Assessment of Knowledge and Skills on Covid-19 among Frontline Nurses in Zanzibar

Abstract

Background: Covid-19 is one of the most serious pandemic outbreaks in history the world ever experienced. Its emergency and reemergence poses a substantial threat to nurses who often get close contact with patients, their knowledge and skills on managing the suspected and confirmed cases serve the foundation for positive response toward the outbreak; thus this study aimed at assessing the knowledge and skills of Zanzibar nurses on Covid-19

Methods A descriptive cross-section web-based survey was conducted in a set of 139 nurses from Zanzibar to assess their knowledge and skills for the covid-19 pandemic outbreak. Multistage sampling was employed to select the regions, hospitals and final the participants. Computer-generated questionnaires with a total of 50 items were used to collect information on the recruited respondents; data were analyzed using SPSS software.

Results: The assessment of knowledge and skills on covid-19 among frontline nurses from Zanzibar indicate that; the overall mean score knowledge of all respondents was (20.7±3.06) ranged from 13-26 while the overall skills scores were (20.69±3.06) ranged from 8-18. Age, level of education and working experience were found to be a significant predictor for both knowledge and skills on covid-19 at the level of 5% while working at the referral was only significant to skill.

Conclusion: The participants were knowledgeable and skilled regarding the topic of interest however this competence wasn’t directly associated with the study domain of covid-19 rather were significantly associated with other domains related to nursing activities such as IPC and general nursing care.

Background

Coronavirus disease 2019 (Covid-19) is one of the fatal pandemic outbreaks the world ever experience. The disease is caused by severe acute respiratory syndromes coronavirus-2 (Sars-Cov-2) and mostly affects the human respiratory system (1).

Covid-19 was firstly discovered in Wuhan China in December 2019 where the doctors started to notice patients with a similar clinical presentation to other previous Sars-Cov infection including fever, dry cough, frequent sneezing and lung infiltration in severe cases (2), which are precisely now known as the common symptoms for this disease; the other symptoms include body ache and pain, sore throat, diarrhea, nausea and running nose (3) and occasionally losing the sense of taste and smell.

On January 30, 2020, the World Health Organization (WHO) declared this disease to be a public health emergency of international concern and calling for countries to take urgent precautions to stop the spread of this infection. However, the disease was also reported to be highly infectious with a fatality rate of about 4%, that’s; for three months (December 2019 – early March 2020) has already spread over 114 countries and infected more than 118,000 peoples including 4291 deaths, thus WHO on March 11, 2020, had again declared this disease as a global pandemic (4).

As for the other countries; the United Republic of Tanzania had also reported being hit by this novel disease. The country through the Ministry of Health announced its first case on March 16, 2020 (5) and, since then, the number of reported cases was increased day to day until April 24, 2020, in the last published report, there have been 509 confirmed cases with 21 deaths reported to WHO (6).

While responding to the WHO declaration of January 30, 2020, that calls for the countries to take urgent and collaborative efforts to stop the spread of the virus; the government of Tanzania also adopted several measures to control the transmission such that closing schools and universities, screening campaign, exercising physical distance policy, avoid mass gathering, keep all travellers into two weeks quarantine, isolation and care of suspected and confirmed cases in a well-designated place (7). However, by the end of May 2020, Tanzania declared the country coronavirus free (8) and all of the above-mentioned measures were suddenly declined.

Surprisingly, from January 2021 reports from colleagues and other un-published sources indicate that different hospitals in the country were overwhelmed with the patient presenting with coronavirus like symptoms and being diagnosed as “Severe Pneumonia” while the number of death from the same condition continue to tally day to day within the country.

This for some reason put nurses who often get close contact with patients at an increased risk of being infected with this disease; as the risk of infection to this particular group is always higher compared to the general population (1). A different study has shown that inadequate knowledge and skills for nurses to identify the signs and symptoms of covid-19 as well as how to deal with them might be a threat to theirs’ and their family’s lives (1, 9).

The study of (7) which has been done in Tanzania mainland, shows that nurses were knowledgeable on covid19 but this knowledge was significant only to the level education, that, those who had lower than bachelor degree level were significantly associated with lower knowledge score. The study concerned the nurses’ knowledge and awareness but neither the skills (Practice) nor including nurses from Zanzibar.

Therefore, there is an urgent need to understand nurses’ knowledge and skills on covid-19 in Zanzibar to facilitate effective prevention of this vulnerable group from this novel disease as well as planning for effective outbreak management of this disease, thus, this study was conducted to assess the knowledge and skills for Covid-19 pandemic preparedness and response among frontline nurses in Zanzibar.

