Bone Marrow Transplantation: Effect of Multimodal Preparation Package on Patients` Needs and Satisfaction

 Introduction: 

Bone  marrow  transplantation  (hematopoietic cell  or  stem  cell  transplantation) is  a  procedure that can restore marrow function for patients with  severe marrow injury (due to primary failure, destruction , intensive chemical / radiation exposure)  or abnormalities of  immune system  due  to :   oncological diseases, hematologic, oncohematological, metabolic disorders  e.g  leukemia, lymphoma, myeloma , aplastic anemia, myelofibrosis , myelodysplastic syndromes , thalassemia  ,  immunodeficiency and  germinative  cell  tumor  among  other  potentially  lethal   diseases .  Bone marrow is the soft, spongy area in center of some large bones of the body and produces millions of different cells every hour (Schmitz et al., 2018 & Lewis   et al., 2014). The marrow  produces all  different cells from  a cell type  called    hematopoietic stem  cell   that make up the blood  such as red / white blood cells  and platelets added to  cells of  immune system . Most of the stem cells stay in the marrow until they are transformed into mature blood cells, which are released into the blood stream where they perform specific functions such as carrying oxygen, providing protection from infection and helping blood clot (Hashmi et al., 2017 &   Larsen et al., 2013) . 

Types of transplantation are:  Allogeneic, stem cells are acquired from a donor (related family member). The Benefit of this type is not only eradication of tumor cells with high dose therapy, but also the potential stimulation of the graft – versus tumor effect in which donor WBCs identify and attack malignant cells in the recipient. Common indications for allogenic transplant are certain types of leukemia, multiple myeloma, lymphoma.  Syngeneic  is a type of allogenic transplant that obtain stem cells from one identical twin that have a same human leukocyte antigen HLA type and no graft versus host occurs.   Autogenic, patient receives their own stem cells after myeloablative (destroy bone marrow by chemotherapy). Restoration usually takes 4 to 6 week depending on particular conditioning regimen administerated  (Ozdemir  et al., 2018  &  Ford  et al., 2013)   .

Bone  marrow administrated   (hematopoietic stem cell) transplantation  involves the intravenous infusion of autologous or allogeneic stem cells collected from bone marrow, peripheral blood, or umbilical cord blood to reestablish hematopoietic function in patients whose bone marrow or immune system is damaged or defective   .  In transplantation process , patients are  given very high doses of chemo or radio  therapy  then   healthy supply of stem cells is  reintroduced  or  transplanted  to  reestablish  the blood cell production  process in  bone marrow called engraftment  that  measured daily by  blood cell counts  and  used to determine when it is safe  to discharge  /or reduce isolation procedures  . Medications that stimulate the bone marrow to produce white / red cells may be used routinely or when engraftment is slower than expected (Tiren-Verbeet et al., 2018 & Adewumi et al., 2016). Moreover, cells that will be transplanted can be taken from bone marrow (called bone marrow harvest), from bloodstream (called peripheral blood stem cell collection) or from umbilical cord after birth (which are stored in umbilical cord blood banks).   Side – effects  of  transplantation  includes  : mucositis , abdominal pain , diarrhea , nausea and vomiting  , Loss of hair , Infertility , Organ toxicity , Secondary cancers   and  graft-versus-host  disease  (Howida  , 2016  & Abd - Elmoniem  , 2012)  .

Multimodal preparation package consists   of  patients`  instructions, educational pamphlet  and  film  ,  orientation round in the  BMT Unit  that   could be effective in improving  health ’ condition  .  Patients` education and appropriate preparation would positively affect health promotion, awareness, attitudes, skills and behaviors. Education can  reduce  patients`  anxiety, increase  coping   with health condition   and  decrease  length  of  hospital sta    (Elsaay  et al., 2016   ,  Moradi    &  Hajbaghery  , 2015    and   Hajbaghery  et al., 2014)     .

The needs were defined as ‘the requirements of individuals to enable them to achieve, maintain or restore an acceptable level of social independence or quality of life . Health  is  defined  as a “state of complete physical, mental and social wellbeing not merely absence of  the  disease or infirmity”. The  needs include     physical , psychological, social, spiritual, and educational aspects ( Dewit  et al., 2016 & Lewis  et al., 2014  ) .

