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The Effect of A Neurological Training Module On The Competency of Neurocritical Care Staff Nurses

Submitted by Ruperto A. Asesor Jr., MSN, RN

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ABSTRACT

Aims: To determine the effect of the “Brain EMERGENT Training Module” to the competency of neurocritical care staff nurses (SN’s) in Neurocritical Care Unit (NCCU) and Acute Stroke Unit (ASU) in managing post-operative neurological patient (PONP) with increased intracranial pressure (IICP).

Methods: This quasi-experimental study enrolled 19 SN’s through purposive sampling to attend a Brain EMERGENT training module. Four instruments were developed to measure pre & post- test competencies in four domains based on Miller framework: 1) Knowledge: Cronbach’s alpha
= 0.82, 2) Affective: Cronbach’s alpha =0.88, 3) Psychomotor: Cronbach’s alpha = 0.84 and 4) “Does” Domain: validation of skills measured after 4-weeks.

Results: The training module had a very high significant effect 2-weeks after the post-test: 1) Knowledge: mean =7.8, SD=1.6, p-Value = 0.0009, and 2) Affective: mean = 63.2, SD 6.6, p- Value=0.0228. There was no effect on the post-test of Psychomotor: mean = 28.5, SD = 2.8, p- value = 0.0855. Out of 10 SN’s in validation of skills, 8 SN’s were deemed competent whereas 2 SN’s did not meet competency level.

Conclusion: “The training module” had an effect on the post-test in Knowledge and Affective domains and no effect in the psychomotor domain.

Keywords

Miller Framework, Brain EMERGENT training module, Neurocritical care, Increased Intracranial Pressure

Introduction

The care of PONP requires a higher level of nursing skills to respond to subtle changes that could lead to permanent disability and sudden deaths (Schimpf, 2012). Currently, there are no certifications for “Neuroscience Nurses” in the Philippines; however, the Critical Care Nurse of the Philippines (CCNAPI) provides a training program for “Stroke Nurses”; Neuro assessments competency of SN’s are often non optimal (Cook et. al., 2019).

The primary aim of neurocritical care is to detect and avert neurological deterioration (Pritchard, 2011). Neurology patients have lower mortality and better outcomes when cared for in specialized NCCU than in general critical care units (Kurtz, P. et. al., 2011). According to Levett-Jones et al., (2011, p.64) “competence test is a process to measure knowledge, skills, and attitudes according to a professional standard to give assurance that they can perform professional role safely and effectively in a society”.

The goal of the study was to develop highly skilled SN’s in the field of neurocritical care nursing. The purpose of the study was to determine the effect of the training module to the post- test of the four domains of the Miller framework (Figure 1) in the aspects of 1) Knowledge, 2) Psychomotor, 3) Affective, and 4) “Does” domains.

The care of PONP based on Monroe Kellie doctrine describes IICP as a condition of a rigid skull that is non-compressible. The brain, interstitial fluids, intravascular blood, and CSF must stay constant in volume to maintain equilibrium. Nursing interventions identified that could IICP include, suctioning, coughing, straining, Valsalva maneuver, fever, pain, anxiety, and blood pressure elevation (Hickey, 2014). The Glasgow Coma Scale (GCS), widely used to evaluate neuro patient’s responsiveness was reported with potential incorrect and inconsistencies in GCS scoring by nurses (Braine, 2016).

Ugras et. al (2015), identified chest physiotherapy, coughing and tracheal suctioning are activities which contribute to IICP; thus, they should be performed when extremely necessary for shorter periods. Signs of respiratory distress and agitation, such as an increase in pulse and sweating are assessments that requires sedation to prevent IICP before and after suctioning (Hickey, 2014). Agitation and acute pain are post-operative neurological changes that may arise from intracranial hemorrhage and brain edema (Zhao, 2017). Undertreated pain and agitation cause an increased demand for brain oxygen, resulting in ischemia (Zhao, 2017).

A self-administered survey of competency in the of care traumatic brain injury (TBI) was reported by Kiewet (2019); SN’s (n=98) was conducted in multiple Intensive Care Units (ICU). Knowledge and clinical practice based on Patricia Benner’s model (1982) was utilized. Results revealed ICU nurses without exposure to NCCU had the lowest knowledge, whereas those with 1 to 2-years NCCU experience had the highest knowledge.