Method And Setting

A descriptive cross-section web-based survey which was part of the quasi-experimental study that aimed at designing and testing the efficacy of web-based nursing education tools for pandemic preparedness and responses among frontline nurses in Zanzibar was successfully employed to assess the baseline knowledge and skills on covid-19 among frontline nurses in Zanzibar. The covid-19 was used as a reference pandemic outbreak as it is currently affecting the world.

The study was conducted In Zanzibar, a semi-autonomous country in the United Republic of Tanzania. This country is formed by two major islands namely Unguja in the southern part and Pemba in the North and is surrounded by the Indian Ocean. In this country health services is divided into three levels; the Primary level which comprises Primary Health Care Units (PHCUs); the secondary level covers the district and cottage hospital and the tertiary level covers the referral hospital. All nursing activities in Zanzibar are controlled by the nursing and midwifery council (ZNMC). Until the last published statistic of covid-19 from Tanzania, Zanzibar contributed about 11.4% (58 cases) (10) and become the second leading part after Dar es Salaam.

Sample size and sample technique 

A multistage sampling technique was used to obtain the sample frame and final respondent of the study. In stage one, Simple random sampling by lottery with replacement method was engaged to handpick two regions out of the five existing in Zanzibar. Stage two: Systematic random sampling was engaged to select the health facilities; the list of facilities was obtained from the DHMT office, then from the list, every after defined interval one facility was selected. The interval was obtained by using the K^th formula: (K^th = N/n).

Stage three: the proportional sampling method was adopted in this study to handpick the number of study participants from each selected facility by using the formula: ni = Ni/nt *n. And finally in stage four; a simple random sampling was employed to select participants from each facility within the obtained proportion. 

The sample size estimation was 132 nurses (with an attrition rate of 10% made it 145). The estimation was made by using the formula:

Data collection tool and outcome measurement

A self-administered computer generated questionnaires were adapted, modified and distributed to respondents through the developed web-based tool. The questionnaire was divided into three parts, demographic characteristics, knowledge questions as well as skills questions and consisted of both multiple-choice questions and Likert scale items. 

The demographic characteristics consisted of ten items including age, gender, residence, level of education, working experience, level of the working facility, current section (department) of working, the status of IPC training uptake, the status of online training uptake, and status of any respiratory tract infection training uptake. 

The knowledge questionnaire was divided into three domains which are general knowledge, knowledge on IPC and knowledge on nursing management of the suspected and/or confirmed patient; each domain consisted of 10 items where each item carry 1 point, hence, make a total score of 30 points in knowledge questionnaire. 

The skills questionnaire was however divided into IPC implementation and nursing management skills for patients with covid-19 infections; each of these two domains consisted of 10 points and make a total score of 20 points for the skills questionnaire. 

To pledge the reliability of the tool for this study, the pre-test intervention was conducted on 20 BSc nurse students from the University of Dodoma and 16 Diploma Nurse Students from Huruma Institute of Health and Allied Sciences. A Cronbach's alpha reliability test was done to determine the coefficient reliability between items within the group; the alpha coefficient for 30 items of knowledge was 0.748 and 0.659 for 20 items of skills 

Data management and data analysis 

Data from this study were statistically analyzed through the Statistical Product for Service Solutions (SPSS) software program version 20. A descriptive analysis was employed to determine the pattern of distribution of the respondents concerning their socio-demographic characteristics. One-way analysis of variance (ANOVA) was then done to determine the mean score difference for knowledge and skills. To identify predictors for knowledge and skills for covid-19, a multiple linear regression analysis was then performed.  

Results

Nurses knowledge on covid-19 pandemic responses 

The results of the assessment of knowledge on covid-19 among frontline nurses from Zanzibar indicate that; the overall mean score knowledge of all respondents was (20.7±3.06) ranged from 13-26. Male and female respondents demonstrated nearly similar mean score knowledge (20.73±3.39 and 20.86±2.86 respectively) with no statistically significant difference.  

With regards to the age groups of the respondents; elder nurses in the age group of (40+ years) shows a significantly higher mean knowledge score (23±2) compared to the young age groups P< 0.001(Table-2). However, this difference was significantly observed in the IPC and Nursing care knowledge (P< 0.001) only but not in the general knowledge of the covid-19 domain where both age groups present almost similar mean scores, age group of 20-30 years (7.81±1.1), 31-40years (8.11±1.2) and 41+ years (8.67±0.52) with P= 0.107 (Table-3) 

Nurses with master degree levels were having a statistical significance mean knowledge scores (24.0±3.39) compared to those in the diploma, advanced diploma and bachelor degree level       (P< 0.001). Again, there was also a statistically significant difference in the mean score knowledge between nurses with working experience of more than 10 years (22.24±3.17) compared to those with <2years, 2-5 and 6-10 years (18.8±3, 20.17±2.66 and 21.88±2.96 respectively) P< 0.001 (Table-2). This significant difference was specifically observed under the domain of IPC and Nursing care knowledge (P< 0.001) but not in the domain of general knowledge for covid-19 P=0.063 (Table-3)

Regarding the status of IPC, RTI and eLearning training uptake; nurses with a history of participation in those training demonstrated a significant mean score difference while compared to those who had not (P< 0.001); yet, the difference in IPC training variable was observed being no statistical significance (P=0.132) in the domain of the general knowledge on covid-19 when it came to domain analysis. 

