Keywords chronic kidney disease - staff nurses - knowledge - planned teaching program
Introduction
Chronic kidney disease (CKD) is a continuous and progressive deterioration of kidney
function over several years, which is characterized by the formation of fibrotic tissue
and loss of normal kidney structure. As a result of this, kidneys fail to process
the waste in the blood and other functions. Initial stages of CKD are characterized
by slight decreased or normal glomerular filtration rate (GFR) and later it leads
to chronic renal failure (CRF) or end-stage renal disease (ESRD).[1 ]
ESRD denotes the end of the CKD continuum. It is an overwhelming medical, social,
and economic problem for the patients, their families, and for the whole country.[2 ] CKD is a significant component of chronic noncommunicable diseases (NCDs).[3 ]It is contributing to the highest rates of mortality and morbidity.[4 ]
About 10% of the population worldwide is affected by CKD, and millions die every year
due to unaffordable treatment.[5 ] As per the 2017 Global Burden of Disease study, in 2017, worldwide 697.5 million
cases of CKD have been reported and mortality was 1.2 million.[6 ] CKD patients have risk factors for atherosclerosis, dyslipidemia, hypertension,
and insulin resistance which can be controlled by a fat, sodium, and sugar-restricted
but high-fiber diet.[7 ]
According to Bergstrom, CKD entails variations in calorie, protein, and micronutrient
intake. These may contribute to the high incidence of protein–energy malnutrition
(PEM) and the most critical risk factors for increased morbidity and mortality in
ESRD.[8 ] At the same time, the ingestion of excessive potassium, phosphorus, sodium, and
fluid may have hostile effects on fluid balance and other complications caused by
electrolyte instabilities.[9 ] Hence management of the nutritional aspects displays many challenges.
Due to extensive changes in lifestyle as well as diet and fluid restrictions, CKD
has caused the involvement of families along with patients and dietitians.[10 ] Moreover, the assessment of nutritional requirements and nutritional modifications
requires the involvement of a nephrologist and nurses on a patient-to-patient basis
depending upon the underlying comorbid diseases and conditions.
Studies have conveyed that 33 to 50% of hemodialysis patients were noncompliant with
fluid restriction regimens, which challenges the effectiveness of treatment, resulting
in inconsistent progress of the disease and a higher chance of complications. Researchers
have concluded that interventions that encourage fluid intake compliance are vital
for these patients.[11 ]
Nurses are recognized as being more passionate about constantly working in hospitals,
particularly in renal dialysis. It is a very specialized field because the health
care team members give special care to fulfill the basic needs of renal patients.[12 ]
The current study was done to determine the effectiveness of a planned teaching program
on the knowledge of staff nurses with regard to the nutritional requirements of patients
with CKD.
Methods
Study Design, Settings, Participants
This study was conducted between April 2018 and May 2018 in a hospital by using uncontrolled
before-and-after study design. A total of 40 staff nurses working at the hospital
were selected using a convenient sampling technique.
Eligibility Criteria
The inclusion criterion was staff nurses who were willing to participate in this study.
The exclusion criterion was staff nurses who had already undergone nutritional training
programs.
Data Collection Methods
The planned teaching program was given to 40 staff nurses working at the hospital
during the data collection period. The data collection instruments included demographic
proforma and a structured questionnaire on a renal diet. Formal written permission
was taken from the medical superintendent, the nursing superintendent, and the head
of the department (HOD) of nephrology. Informed consent was obtained from the staff
nurses individually after explaining the objectives and purpose of the study. The
pretest was done by administering instruments like demographic proforma and structured
questionnaire on a renal diet among the staff nurses. The average time taken to complete
this was 10 to 15 minutes. After the pretest, the staff nurses underwent planned teaching
for 60 minutes with the help of Microsoft PowerPoint slides. Followed by that the
posttest was conducted four times on the 7th, 14th, 21st, and 28th day by administering
the same tool to determine the posttest level of knowledge after the administration
of PTP. The sequence of data collection was shown in [Fig. 1 ].
