Effect of Educational Protocol Regarding Accurate Monitoring Fluid Balance on Critical Care Nurses' Knowledge and Practice

Discussion

Results of the current study demonstrated that the mean average age of the study group was (26.76 ± 5.027) years; this may be due to the desire of university′s hospitals to provide high-quality health care services, through employing new graduates of the faculty of nursing or nursing technical institute in critical units. 

Results of the current study was compatible with (Aslam, Afzal, Kousar, Waqas, & Gilani, 2018) they conducted a study entitled the Assessment of Nurses’ Knowledge and Practices about Fluid and Electrolytes Monitoring and Administration among Cardiac Surgery Patients: A Case of Punjab Institute of Cardiology  and they found that the highest percentage of the study group′ age was between 26-30 years (82 %). Also, results validated by (Vijayan, 2011) who stated that the majority of study sample′ age of nurses (70%) belonged to the age group 23-35years.

Results of the current study also were supported by (AbdElalem and Fouad 2018), who discussed that more than half of studied sample from nurses at the age between 25 - 35 years old (67.1%) and only (6.3%) of the sample ′ age was more than 35 years. On the other hand, (Diacon, 2012) found that the majority of the nurses (39 out of 58; 76%) were in the age group 35 to 55 years, with a peak of 13 nurses (22%) in the age group 45 to 50 years. The mean age was 42 years. Only 14 participating nurses (24%) were available in the age group of 20 to 35.

Findings of the present study showed that more than half of the total study group was female. These results may be explained by the fact that nursing is a universal feminine profession especially in Egyptian society culture as well as the enrolment of the male students in this profession was started in the late decades. These findings agreed with (Aslam et al., 2017) they conducted a study on critical care nurses and he stated that all study sample 100% of participants were females. Also, results validated by (Diacon, 2012) who found that 96% of study sample were female and only 4% were male. In addition to, (AbdElalem and Fouad 2018) they stated that about three - quarters of the sample were female (74.7%).   

Concerning to educational level; the present study findings demonstrated that, half of the study sample graduated from a technical institute. This may be explained by a little number of faculty′s graduates had employed in the university hospital and other work in schools or ministry of health hospital.  This study results is similar to the study done by  (Sheta, Mahmoud, 2018) and revealed that More than half of the nurses (53.3%) carrying a degree of the nursing technical institute, 28% are diploma in nursing. Also, a further validation by (Eldsouky, Taha, & Saleh, 2016) they emphasized that near to half (44.3%) had a degree of the nursing technical institute of nursing education.

This result was contradicting with (Malekzadeh, Mazluom, Etezadi, & Tasseri, 2013) they found  that most of participants (98.2%) held a baccalaureate degree in nursing. Moreover, other study done on critical care nurses by the Society of Critical Care Medicine and Lippincott Williams & Wilkins, (2013), stated that most of the nurses who are working in critical care units have a bachelor degree and their new involvement in the work field.

Study results displayed that, more than half of the study group had less than five years of experience in working at critical units because participants sample level were newly graduate. Study results were validated by (Vijayan, 2011) who found that (77.5%) of nurses have less than five years of critical care units′ experience while only (22.5%)  have more than 10 years of experience in working at ICU. Also, these findings was in accordance with a study done by (Eldsouky et al., 2016) they stated that about one third of the studied sample had experience from five to ten years. These results contradicting with  (Aslam et al.) they stated that (36.54%) have  1-5 years of experience in critical care units  and (37.02%) have 6-10 years of .

Study findings illustrated that, the majority of the study sample had not attended any previous workshop regarding fluid balance monitoring. This may be due to neglicance from in-service educational training unit in the hospital, no preparatory program for new staff and lack of interest from critical care nurses to attend any conferences or workshops.

These study findings agreed with (Bhagwanjee & Scribante, 2007), they illustrated that sixty percent of critical care nurses had no previous workshop attendance. In addition to, (Kanakalakshmi, 2014), whose results agreed with this study, the researcher conducted a study to assess the knowledge and practice regarding fluid and electrolyte replacement therapy for patient with burns among working nurses in Narayana Medical College & Hospital (NMCH) and she was agree with these finding and stated that (66.7%) of critical care nurses not attended any previous training workshop regarding fluid administration. Also, results validated by (Sheta, Mahmoud, 2018) they concluded that the majority of studied nurses (85%) did not participate in any previous training program.

Findings of the study represented that the majority of the study sample had unsatisfactory knowledge level regarding fluid balance monitoring pre- educational protocol. These results may be explained that they haven't attended any previous training regarding fluid balance. These results were agreed with (AbdElalem and Fouad 2018) who assess critical care nurses′ knowledge and practice regarding the assessment of fluid balance and she found that (60.8%) of the study group had poor level regarding the fluid balance assessment pre-educational program and only (17.7%) of them had a good level.

These results match with the results of the study done by (Mogileeswari and Ruth 2016) they conducted a study to assess nurses‟ knowledge and practice regarding fluid therapy at burn critical care units. The researchers found that 15% only from critical care nurses have adequate knowledge. This result in the same line with (Kol, İlaslan, & Turkay, 2017) who concluded that continuous in-service training for nurses is considered a very important concern that helps the professional nurse to be updated by a nursing science which enhances nursing practice.