On the other hand, no difference in knowledge was observed according to the gender, residence and level of working facility P >0.05 (Table-3). Conversely, the domains based analyses indicate significant differences in the mean knowledge score in the domain of the general knowledge on covid-19 (P< 0.001); see table 3.  

Predictors of knowledge for covid-19 by linear regression 

Multiple linear regression was run to predict the knowledge for covid-19 from age, level of education, working experience and status of nursing training uptake among nurses from Zanzibar.  The results show that age, level of education and working experience were found to be the factor associated with the knowledge for covid-19 at the level of P< 0.05 (Table-4). Age was found to be a significant predictor of knowledge in this study (β= -0.354, P= 0.024) indicating the decrease of knowledge score by 0.354 as the age increase by 1 year. 

Regarding the level of education; the result shows that nurses with master degree level, bachelor degree and advanced diplomas were more knowledgeable about the covid-19 pandemic compared to the reference group (diploma). All variables for master degree level (β= 4.3, P= 0.002), bachelor level (β= 1.34, P= 0.016) and advanced diploma level (β= 2.76, P= 0.001) were statistical significance at the level of 5%. The working experience was also followed the same trend (β= 0.45, P= 0.016) (Table-4)

Nurses Skills on covid-19 pandemic response

Nurses’ skills scores were significantly different among respondents based on their demographic characteristics. Of all respondents; the overall mean scores were (20.69±3.06) ranged from 8-18. There was no statistical mean difference between male (13.00±2.46) and females (12.53±2.70) skills scores (P=0.302). 

Nurses within the age group of (40+ years) were observed to have significantly higher Mean skills scores (14.50±1.87; P=0.017) when compared to the young age groups in overall skills scores (Table-2). Nevertheless; the domain-based analysis (Table-5) demonstrate that the difference was only significant in the domain of IPC skills (P=0.031) but not in Nursing care skills, where all groups present nearly the same mean scores with no statistical significance difference (P=0.077). 

Regarding the level of education, nurses with a master degree were found to have higher mean skills scores (15.80±2.28) compared to those in the diploma, advanced diploma and bachelor degree level (P<0.001). Nurses with working experience of more than 10 years yet were found to significantly differ in mean skills score (13.18±2.38, P=0.008) from those with <2years (11.41±2.70), 2-5(12.51±2.41) and 6-10 years (13.18±2.38). Specifically, this significant difference was more of IPC related skills (P=0.003) rather than nursing care skills (P=0.195) (Table-5). 

A mean skills score for nurses working at the referral hospital level (14.90±2.10) was significantly higher compared to those at PHCU level (11.90±2.39), cottage (12.56±2.58) and district level (12.97±2.58) at the level of 1% (P<0.001). Concerning the status of IPC, RTI and eLearning training uptake; nurses with the history of participation in those training demonstrated a significantly higher mean score as compared to their counterpart (P< 0.01); however the domain-based analysis indicate the difference to be significant under the IPC domain only P<0.001 (Table-5)

Discussion

Covid-19 is one of the most serious pandemic outbreaks in history the world ever experienced. Its emergency and reemergence pose a substantial threat to nurses who often get close contact with patients, their knowledge and skills on managing the suspected and confirmed cases serve the foundation for positive response toward the outbreak; thus this study aimed at assessing the knowledge and skills of Zanzibar nurses on Covid-19.

Findings from this study indicate that the majority of the respondents were having adequate knowledge about covid-19 with an overall mean knowledge score of all respondents of (20.7 ± 3.06). This finding is consistent with the findings of other studies which have shown an adequate level of knowledge on covid-19 in different places. In the study of (1, 11–13) for example, all of them were demonstrating a satisfactory level of knowledge on covid-19 among nurses. Although the majority of respondents (59.7%) in the current study had lower than bachelor degree level of education, the higher rate of the correct answers wasn’t surprising as the study was conducted some more days later the after the first wave of the outbreak this could probably make nurses more aware of the disease condition through different mass media and peer learning while at workplaces.

