Study design, sample, and procedures
The current study was a quasi-experimental pre-test post-test study with two control and experimental groups that was conducted in the neonatal and pediatric intensive care units of Namazi Hospital in Shiraz in the in December 2020 until April 2021 in. Namazi Hospital is the largest educational medical hospital of Shiraz University of Medical Sciences which has hospital beds and intensive care beds.
Participants
The study population consisted of all nurses working full-time in the pediatric intensive care unit who entered into the study through a census of 60 nurses from the two pediatric intensive care units. Considering that all the nurses working in the pediatric intensive care unit of Namazi Hospital were women, gender was excluded from the underlying variables leaving only the nurse's age as the underlying variable. The inclusion criteria included being an intensive care nurse (with at least one year of experience in this field) and having an interest and willingness to participate in the study, whereas refusing to continue attending training sessions considered to be an exclusion criterion.
Initially, the purpose of the study was explained to all nurses who met the inclusion criteria and were included in the census, either individually or in groups. Then, a knowledge questionnaire on how to flush triple-lumen was distributed to them, followed by a pre-test. Then all participants were randomly divided into two groups of 25 people.
Instrument
The triple-lumen flushing guideline is divided into three sections: practical explanation, flushing procedures, and aftercare, which will be briefly explained. Flushing central venous catheters in children result in serious complications and injuries, such as an increased risk of obstruction, embolism, infection, and a reduction in the life of central catheters. Here, in the internal wards of the first and second departments of the Namazi hospital, employing a new technique, a controlled trial is used to perform flushing, blood sampling, and replacement of central venous catheter dressing, which is not performed in any of the hospital wards in the south of the country. This technique increases the central venous catheter's durability, controls infection, and increases the venous catheter's potency.
Guideline teaching and protocol
Making a standard heparin flushing solution at a rate of 10 units per cc of 0.9% normal saline solution begins hand washing with the aseptic method. For flushing, a 10 cc syringe is always used because, contrary to popular belief, a 10 cc syringe creates less pressure. More pressure causes the central venous catheter to be damaged and ruptured, causing serious damage. The push-pause method is used with a 10 cc syringe and standard solution. Hands are washed first, followed by sterile gloves and a catheter impregnated with a disinfectant solution (chlorhexidine 0.2 percent + alcohol 70%). First, one cc of the solution is pushed, followed by a pause, and then another cc pauses and continues. The solution's volume is determined by the size of the central venous catheter. It should be at least twice the volume of the catheter or equal to it. The positive pressure in the push-pause method flushes the particles in the catheter and keeps it from becoming clogged (this method has a significant impact on increasing the life of central catheters, as rapid drug push or flushing reduces the life of the catheter and damages the arteries) the catheter is then clamped.
This checklist was made by the researcher to ensure that the triple-lumen flushing steps are followed correctly. This checklist, which has 10 items and a yes or no answer, was completed by the researcher while observing the work of the studied samples. This checklist also has a score range of 0 to10, with higher scores indicating that the steps were completed correctly. The checklist was created using the most recent triple-lumen flushing guide. After making changes, the validity and reliability of this questionnaire were confirmed by face-to-face validity and content validity by nursing education and medical education specialists. To confirm the reliability, a questionnaire was completed by the administrators for ten nurses. Cronbach's alpha coefficient for questionnaires completed by students was equal to 0.85, which was approved.
The 10-item, multiple choice questionnaire (MCQ) created by the researcher was reviewed. This questionnaire presents the correct basis for performing the triple-lumen flushing technique in the form of four-choice questions and compares them in the form of a pre-test and post-test. The questionnaire's scoring method is as follows: scores 0-3 indicate poor knowledge, scores 4-6 indicate moderate knowledge, and scores 7-10 indicate high knowledge of nurses concerning the triple-lumen technique. After making changes, the validity and reliability of this questionnaire were confirmed by face-to-face validity and content validity by nursing and medical education specialists. A test-retest procedure was used to confirm the reliability of completing the questionnaire. Pearson correlation coefficient of 0.79 and reliability were confirmed for the test in two stages of Baber. The intervention group received 10 sessions of theory training, as well as the presentation of a video and an explanation of the triple-lumen flushing guide in the clinical skills hall of Shiraz School of Nursing, Midwifery, and Medical Sciences. These sessions lasted between 60 and 90 minutes and were held twice a week. One person provided all training based on the guideline, which was reviewed and compiled by professors from the Departments of Nursing and Cardiology (university ICU specialist who is well-versed in all concepts and the triple-lumen guideline). A knowledge post-test was administered to both the intervention and control groups after the theory sessions.
Three questionnaires from different studies were used in this study as the instrument 18-20. Researcher-made attitude questionnaire with 5 questions: This questionnaire is classified as a 5-point Likert from completely disagree (1) to strongly agree (5) score. This questionnaire has a minimum score of 5 and a maximum score of 25 points. The higher the results of this questionnaire, the more positive the attitude toward education. After making some changes, nursing education and medical education specialists confirmed the validity and reliability of this questionnaire using face validity and content validity. To confirm the reliability, ten nursing students were asked to complete a questionnaire. Cronbach's alpha coefficient for questionnaires completed by students was equal to 0.81, and it was approved.
Each nurse in the control group then practiced and repeated the triple-lumen flushing skill on the patient's bed, and this repetition continued until the procedure was correctly performed. This clinical session lasted up to two hours for each nurse and included face-to-face and practical training, supervision, and researcher feedback. A post-test was given to all participants two weeks after each nurse received face-to-face training. In addition, the attitude questionnaire was completed by the studied samples, while the performance checklist was completed by the researcher. Nurses' evaluation scores were calculated on a scale of zero to ten to determine their level of clinical knowledge before and after the triple-lumen flushing training course; which means that the minimum and maximum scores that each nurse could obtain from the triple-lumen flushing scale are within this range. The preceding variable is described in light of this. As a result, the results from zero to three indicate that nurses have low levels of clinical knowledge, the results from four to six indicate that nurses have moderate levels of clinical knowledge, and the results from seven to ten indicate that nurses have a high level of knowledge. As a result, the total score of nurses' clinical knowledge prior to and after the training course was calculated on three scales: low, medium, and high. Then, according to the scores obtained from the response of the participants in the range of each of the above three scales, their frequency distribution, and frequency percentage were determined.
Data analysis
The data were analyzed using descriptive and inferential statistics as well as SPSS version 22 software. The main variables of the study were analyzed using descriptive statistics (mean and standard deviation) and inferential statistics (paired t-test, chi-square). Due to the non-normality of the data after the Kolmogorov-Smirnov test, non-parametric Wilcoxon and Spearman correlation tests were used for analyzing them.
The significance levels in the tests are 0.05 and 0.01, and the confidence percentages are 95 and 99%, respectively.
Ethics in research
Participants in this study signed written informed consent and were reminded that they could withdraw from the study at any time, in addition to adhering to the principle of confidentiality. This study has been approved by the University Ethics Committee with the code IR.SUMS.REC.1399.947.