In addition, (Scales & Pilsworth, 2008) stated that nurses‟ knowledge regarding fluid balance should be improved because nurses are the primary persons responsible for monitoring of the fluid balance. Contradicting this study, the study done by (Asfour, 2016) which revealed that the level of nurses′ knowledge regarding fluid balance monitoring in ICUs was moderately adequate. Also, she concluded that nurses should have knowledge and skills for assessing and monitoring body fluid. Inaccurate assessment and documentation of body fluid can lead to severe problems in body homeostasis especially for critically ill patients who have serious health problems.

Regarding nurse role at monitoring fluid intake results revealed that the majority of the study sample had accurate practice post-educational practice (one month, three months), this may be due to lack of training and skills regarding monitoring fluid intake. This agreed with (Sheta, Mahmoud, 2018) they concluded that, there were highly significant differences between pre and post- program implementation in relation to total mean score of nurses’ practices regarding to measuring fluid input for critically ill patients for all items of fluid input (P < 0.001).

Moreover, this results supported by (Eldsouky et al., 2016) who conducted a study in intensive care units and he mentioned that (27.8%) of study sample measure fluid intake (all drinks per mouth) pre educational program and increased to (72.2%) post-educational program.  While this result was contradicting with the study′s results of (Vijayan, 2011) who stated that about in about 91.67% of the situations the amount, type of fluid are checked against doctor's prescription. Only in 43.33% of the occasions, the flow rate is accurately adjusted. And in 71.67% of the situations, the prescribed fluid on the chart is documented. 

Regarding nurse role at monitoring fluid output results revealed that the highest percentage of the study group pre- educational protocol had accurate practice regarding observing drainage if found and document its amount constituted, while the rest of other items′ results revealed low and zero percentage, these results improved post-educational program (one month, three months).

These results validated by (Waqas, 2017) who conducted a study entitled the assessment of nurses’ knowledge and practices about fluid and electrolytes monitoring and administration among cardiac surgery patients, he mentioned that highest percentage of study sample measure fluid output correctly in ICU. Also, these results supported by (Sheta, Mahmoud, 2018), they concluded that indicates that there was a highly statistically significant improvement in relation to total mean score of nurses’ practices post- program implementation regarding to measuring fluid output for critically ill patients’ for all items of fluid output(P < 0.001).

This finding was also in the same line with (Perren et al., 2011) who found that fluid balance was inaccurate in one-third of a critically ill patient with incomplete recording ranging from -3606 mL to+2020 mL of fluid. Also, (Johnson & Monkhouse, 2009) found discrepancy between fluids administered and fluids documented in the patients' chart. (Diacon & Bell, 2014) who mentioned that monitoring of fluid balance chart for more than two - thirds of a critically ill patients illustrated increased more than 50 mL from the wanted balance.

On the other hand, these results disagreed with the study done by (Vincent et al., 2015) they performed an audit on fluid balance monitoring for 117 patients and it showed that less than half of fluid balance charts were fully completed because of incomplete documentation of fluid intake.

Regarding accurate practice levels, findings of the present study demonstrated that the majority of study participant had poor level pre-educational protocol, while about two - thirds of them had good level of practice post- educational protocol (one month- three months). 

These findings validated by (AbdElalem and Fouad 2018) who stated that one hundred percent of the study sample had poor level regarding monitoring fluid balance pre- intervention; while post-intervention the majority of them had a good level.

As well, (Mogileeswari and Ruth 2016) conducted a study to assess nurses‟ knowledge and practice regarding fluid therapy. The researchers found that 37% of nurses had safe practice regarding fluid therapy, 42% had moderately safe practice and 21%of nurses their practice was considered unsafe. However, also, (Diacon, 2012) reported that critical care nurses are equipped with theoretical and practical knowledge about fluid balance monitoring.

This result was the same line with (Payen et al., 2008) who founded that nurse' knowledge and practices regarding fluid balance is low which affect in the quality of nursing care among the public hospitals. Moreover, (Asfour, 2016) concluded that critical care nurses had incompetent and incomplete nursing practice related to fluid balance monitoring accuracy in intensive care units.

Regarding Correlations between total knowledge and practice score among study sample pre& post educational protocol (one month, three months) results revealed that there was no statistical significance between total knowledge score at pre & post  educational protocol and total practice score pre and post –education (one month & three months) .

These results disagreed with (Tina et al., 2001) they stated that decreasing knowledge level at the initial baseline data assessment for the nurses in ICU that also reflected in the nurses' practice at pre-intervention of the program that converted to a significant improvement of both knowledge and practice after the intervention.

Recommendations

Recommendations related to hospitals and nurses:

• Greater attention should be given to monitor and closely observe nurses performance during monitoring fluid balance.
• Educational needs should be assessed for staff and newly employed nurses working in intensive care units.
• Training program should be arranged for nurses working in intensive care units about fluid balance.

Recommendations for furthers researches:

• Replication of the study on a larger probability sample from different geographical areas in Egypt to obtain more generalizable data.
• Future studies have to be carried out in order to assess factors associated with poor level of practice regarding monitoring fluid balance pre-educational protocol.
• Encourage other researches to include patients in other studies to evaluate the effect of an educational protocol.

Acknowledgment

The researchers would like to acknowledge the contribution of all participants who kindly agreed to take part in the study. They generously gave their time and attention to conduct this study. This study would have been impossible without their generosity.