The findings also indicate that elder nurses in the age group of (40 + years) and those with master degree level of education were having significantly higher mean knowledge scores (23.0 ± 2) and (24.0 ± 3.39) respectively at a level of 5% (P < 0.05) when compared to their counterparts. However, these knowledge scores differences were statistically associated with IPC and nursing care management of the patient but not directly associated with the study domain of the knowledge on covid-19. This result indicating that majority of the nurses in Zanzibar were using their prior knowledge acquired from the previous infectious outbreak to respond to the pandemic outbreak, this finding supports the observation in the study of (14) that Tanzania draws from Ebola to tackle the covid-19 outbreak.

The reason for this observation in Zanzibar could be because covid-19 made a surprising attack while the country wasn’t prepared for this war particularly came with new features that need to be adequately learned from the experts on how to respond to it. However, due to the fatality rate of the disease that emphasized for social distance and lockdown to be set in place, the training seminars were not able to be conducted as it was only for online learning that could break up this gap but the nursing authorities in the isles had none. This finding indeed highlights and emphasizes the need for the revolutionary government of Zanzibar through its nurses and midwifery council to have an online platform that could break this gap as far as the emerging and remerging of the novel covid-19 in the isles are frequently observed.

Again, findings from this study indicating that age, level of education and working experience were found to be the significant predictors for knowledge on covid-19. This finding is supported by the findings of (11, 15, 16) who found that experienced elder nurses and those with higher-level nursing education were more knowledgeable on the emerged outbreak when compared to their counterparts. With this finding, the current study suggests to the government that, a greater emphasis and opportunities should be provided for nurses to pursue higher-level nursing education to increase the number of potential nurses in the prevention and management of the emerged outbreak both epidemic and/or pandemic.

Regarding nursing skills, participants in this study showed the overall higher skills scores toward the prevention and management of the covid-19 outbreak in Zanzibar with the overall mean scores of (20.69 ± 3.06). The high skills result in the present study could be sure the results of the high knowledge participants had, and thus being translated into skills, this suggests that nurses from Zanzibar were competent enough to provide care for the suspected and confirmed cases of covid1-19 infection.

The findings also indicated that nurses of elder age and those with a higher level of education, as well as those working at referral hospitals were having higher mean skill scores and were significant predictors for this outcome. The essence of this result could be because, these potential groups of nurses are having higher coping behaviours, awareness of educational needs, problem focus and supporting seeking behaviour (17) that made them always to appeared as the most competitive groups in the nursing professions.

However, despite the higher skills scores, findings further reveal that the results were specifically significant associated with IPC skills rather than the skills on nursing management of the patient with suspected or confirmed signs and symptoms of covid-19. This could also be because the majority of respondents (71.2%) in the current study had several sit on IPC training while none of them (as per inclusion criteria) up to the time of this data collection was officially trained to tackle the covid-19.

This finding suggests the need for nurses to be trained based on newly emerged diseases to prevent nosocomial and cross infection among nurses and their families. Indeed the web-based nursing education is emphasized to break the barrier for mass gathering during any of the pandemic influenzas as for this covid-19 pandemic outbreak.

Conclusion

The present study provided a comprehensive assessment of knowledge and skills on covid-19 among frontline nurses from Zanzibar. The participants were having higher knowledge and skills regarding the topic of interest however this competence wasn’t directly associated with the study domain of covid-19 rather were significantly associated with other domains related to nursing activities such as IPC and general nursing care. As for this finding, the study suggests and emphasize the need for establishing an online platform that will breakdown the barrier for face to face training such as lockdown and social distances, and allow nurses to continue educating themselves at their own free time and pace.

Declarations

Participants' consent: Participants were fully informed about the study and free to make an informed decision. The consented participants were free to withdraw at any time of the study or refuse to answer any question without any consequences.

Competing interests: The authors declare no competing interests.

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Tables

Table 1: Demographic Characteristics of Respondents (n= 139)

Source: Field data 2021, Zanzibar

Table 2: Relationship between socio-demographic characteristics of the respondents with the overall mean knowledge and skills scores on covid_19 pandemic (n=139)

Table 3: Relationship between socio-demographic characteristics of the respondents and the mean scores knowledge on covid_19 Pandemic within the respective study domain (n=139)

Table 4: predictor of knowledge for covid-19 pandemic response among frontline nurse from Zanzibar by linear regression (n=139)

Table 5: Relationship between socio-demographic characteristics of the respondents and the mean scores within the domains of the perceived skills on covid_19 Pandemic (n=139)

Table 6: Predictor of Perceived skills for covid-19 pandemic response among frontline nurse from Zanzibar by linear regression (n = 139)