EFFECTIVENESS OF CAPACITY BUILDING PROGRAM ON THE USE OF ASSESSMENT SCALES FOR CRITICALLY ILL PATIENTS IN TERMS OF PRACTICE OF NURSES

1. MSN, RN, Postgraduate Student, College of Nursing, Institute of Liver and Biliary Sciences, ILBS, New Delhi. 2. MSN, RN, Reader, College of Nursing, ILBS, New Delhi. 3. MSN, RN, Lecturer, College of Nursing, ILBS, New Delhi. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 15 January 2020 Final Accepted: 17 February 2020 Published: March 2020

There is a need for nursing education on assessment scales used in ICUs. A competent nursing workforce is important for an effective healthcare system. Providing up to date and practical strategies may help to reduce nurses' challenges in managing critically ill patients. Broader autonomy and effective decision making can be seen as beneficial for the nurses besides having a clearer and structured management guidelines (Subramanian et al., 2012).
With the view of reviewed literature and self-experience of investigator during clinical posting, researcher came to know that many nurses are facing difficulty while practicing and using the assessment scales for the critically ill patients and many studies revealed that teaching program and instruction improves the knowledge and practice. Therefore, current study has been undertakenthereby improving the care of the patients in the critical care units

Methods:-Research Approach and Design
The primary objective of the present study was to assess the effectiveness of a Capacity Building Program on use of Assessment scales for critically ill patients in terms of Practice of nurses in ICU. Therefore, quantitative research approach was considered for the present study.
The investigator considered pre-experimental, one group pre-test post-test design to be suitable for the present study, because the study intends to ascertain the improvement in Practice of nurses who had attended capacity building program regarding the use of assessment scales for critically ill patients.

Population and setting
The study was conducted in Liver Coma ICU, Institute of Liver and Biliary Sciences, D-1 VasantKunj, New Delhi. The rationale for selecting this setting:-Familiarity with the setting, Feasibility of conducting the study, Availability of sample subjects, Administrative approval and anticipated co-operation from nurses for conducting the study.
The population of the study includes nurses who are working in Intensive Care Unit of selected hospital of Delhi and involved in direct patient care. The accessible population is nurses who are working in ICU of ILBS. The target population is nurses who are working in Intensive Care Unit of selected hospital of Delhi and involved in direct patient care.

Sample and Sampling Technique
Total enumeration sampling was used in the study. All nurses working in Liver Coma ICU of ILBS New Delhi and meeting the inclusion and exclusion criteria were enrolled as subjects for the study.

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Criteria for sample selection Inclusion criteria Nurses who are:-1. Involved in direct patient care in LCICU. 2. Working in LCICU for at least one month.

Exclusion criteria
Nurses who are:-1. Relievers from other areas of hospital for a day/ few days posted in LCICU. 2. On long leave (More than 15 days)

Sample Size
The sample comprised of all the nurses working in LCICU in ILBS and who are involved in direct patient care during data collection period. The total number of nurses working in LCICU was 45. Out of them one nurse was ICU in-charge and five nurses were Team Leaders and therefore, they were not involved in direct patient care. From the remaining 39 nurses, three nurses were on long leave during the data collection period. Finally, 36 nurses were enrolled for the study.

Tool for data collection
The investigator had developed the tool (Observation checklist) for data collection. Observation checklist was based on statement and objective of the study, to assess the effectiveness of Capacity Building Program on the Practice of Nurses regarding the use of Assessment Scales for Critically Ill patient in ICU of selected Hospital of Delhi. Demographic details, it has 6 items that are constructed to obtain data related to Age, Gender, Educational Qualification, Working Experience in ICU, Reads Literature about Assessment Scales and Attending In-Service Education program(s) on assessment of critically ill patient.Tool-I Observation Checklist to assess the Practice of Nurses regarding the use of assessment scales for critically ill patient. It comprised of total 22 items. The practice checklist was divided into three practice domains: Glasgow coma Scale, Pupil reaction scale, Modified Ramsay sedation scale. The observer observes the performance of the nurses. Each item was marked by the observer as "YES" if the participant performed the respective activity (item), "NO" if the participant failed to perform. Each of the "YES" response was scored as "1" and "NO" was scored as "0". Possible maximum score is 22 and minimum score is zero. In order to establish the reliability of Observation Practice checklist, inter-rater reliability was calculated. The Intra-class Correlation of Observation Practice Checklist of Glasgow Coma Scale, Pupil reaction scale, Modified Ramsay Sedation Scale was -0.93, 0.92, 0.95 respectively.

Development of Capacity Building Program
The Capacity Building Program was prepared on the basis of the in-depth review of research and non-research literature and expert opinion in the field. Some of the important factors considered while preparing the capacity building program was simplicity of language, content coverage, simplicity and practicability. The content of Capacity building program was organised under the following heading:-1. Glasgow Coma Scale 2. Pupil Reaction Scale 3. Modified Ramsay Sedation Scale Capacity building program on the use of assessment scales for critically ill patients was provided to nurses by the investigator. Administration of complete duration of program is approximately 30 minutes. Lecture cum discussion teaching method on one-to-one basis was used with the aid of Power-point presentation.