Fig. 1 The sequence of data collection.A1 —pretest (assessment of knowledge of staff nurses before the planned teaching program
[PTP]); X—intervention of PTP on renal diet; A2 —posttest 1 (7th-day assessment of knowledge of staff nurses after PTP); O3 —posttest 2 (14th-day assessment of knowledge of staff nurses after PTP); O4 —posttest 3 (21st-day assessment of knowledge of staff nurses after PTP); O5 —posttest 4 (28th-day assessment of knowledge of staff nurses after PTP).
Ethical Permission
Ethical permission for the study was obtained from the ethics committee on January
1, 2018.The registration number was NUINS/CON/NU/IEC/2017–18. Participation was voluntary
and informed consent was obtained from all the participants after the purpose and
objectives of the study were explained to them with the participant information sheet.
Data confidentiality was guaranteed.
Analysis
Data analysis was done by using Statistical Package for Social Sciences 20 SPSS-20
(SPSS Inc., Chicago, IL) software. Descriptive statistics and inferential statistics
were used for analyzing sociodemographic data and structured questionnaires. Analysis
of variance (ANOVA) test was done to evaluate the effectiveness of the planned teaching
program.
Results
The data collected from the subject were organized and are presented in the following
sections.
Description of Sample Characteristics
The data obtained on sample characteristics were analyzed using descriptive statistics.
The frequency and percentage of the staff nurses by the demographic characteristics
are presented in [Table 1 ].
Table 1
Distribution of demographic characteristics of the staff nurse
(n = 40)
Variables
Frequency
Percentage
Abbreviations: GNM, general nursing and midwifery; BSc, bachelor of science; n , number.
Age (y)
22–24
19
47.5
25–27
14
35.0
28–56
7
17.5
Gender
Female
37
92.5
Male
3
7.5
Qualification
GNM
23
57.5
BSc
16
40.0
Post-BSc
1
2.5
The distribution of staff nurses according to age depicts that the mean age of the
staff nurses was 25.78 years. According to the gender, data reveal that 92.5% were
females, and 7.5% were males. The distribution of the staff nurses based on qualification
reveals that majority 57.5% of them have completed general nursing and midwifery,
40% had completed bachelor’s degree in nursing sciences, and only 2.5% had completed
postbasic nursing.
Distribution of the Level of Knowledge Among the Staff Nurses
[Table 2 ] depicts the distribution of knowledge level of staff nurses in which good knowledge
score was seen among 12.5% staff nurses during pretest, whereas the majority had good
knowledge score in posttest, that is, 7th day posttest—60%, 14th day posttest—87.5%,
21st day posttest—77.5%, and 28th day posttest—97.5% . In pretest majority (77.5%)
of staff nurses had average knowledge score and 2.5% had average knowledge score in
the 28th day posttest. Lastly, poor knowledge score was seen among 10% of staff nurses
in pretest, whereas none of the staff nurses had poor knowledge score in the 21st
and 28th days of posttest.
Table 2
Distribution of the level of knowledge among the staff nurses
Knowledge (n = 40)
Pretest
Posttest 1
Posttest 2
Posttest 3
Posttest 4
Poor (1–10)
4 (10)
2 (5.0)
1 (2.5)
–
–
Average (11–20)
31 (77.5)
14 (35.0)
4 (10.0)
9 (22.5)
1 (2.5)
Good (21–32)
5 (12.5)
24 (60)
35 (87.5)
31 (77.5)
39 (97.5)
Effectiveness of Planned Teaching Program by Using Repeated Measures of ANOVA
[Table 3 ] shows the mean pretest knowledge score of the staff nurses (x̄1 =16.10) was significantly lower than their mean posttest knowledge scores (x̄2 = 20.78, x̄3 = 24.35, x̄4 = 24.20, and x̄5 = 28.75). In the repeated measures ANOVA, p -value is less than 0.05, and hence there was a significant difference in the level
of knowledge of staff nurses after the planned teaching program.
Table 3
Effectiveness of planned teaching program on knowledge levels among the staff nurses
by using repeated measures analysis of variance (ANOVA)
Variables (n = 40)
Mean
Standard deviation
F
p -Value
Note: p -Value ≤ 0.05 considered significant.
Pretest
16.10
3.68
56.83
<0.001
Posttest1
20.78
5.38
Posttest 2
24.35
4.061
Posttest 3
24.20
4.177
Posttest 4
28.75
3.410
Comparison of Pretest and Posttest 4 Questionwise Answers
Questionwise comparison of knowledge among the staff nurses between pretest and posttest
4 was depicted in [Table 4 ]. It indicates that staff nurses had good knowledge in posttest 4 as compared with
pretest.