Satisfaction of  patients  referred to  an expression of overall judgment on  quality  of care  particularly in the interpersonal process  aspect  . It was  defined  as  patients`  opinions of care received from staff of nurses  during  hospitalization period  . Patients satisfaction with  medical treatment  and   nursing management  has been reported as the most important predictor of the overall satisfaction with hospital care and an important goal of any health care  organization (  Smeltezer & Bare , 2015  and  Kleefstra  et al., 2012    )  .

Significance of the study:  

Bone  marrow  or  hematopoietic stem cell transplantation is an aggressive therapeutic option for many malignant and non malignant diseases  thus, there is a need to initiate  update and reinforce patients' teaching  to  affects on their experiences  and  recovery  .  In addition, transplantation process involves actions that are highly complex and requires a multidisciplinary team to assist. Patients have six basic stages: decision to undergo transplant, waiting for admission, conditioning regimen, transplantation, immunosuppression and hospital discharge. The occurrence of pancytopenia, gradual proliferation of cells (successful infusion of stem cells) and complications of various kinds can lead to death or affect the quality of life generate anxiety, tension for patient, family and health team that participates in the procedure.   Bone  marrow  transplantation  is  performed worldwide, about 40,000 each year  and  around 40% of patients  may have a fatal clinical outcome (Schmitz  et al., 2018  , Hashmi  et al., 2017   &  Bashir  et al., 2014)  . In Egypt according to statistical record, the incidence of bone marrow transplantation in Nasser institute Hospital during the period of 2016 to 2017 was approximately 600 patients.  Multimodal preparation package can help them to self-care, prevent complications, carry out prescribed therapy and solve problems.    

Aim of the study:

This study aimed  to evaluate  the   effect   of  multimodal   preparation   package   on   patients`  needs    and  satisfaction     with    bone  marrow transplantation  procedure (  pre / post  and  in  follow – up  period )  . This aim was achieved as follows    :

• Assess health needs (physical, psychological, social spiritual and educational) for the studied    patients    .
• Identify   patients` satisfaction   level  with   bone  marrow transplantation   
• Develop and implement the multimodal preparation package   for the studied patients.
• Evaluate   its effect on their health needs, added to   satisfaction level  .  

Hypothesis:

It  was  hypothesized   that  , the   multimodal preparation  package   had   a  positive effect on health needs  and  satisfaction  among  patients  undergoing   bone  marrow   transplantation   .

Operational definitions:

Patient's health needs: means physical, psychological, social, spiritual and educational dimensions     . 

Bone  marrow transplantation  BMT : means  procedure that  need  hospital  admission  of the patient prior  to  the intervention  .   

Multimodal preparation package: means individualized face-to-face patient education, provision of an educational pamphlet, presenting a video, and performing a round in the bone marrow transplantation   unit.  

Subjects and Methods:

Research design:

 A quasi-experimental design was utilized to conduct this study

Setting:

The study was carried out in the Bone Marrow Transplantation Unite   and   Outpatients` Clinics  at  Nasser Institute Hospital.

Subjects:

A purposive sample of (70) adult patients from both genders  having   bone marrow transplantation   from the above mentioned settings  . They were selected according to the sensitive analysis in relation to the number of patients with  bone marrow  transplantation  within the year 2017 in  Naser  Institute  Hospital , according to the statistical department affiliated to the  same setting with the following criteria   :

Inclusion criteria:

• Conscious  adult  patients 
• Patients who agree to participate in the study.
• Patients  with  no  co-morbid   conditions 

Tools of  data  collection :

Tool I: 

Patients` needs assessment sheet (pre / post   and follow up   tests) .  It was designed by the researchers after reviewing the related literature and consulting the experts to assess studied patients’ health needs about bone marrow transplantation. It was written in simple Arabic language and divided into the following parts:

Characteristics of the studied patients such as:  age, gender, marital status, income, educational level and smoking.

Patients' medical records to identify past, present medical and surgical history, diagnosis, diagnostic measures and management.

Patients` needs included:

Physical needs  such as ( control   of   blood sugar level,  vital signs,   fluids chart,   therapeutic  diet,   prescribed   drugs,     hygienic    measures  and exercises, relief  of  the   side   effects  of   immunosuppressive    drugs,  assessment  of  fatigue level  ,   skin    and   oral   condition    .  The following scales were assist:

Numerical pain scale: It was based on Jacques (2011)  to measure pain severity and formed   of  a line divided by numbered points from (0-10) . Patients' answers were sorted as follows : no (zero), mild (0 - less than 4), moderate (4-less than 7) and severe  (7 - 10).