A study conducted among Filipino nurses showed permanent status SNs was associated to higher competency. Other factors identified were marital status, and length of service (Feliciano, 2019). Other factors that contribute to theory-practice gaps were resource restrictions, lack of experience and collaboration between clinical staff/SN’s in educational institutions (Salifu, D.A., et. al, 2018).

Methods

This research is quantitative quasi-experimental study conducted in NCCU/ASU in a 307-bed capacity university tertiary setting. Purposive sampling was employed due to low number of SN’s in NCCU/ASU based on a survey of 4 other tertiary hospitals. All 22 SN’s were enrolled, but only 19 completed the module which is the minimum number of participants required (Krejcie, R.V., & Morgan, D.W., 1970). Inclusion criteria were Registered Nurses employed longer than 3-months, completed the hospital orientation program, and assigned in NCCU/ASU.

Five questionnaires were developed based on the Miller model. Questionnaire number 1: “Knowledge Level of SN’s in the Assessment/Monitoring of PONP with IICP”; a 12-item tool about anatomy & physiology of the brain based on the Monroe Kellie doctrine; tested with a Cronbach’s alpha = 0.82 and average CVI 0.9583.

Questionnaire number 2: the affective domain, “Perceived Level of Confidence of SN’s in the Care of PONP with IICP”; a 15-item tool interpreted as follows; level 1 (Strongly Disagree) - very low level, level 2 (Disagree) - low level, level 3 (Neutral) – undecided level, level 4 (Agree) – high level; and level -5 (Strongly Agree) – very high level; tested with a Cronbach’s alpha =0.88.
Questionnaire number 3: “Decision Making Skills of SN’s in Psychomotor Interventions”; a 33-item tool; tested with Cronbach’s alpha = 0.84 and average CVI is 0.9393 indicative of excellent content validity.

Tool number 4: “DOES” domain “Validation of SNs’ Skills Learned in the Brain EMERGENT Training Module”; a 28 items checklist used for direct observation and face-to- face/questions and answers; piloted in a different hospital.

Questionnaires 1 and 3 were developed though review of literature and guidelines by Neurocritical Care Society (Malaiyandi D., Shutter L., 2017). The Goldilock’s method Zieky (1994) suggested 80% as the minimum passing level (MPL).

Statistical approaches utilized were descriptive analysis with means and standard deviations, Wilcoxon, and ANOVA to analyze the variables. Stata version 10 software was used for data analysis and a p-value <0.05 was considered significant.

The “Brain EMERGENT” training module entailed 4-hours interactive lecture and video/slides presentations in the morning and a 2-hours workshop in the afternoon with OSCE return demo of psychomotor skills. Each participant was given a code in numbers on both pre and post-test to ensure confidentiality and maintain privacy. The head nurse scheduled a maximum of 6 SN’s for each training module until 19 SN’s were completed.
Post-test were given after 2 weeks and the “Does” domain was evaluated after 4 weeks.

Results

There were 9 men and 10 women in this study, and most were single (n=16); have more than one to five year’s work experience (n=16), and 1 year experience (n=3). Demographic profile did not show any significance to the post-test.

The Knowledge domain results showed high significant in Anatomy, and Physiology of the Brain p=0.0299, and the Blood p=0.0053, not significant in CSF (p=0.0815). In addition, about 7 participants got 0 scores in computations of CPP and MAP. Overall pre-test result was lower mean at 7.8, SD 1.6 compared with post-test mean 9.7, SD 1.3 highly significant with p= 0.0009 (Table 1).

“Affective” domain results showed high significance to “assessing the needs of the family” (p=0.0111), “ability to teach neurovascular assessment to others” (p=0.0452), “not affected by too many workloads” (p=0.0023) and “looking forward to administrative tasks” (p=0.0299). Overall pre-test result was lower mean at 58.8, SD 7.6 compared with post-test mean 63.2, SD 6.6 significant with p= 0.0228 (Table 2).

Most of the respondents were perfectly competent (100% correct) at pre-test with regards to Psychomotor domain such as: oxygenation, Target Temperature Management (TTM), positioning and providing patient/family education and lower competency related to assessment and prevention of IICP, medication management, and prevention of complications. The training program had no effect in the overall “Decision-making in Psychomotor skills domain” results (p=0.0855) except in the neuro assessments skills which resulted in significant level (p=0.0352) (Table 3).