Try out
Try out was conducted on 10 nurses in Surgical ICU and Transplant ICU of ILBS, New Delhi from 22 nd October 2018 to 27 th October, 2018. Prior permission was obtained from the hospital authority. Participant Information Sheet was given and Informed Consent was taken from all the nurses before collecting the data. It takes around 15 minutes to administer tool to each nurse and then item analysis was done to assess the item discrimination index and item difficulty. The tool was found appropriate for the nurses under the study.

Pilot Study
Pilot study was conducted on five nurses in High Dependency Unit (HDU) of ILBS, New Delhi from 29 nd October 2018 to 03 rd November, 2018.Findings of the pilot study reveal that it was feasible and practicable to conduct the study.

Data collection Process
Formal administrative permission was obtained from College of Nursing Ethical Committee, ILBS New Delhi, prior to the start of the study. Permission was taken from Institute of Liver and Biliary Sciences prior to the start of the study. Data were collected from Nov"3, 2018 to Dec"3, 2018. All Nurses working in Institute of Liver and Biliary Sciences who met the inclusion criteria were enrolled in the study. Participant Information Sheet of the study was given to the subjects. Consent forms were signed before participation in the study. Total enumeration sampling technique were used. Nurses working in Liver Coma ICU of ILBS who met the inclusion criteria were enrolled for the study. Firstly the practice of nurses were assessed (on Day-1) using observation checklist. After assessing the practice, Capacity Building Program was administered (Day-1) on one-to-one basis. After intervening the intervention Practice were reassessed on Day-7.

Results and Data Analysis:-
The data was obtained from the thirty six subjects. The responses from the thirty-six subjects was entered in the master data sheet in the Microsoft Excel. Data analysis was done in SPSS V.22 using descriptive and inferential statistics.

Demographic Characteristics of Nurses
More than half (52.8%) of the nurses were above 30 years of age.There were 55.6% male among the nurses, while 44.4% were females. Maximum nurses (69.4%) had done Diploma/GNM. About one-third of the nurses (36.1%) had 6-10 years of working experience in ICU.Equal number of nurses (41.7%) used to read literature most of their times and sometimes and only 16.6 percent nurses never read literature. More than half of the nurses (55.6%) had previously attended in-service education program(s) on assessment of critically ill patient whereas 44.4 percent nurses had never attended any in-service education program(s). About thirty percent of nurses had attended once, 13.88 percent nurses had attended 2-3 times and 11.11 percent had attended in-service education program 4-5 times respectively.About one-third (33.33%) of nurses had attended more than 6 months ago, 19.44% had attended 2-6 months ago and only 2.77% nurses had attended less than one month ago.

Practice Scores of Nurses regarding the use of Assessment Scales Effectiveness of Capacity Building Program in terms of gain in Practice Scores of Nurses
The mean post-test practice score (18.83±2.11) was higher than their mean pre-test practice score (9.36±2.07) with mean difference of 9.47.
The Capacity Building Program regarding the use of assessment scales was found to be effective in improving the practice score of nurses. It was highly appreciated from "t" value of 21.84 (p<0.000)  Area chart of Pre-test and Post-test Practice scores of the Nurses. This figure illustrates the Practice scores of nurses regarding the use of assessment scales for critically ill patients before and after the administration of Capacity Building Program. Pre-test is shown nearer to the Y-axis and Post-test further away from Y-axis. The whole area chart of post-test scores has shifted towards the right side on the X-axis. The graph clearly demonstrates an improvement in the Practice score with mean Post-test Practice score of 18.83, which is more than mean Pre-test Practice scores 9.36.

Frequency and percentage distribution of Pre-test and Post-test Practice score
Majority of nurses (80.55%) scored average in pre-test practice scores, 13.88% nurses were above average and only 5.55% nurses were below average in pre-test practice scores, whereas all the nurses (100%) scored above average in post-test practice scores.

Domain wise mean percentage of Pre-test and Post-test Practice scores of Nurses
Maximum gain (50%) present in Modified Ramsay Sedation Scale, followed by Pupil Reaction Scale that was 46.11 percent and Glasgow coma scale was 36.73 percent respectively.   573

Effectiveness of Capacity Building Program for Nurses in terms of gain in practice regarding the use of assessment scales for critically ill patient
In the current study, the Capacity Building Program was also found effective in improving the Practice of the Nurses. The mean post-test practice score (18.83±2.11) was higher than their mean pre-test practice score (9.36±2.07) with mean difference was 9.47. It was highly evident from "t" value 21.84 (p<0.000).
The findings were consistent with the study of Teles, Bhupali&Madhale (2013) on Effectiveness of Self Instructional Module. The study also revealed that during the pre-test all the staff nurses 83.64 percent had average skill. After the administration of the Self Instructional Module in post-test 35(63.64%) of staff nurses had average skill and 20(36.36%) had good skill, t value was 40.8 and p value was 0.002, which implies the effectiveness of Self Instructional Module.
Findings were also similar with another study done by Nair (2015) on the effectiveness of Planned Teaching Program in terms of knowledge and practice of nurses regarding changes in pupillary reaction. The finding of the study revealed that nurses significantly gained ability related to assessment of changes in pupillary reaction and the PTP was effective in terms of assessment of pupillary changes.

Association between post-test Practice score of Nurses with selected demographic variables
The findings of present study revealed that there was no significant association between post-test practice score age, gender, educational qualification, working experience, Literature variable and status of attended in-service education program and last attended in-service program in-service education.