Fatigue  Severity Scale  : It was adapted from Krupp (1989), to measure fatigue level and consisted of nine statements with score ranged from 1-5, where  1 indicates strongly disagree (low fatigue level) and 5 indicates strongly agree (high fatigue level). The total score  ranged from 9 – 45, mild fatigue  with (13.5 - 22.5) , moderate fatigue (23-31.5) and severe fatigue (more than 31.5 - 45)  . Testing reliability of the scale items using alpha cronbach test = 0.95.

Psychological needs  such as ( Decrease   feeling of  worthiness   ,  anxiety  and dispelling  of  preconceived image  , depression  ,  fear  from  complications   , family  worries  ,  improve    awareness    and   positive  adjustment   of the   health condition . The following scale  was  assist  :

Hamilton Anxiety Rating Scale :It was developed by Hamilton (1959) , modified by the researchers  to assess anxiety level  and  consisted of thirteen variables : anxious mood, tension , insomnia , cognitive changes, depression, somatic(sensory), cardiovascular, respiration, gastrointestinal , genitourinary, autonomic symptoms, somatic (muscular) and the behavior at the interview. Testing reliability of the scale items using alpha cronbach test = 0.83.

Patients` responses  were  (0-3) scores and  total score ranged from 0-39 .    They  categorized  anxiety level  as  follows  :  no (zero) , mild  (0 - less than 23) , moderate  (23 - less than 29)  and   sever   (29 - 39).

Social needs such as ( decrease  financial   burden ,  assistance  with    activities  of daily   living  , awareness  with sexual  activity  ,   job   adjustment  and   improve    social  support ) . 

Spiritual  needs  such as   (  Enhance   spiritual   activities   ,  positive   vision    for the future   ,  sense  of   using   fullness   ,  safety  and  security  )  .

5- Educational  needs such as : Anatomy and physiology of bone marrow,  definition , types ,  causes  and  advantages of   transplantation,  definition of immune system,  types of stem cell  ,  donation criteria of bone marrow ,  indications  of chemo / radio   therapy . Pre procedure  preparations  such as :   investigations  ,  informed  consent , drugs   administrations ,  fasting  pre  procedure  , site  preparation   and  smoking  .   Post  procedure   care   such  as  :   early ambulation , pain  relief   ,   position  ,   diet    ,   deep   breathing   ,   coughing  and   extremity  exercises   .  Discharge   instructions    such   as   :   wound   care , hygiene ,  infection   control   , skin   and  oral  mucosal  care  , medications ,   diet   ,   follow up visits , immediate  physician  calling  ,  work ,  daily  living   activities  ,  self   care   activities  ,   life  style   changes   ,  exercises  technique , daily  life  activities , safety  precaution , complications   (  pain , nausea  and vomiting , bleeding ,  infection , impaired  oral  mucosa  , graft versus host disease  , veno-occlusive disease  ,  renal  insufficiency   )  .  

Scoring system of patients` needs:

Patients' responses regarding the presence of health needs (scored as two marks) or absence (scored as one mark), were categorized into either yes or no. Total items of health needs = 41 items, whereas needs absence were considered from less than 50%   and needs presence from 50% & more    

Tool  II:

Patients` satisfaction   assessment   sheet ( post test  ) . It was based on   Kleefstra et al. (2012) and composed of a   core questionnaire for the assessment of patient ` satisfaction   for general day care (COPS-D). It consisted of six dimensions: 

Admission procedure (Pre-admission visit:  reception, personal attention, expertise, information and instruction.  Admission   :  rapidity of being able to speak to and   degree of   support) , Operative  room (reception , personal attention and   expertise  operative  staff) .

 Nursing care (personal attention, expertise, day of surgery)     .

Medical care (personal attention and   expertise).

Information (information by nurses, doctors and rapidity of research results).

Autonomy (self-sufficient, participation in treatment decisions and    privacy).

Discharge and aftercare   (Information about further treatment, transfer of information to external professionals and   discharge   procedure)  .  

