching programme.
2. Inferential statistics:
 Paired t-test will be used to examine the effectiveness of structure
teaching programme by comparing the pre and post test score.
 Chi-square test will be worked out to determine the association of
the socio demographic focuses of staff nurses with pre test
knowledge.
12
7.2.7. TIME AND DURATION OF THE STUDY:
The time and duration of the study will be conducted as per the
research committee.
7.3.
DOSE THE STUDY REQUIRES ANY INVESTIGATION OR
INTERVENTION TO BE CONDUCTED ON PATIENT OR OTHER
HUMAN OR ANIMALS?
Yes, the study require investigation or intervention conducted on
staff nurses written permission will be obtained from the research
committee of the college, head of the institution and samples.
7.4.
HAS ETHICAL CLEARENCE BEEN OBTAINED FROM YOUR
INSTITUTION IN CASE OF 7.3?
The pilot study and main study will be conducted after the approval
from the research committee permission will be obtained from the
concerned head of the institutions. The purpose and the details of the
study will be explained to the study subjects and an informed consent will
be obtained from them. Assurance will be given to the study subjects on
the confidentiality and anonymity of the data collected from them.
8. LIST OF REFERENCES (VANCOUVER STYLE FOLLOWED):
1. Raksha kamel. Educational needs nurses regarding AIDS. Abstract of
nursing Thesis.tabriz University of medical science; 200I.
2. Rowland and Rowland. Nursing administration hand book. 2th edition.
Ospen system. Corporation may land; 1985.
3. Arena and page. The imposter phenomenon in the clinical nurse specialist
role. Journal of nursing scholarship.1992; 24:2 P121-125.
4. Chuck cheing kaipeter. Clinical nurse specialist and quality patient care.
Journal of advanced nursing. Black well science Ltd. vol.26.1997; P501506.
5. Lewis heistkemper dirksen. Medical surgical nursing. 6th edition. Mosby
publication. Missouri.2000; P1232-1236.
6. Suddarth and Brunner. Medical surgical nursing. 10th edition lippincott.
Philadelphia. 2004; P1285-1290.
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7. Delormo et al., varying heparin requirement is hemodialysis patient
receiving or thropoiat. American nursing association journal. 1997; 19:41.
P367-372.
8. Schere c.jeanne. Medical surgical nursing. 2nd edition. Lippincott
Philadelphia 1977; P639-640.
9. Branno met et al., Medical surgical nursing. Philadelphia. 1991; P1922.
10. Min Sun Park. Renal care scenario in India. The coriter is director. Medical
affair. Renal Division at Baxter (Asia).E mail: [email protected].
11. Vinay Sakhiya Kamal Sud. End-stage renal disease in and
Pakistan:Barden of disease and management issues. Kidney international.
2003; S115-118.
12. Gallery Petter. Moral learning in nrsing education a discussion of the
useful of cogaigive development and Social Learning theories. Black well
Science Ltd. 1990; P324-328.
13. Desai AA. Bolus R .Identifying best practice in dialysis. Clin J Am Soc
Nephrol. 2008 july; 3(4):1066-76.
14. Higgins M.Evans DS. Nurses knowledge and practice of vascular access
infection control in hemodialysis patient in the republic of Ireland. J Ren
care. 2008 Jun; 34(2):48-53.
15. Rabetory CP.Bair BC. Nephrology nurses perspectives on difficult ethical
issues and practice guideline for shared decision and practice guideline
for shared decision making. Naphrol Nurs J. 2007 November-December;
34(6):599-606,629.
16. Barnett T. Fluid Compliance among patients having hemodialysis : can an
Educationl programme make a difference. J dv Nurs 2008; 61(3): 300-6
17. Gardner JK et al, The relationships between nurses perceptions of the
Hemodialysis unit work environment and nurses turnover patient
Satisfaction and hospitalization. Naphrol Nurs J. 2007 May-Jun; 34(4):27181.
18. Sclauzero P. Improvement of nursing quality and out come in intensive
Care patients with acute kidney disease and kidney failure. J Ran care
2006 July-September; 32(3):181-5.
14
19. Al-Ghamdi SM. Nurses knowledge and practice in hemodialysis Unit:
Comparison between nurses in units with high and iow prevalence of
Hepatitis C virus infection. Saudi J Kidney Dis Transpl. 2004JanuaryMarch; 15(1):34:40.
20. Deschenes D. An educational tool for the care of the hemodialysis patient
Admitted to an acute care hospital. CANNT J. 2002 October- December;
11(4):24-9.
15
9
Signature of the candidate
10
Remarks of the Guide
11
Name and designation of :
11.1
Guide
11.2
Signature
11.3
Co-Guide (If any)
11.4
Signature
11.5
Head of Department
11.6
Signature
12.1
Remarks of the chairmen & principal
12.2
Signature
16
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