Out of 10 participants validated at bedside after 4 weeks of training, all were able to perform the following skills: GCS scoring, intervened with IICP, oxygenation, CO2 elimination, medications (10 out of 10). Only 3/10 SN’s got MAP computation correctly, 8/10 were able to answer the early signs of IICP and promotion of CO2 elimination. Overall, 22 out of 28 action-based skills, 8 out of 10 participants were deemed competent 4 weeks after the training module.

Discussions

The study showed Anatomy and physiology had no significant change in the aspect of CSF (p=0.0815). In addition, 7 SN’s had incorrect responses to questions computing CPP and MAP. According to White S. (2012), anatomy and physiology continues to be a difficult subject among nursing students who participated in their study due to overwhelming new and complex terms and concepts.

Major strengths of SN’s showed high level of confidence (Agree) in the aspect of patient/family education p-0.011 and in providing patient/family education, p-0.0452. Caregivers are sometimes referred to as “secondary patients,” who need and deserve protection and guidance (Boyle, 2015). Neuro nurses play a vital role in helping family caregivers and must engage in the health care process (Reinhard SC, 2008) in preparation for discharge to rehabilitation and home care.

The level of confidence was low (Neutral) in terms of “being able to do a good job” (Table 2) both pre-test and post-test p-0.2568. This could be attributed to the overwhelming workload during COVID-19. Confidence level improved in “not being affected by too many workloads” at p-0.0023 and “looking forward to additional administrative tasks” p-0.0299 increased at very high significance. Research studies showed that a heavy nursing workload adversely affects patient safety (Lang TA, 2004) and focusing on weaknesses revealed to be a “performance killer”, and a decrease in performance by 27% (Hearn, 2017).

The training program did not have an effect in the post-test of the psychomotor domain except in the aspect of neurological assessment (p=0.0352). The training program only had 2 hours of OSCE and limited technological devices such as: ICP monitor, External Ventricular Drainage, and TTM machines; thus, SN’s were not given enough time for practice of skills. Anecdotal reports of SN’s stated that “they forget what they have learned if they do not use it”. Mwale & Kawala (2016), pointed out that lack of technological devices in the clinical setting has an influence on skills acquisition which has led to the improvisations and missing important steps in the procedures which could result to unsafe practices (Rhodes, et al, 2011).

All SN’s kept the head of bed between 30 to 45 degrees; 9 out of 10 of the SN’s turned the patient every 2 hours to prevent pressure injuries, and 8 out of 10 avoided flexion and extension of the neck. About 8 out of 10 of the nurses suggested pain medication as PRN; however, only 7 out 10 requested a bowel program to the physician to prevent constipation, and only 7 out of 10 SN’s can remember sedation vacation protocol. Neurocritical care SN’s should advocate patient “sedation vacation” to improve patient outcomes and hospital length of stay and reduce the duration of mechanical ventilation of critically ill patients (Oddo, 2016).

Nursing administration must promote neurocritical care specialization by providing training modules every 2-years, to better identify the gaps in knowledge, as well as the areas where additional training and education are needed (Oyesanya, 2017). It is important to examine the knowledge and practice of SN’s before and after training or after an educational intervention to ensure good performance, and quality of competence (Lima MLS, 2018). The psychomotor domain did not have any effect nor improvement in the post-test it is recommended to increase OSCE to 4 hours with updated technology for actual simulations and repetition of the skills. According to Tirado, (2016, p.25), “the absence of individualized feedback diminishes the effects of repeated practice”.

In this study the Brain EMERGENT Bundles of Care Nursing Management (Figure 2) was developed as a standard/algorithm in the care of PONP with IICP to facilitate and respond in a timely manner, independent nursing interventions in NCCU as indicated in the bundles of care.
The Brain EMERGENT training module based on the Miller’s framework had an effect in the post-test in the aspects of knowledge and affective domains only and did not have an effect in psychomotor domain.

Acknowledgement

Gratitude goes to my thesis committee for their unwavering support. I want to thank Dr. Wilhelmina Z. Atos PhD, RN, research panel chair, Milagros B. Rabe, MD, Dean of UERM Graduate School, and Maria Peñafrancia Adversario, MD, for her statistical expertise.

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Figure 2. Increased Intracranial Pressure (IICP) for Post-operative Neurological Patient Brain EMERGENT Bundles of Care Nursing Management (ASESOR, RA, MSN, RN).