Table 4
Questionwise comparison of pretest and posttest 4 nutritional knowledge among the
staff nurses
Question number
(n = 40)
Pretest
Posttest 4
Frequency
Percentage (%)
Frequency
Percentage (%)
1
11
27.5
40
100
2
31
77.5
40
100
3
13
32.5
39
97.5
4
12
30
40
100
5
26
65
38
95
6
17
42.5
26
65
7
34
85
38
95
8
31
77.5
38
95
9
28
70
35
87.5
10
9
22.5
27
67.5
11
25
62.5
35
87.5
12
11
27.5
39
97.5
13
7
17.5
36
90
14
24
60
32
80
15
25
62.5
35
87.5
16
29
72.5
35
87.5
17
17
42.5
31
77.5
18
17
42.5
31
77.5
19
34
85
34
85
20
11
27.5
38
95
21
18
45
36
90
22
10
25
38
95
23
13
32.5
37
92.5
24
25
62.5
37
92.5
25
16
40
35
87.5
26
11
27.5
34
85
27
25
62.5
40
100
28
35
87.5
36
90
29
15
37.5
37
92.5
30
23
57.5
37
92.5
31
28
70
39
97.5
32
13
32.5
38
95
Significant changes in the knowledge level was seen in posttest 1 and posttest 4,
indicating the need for reinforced teaching and better retention of knowledge.
Discussion
CKD is a significant health issue in various parts of the world. Nowadays medical
management is not the only effective treatment of CKD, the patient with CKD also needs
acute nursing care to prevent complications and decrease the stress and anxieties
of dealing with a serious illness. Nursing care is focused toward assessing the fluid
status and identifying possible sources of imbalance, executing a dietary program
to ensure appropriate nutritional intake within the limits of the treatment regimen,
and promoting positive feelings of the patients by encouraging increased self-care
and greater independence.[13 ]
Patients with CKD have nutritional needs, different from healthy individuals. The
identification of these dietary requirements mandates a thorough understanding of
various physiologic and pathologic processes linked to the renal system.[14 ]As staff nurses play a significant role in CKD management by directing the dietary
regulations through patient education, staff nurses should have adequate knowledge
regarding the nutritional requirements of patients with CKD. A planned teaching program
for staff nurses has an influence on increasing the knowledge level.
Majority of studies have shown that nurses are found to have an inadequate level of
nutritional knowledge and that there is a superior need for nutrition education.[15 ] A descriptive cross-sectional study has revealed that ~70.6% of staff nurses had
a fair knowledge score, 17.6% had a good knowledge score, and 11.8% had a low knowledge
score.[16 ] The dearth of knowledge about nutritional modification is an actual concern, as
these health care workers many a time provide information to the patients on their
nutrition. Hence, interventions are essential to guarantee that the information they
pass on to their patients is precise and up-to-date.[17 ]Another study revealed that only 38% of nurses were aware of the requirement of a
higher protein diet for dialysis patients.[18 ]
The majority (59.4%) of the health care workers had low nutrition knowledge in a cross
sectional study conducted in Tanzania with a mean score of 9.8.[17 ] In the current study, the mean pretest score was 16.10 and it increased to 20.78
in posttest 1, 24.35 in posttest 2, 24.20 in posttest 3, and 28.75 in posttest 4.
The result revealed that there is a significant increase in the level of knowledge
after providing PTP for staff nurses.
The current study result shows that the obtained p -value is less than 0.05 for posttest 1 and posttest 4, indicating a significant difference
in knowledge before and after the PTP. Moreover, the results indicate that nursing
staff should be given PTP on the nutritional requirement of patients with CKD, which
in total helps to balance the nutritional requirement of CKD patients.
Conclusion
CKD is a progressive loss of kidney function over several years, leading to ESRD where
the patient needs either dialysis or transplantation for survival. It is imperative
to consider the diet to keep a balanced level of electrolytes, minerals, and fluid
in the body. Staff nurses are giving care to the patients and hence they should be
knowledgeable about what diet should be recommended for CKD patients.