The COPS-D contains 17 questions. The  answer  was   sorted   by  a  5 -  point  Likert-scale (1 = unsatisfied, 2 = somewhat satisfied, 3 = rather satisfied, 4 = quite satisfied and 5 = very satisfied) .

Total  =  17  questions  ×  5  point Likert-scale   =  85     

 High  satisfaction  ( 51 -  85 ) and  

 Low  satisfaction  ( Less  than  51   )  .  

Content validity:

It was ascertained by a group of experts from  Oncology  , Hematology and Bone Marrow Transplantion  and  Medical– Surgical Nursing  . Their opinions were elicited regarding to the tools format layout, consistency and scoring system. Contents of the tools were assessed  regarding to the knowledge accuracy, relevance and competence. 

Ethical considerations:

In the planning stage, an ethical approval was obtained from the directors of the above mentioned settings. All patients were informed about the study and their rights according to medical research ethics that they were free to decide whether or not they would participate in the study. Then a written informed consent was obtained from each patient who agreed to participate in the study.

Pilot study:

A pilot trial was carried out on 10% of the total sample to test  practicability and clarity of study  tools, added to sample  and settings . Pilot sample  was  later  involved   in the study as there were no radical modifications in the study tools.

Procedures:

• Sampling was started and completed within 8 months.
• Purpose of the study was explained to the patients who agreed to participate in the study prior to any data collection.
• The researchers started to collect the data from the studied patients using the pre - constructed tools as follows:
• On the same day of diagnosis when patients came to Outpatients` Clinics of   Bone Marrow Transplantation Unite  
• On the first follow – up visits when the patients came to Outpatients`   Clinics, then after two   months   later.
• Filling in the tools was done by the researchers according to the patients' understanding and health condition.
• The data were collected by the researchers 2 days/ week at the morning and afternoon shifts   .
• The preparation package was designed based on analysis of actual patients' needs assessment through the pre constructed tools. Content of multimodal preparation package was consistent with the related literatures (national and international), included   theoretical and practical sessions. 
• Patients were divided into small groups included   5 – 6 in each group and underwent 4 sessions (2 theories and 2 practice). At the beginning simple written instructions were distributed and orientation about   the objective and outline was   done    .
• The theoretical part was implemented through face-to-face patient education with   lectures and group discussions using data show and poster as a media. In  addition  to  provision  of  an  educational  booklet ,  It was taken in 2 sessions (each session for 45 minutes)  . During this session, bone  marrow  transplantation   procedure   was explained to patients   and  an educational pamphlet about the procedure  which included   :  general  assessment , care  pre  , on the morning  and  immediately  post  procedure , discharge guidelines , home care and follow – up  visits .  In addition , pictures of different parts of  Bone  Marrow  Transplantation   Unit  and a 10-minute video describing  the  environment , transplantation   procedure   , pre / post  procedure  care  and experiences of  another  patients  with  the same  procedure   was  shown  to   studied   patients .  Lastly,   researchers   answered    any questions   about   the      bone marrow transplantation   procedure   at the end.    
• The practical part was   implemented through demonstration, re- demonstration, video and performing a round   in BMT   Unit. It was taken in 2 sessions (each session for one hour) and covered the following items: The first session included wound care and   infection control measures. Second session included correct position, daily activities, ambulation, breathing and leg    exercises.
• Patients were informed to be in contact with the researchers by telephone for any question.
• Patients were assessed either individually or in groups that entail   5-6
• Evaluation for   the effect of multimodal preparation package on the studied patients using the pre constructed tools as follows:
  • Post test  was done    after  one month  from     the  intervention  guidelines  and  BMT procedure   ( on  first  follow – up  visit  ) .  
  • Follow up test   after two   months later   using the same tools. 

Results:

Table (1): Characteristics of the studied patients (n = 70)

Table (1):  Presents    characteristics of   the   studied   patients’.  As    indicated     more than three fifths (77.1) of them   had the age   of 18 - <35 yrs b and   were   male (64.3). In relation to  residence,  occupation   and  BMI  ,  more than  half of  them  were from  urban area, work  and underweight (58.6  , 57.1  & 54.3   respectively).  Concerning income    and    education,   nearly half of them   had    enough   income and secondary education     (54.3 & 50.0 respectively).

Table (2): Presentation   of   studied   patients` physical   needs      in   pre/post  tests  (n=70)

*Significant at p < 0.05  

 Table (2):  Shows   a statistically significant difference between the studied patients` physical needs   in pre/post tests   .  More improvement  was   indicated   in   post  test   compared  to  pre     ( mean  =  35.1 ±6.6 & 51.4 ± 4.4  respectively )  with  t=  17.2   , p < 0.05     . In  addition  , significant difference was  noticed   in  follow  up  test   compared  to  post    (mean  = 9.3 ± 2.0  &  35.1 ±6.6   respectively  )  with   t =  31.5   ,  p < 0.05  .    

Table (3): Presentation of studied patients ` psychological needs in pre/post tests  (n=70)   

*Significant at p < 0.05 

 Table (3) :  Reveals   a statistically  significant difference between the studied  patients` physical  needs   in  pre/post tests   .  More improvement  was   indicated    in  post  test   compared  to  pre     ( mean  =  26.0 ± 5.0 & 51.9 ± 2.7  respectively )  with  t= 38.1 , p < 0.05     . In  addition  , significant difference was  noticed   in  follow  up  test   compared  to  post    (mean  =  8.1 ± 3.3  & 26.0 ± 5.0   respectively  )  with  t=  25.0  ,  , p < 0.05  .    

Table (4): Presentation   of   studied   patients ` social needs   in   pre/post tests (n=70)

Table (4): Reports a statistically significant difference between the studied patients` social needs in pre/post tests.  More improvement  was   indicated     in post  test   compared  to  pre     (mean  =  25.8 ± 4.9 & 43.7 ± 4.8 respectively )  with  t= 21.9 , p < 0.05. In  addition  , significant difference was  noticed   in  follow  up  test   compared  to  post    (mean  =  11.0 ± 4.6  & 25.8 ± 4.9  respectively)  with  t=   18.4   ,  p < 0.05  . 

Table (5): Presentation   of   studied   patients ` spiritual   needs   in   pre/post tests  (n=70) 

Table (5):  Clarifies a statistically significant difference between the studied patients` spiritual needs in pre/post tests. More improvement  was   indicated   in   post  test   compared  to  pre (mean  =  18.8 ± 4.9 & 36.8 ±7.5 respectively)  with  t= 16.8 , p < 0.05. In  addition  , significant difference was  noticed   in  follow  up  test compared  to  post    (mean  = 12.5 ± 7.6  & 18.8 ± 4.9     respectively)  with  t=   5.8     , p < 0.05  .        

Table (6): Presentation   of   studied   patients `educational   needs   in   pre/post tests  (n=70)

 Table (6):   Shows a statistically   significant difference between the studied  patients` educational  needs in  pre/post  tests  .   More improvement  was   indicated   in   post  test   compared  to  pre     ( mean  =  20.9  ± 3.7 & 49.4 ± 5.8 respectively )  with  t= 34.7 , p < 0.05     . In  addition  , significant difference was  noticed   in  follow  up  test   compared  to  post    (mean  = 7.9 ± 2.6  & 20.9  ± 3.7     respectively )  with  t=  24.1   ,  p < 0.05  .    

Table 7: Presentation of pain, anxiety and fatigue levels   among the studied patients in pre/post   tests   (n=70)

Table (7): Reveals studied patients level of pain, anxiety and fatigue in pre/post  tests. As noticed more than two thirds of them had sever fatigue, anxiety and pain levels in   pre test   (86.3, 83.0 & 68.4 respectively). In addition, significant improvement was indicated   in post   and   follow – up tests   compared by pre     . 

Table (8): Presentation of   studied patients` satisfaction   level   post   Bone marrow transplantation (n=70)   

 Table (8): Reports studied patients` satisfaction   level post BMT procedure. As observed  more than three fourths  of them  were satisfied  for the following : Pre-admission  period , admission  preparations  ,  operative  room   , nursing  management  ,  information  and  autonomy . In addition , majority of them   for   medical   treatment  and  discharge   instructions  with  mean number =  52.6 ± 4.7 ,  percent of mean ( 75.1% )    . 

Table (9): Correlation between studied patients` health needs and satisfaction   level  

R = Pearson correlation     

 * Highly positive correlation ≤ 0.001                                   

Table (9): Correlation between studied patients` health needs and satisfaction level.  Results indicated that, there was a highly positive statistical relation between studied patients` health needs (physical, psychological, social, spiritual and   educational) and   high   satisfaction level.