Effect of Educational Program Regarding Care of Children with Intussusception on Nurses' Knowledge and Practice

Background Intussusception is a serious condition that occurs when one segment of the intestine invaginates leading to bowel obstruction. Nursing management involves comprehensive care, including pain management, fluid and electrolyte balance. Developing an educational program for nurses my help to improve children's outcomes and enhance nurses' performance . Aim: The current study was aimed to evaluate the effect of educational program regarding care of children with intussusception on nurses' knowledge and practice. Subjects and Method: A quasi experimental research design was used. Subjects: convenience sampling (60) nurses distributed as 30 nurses from Pediatric Surgical Department of Tanta University Hospital and 30 nurses from Pediatric Surgical Department of Elshatbi University Hospital. Tools: Two tools were used to collect data: Nurses' knowledge about intussusception structured questionnaire sheets and nurses’ practices regarding intussusception observational checklist. Results : Most of the studied nurses had low level of knowledge about intussusception pre the educational program which was enhanced to high level level of knowledge after one month. A high percentage of nurses had unsatisfactory practice regarding care of children with intussusception before educational program, compared to the majority of them who had satisfactory practice immediately and one month after implementing the educational program. Conclusion : Implementing educational program for nurses had a significant effect on nurses knowledge and practice immediately and one month after education. There was statistically significant positive correlation between nurses' total knowledge and total practice. Recommendations: in-service training programs should be conducted periodically for all nurses caring for children with intussusception.


Introduction
Intussusception is a serious condition that occurs when one segment of the intestine telescopes or invaginates into another segment, leading to bowel obstruction.It primarily affects infants and young children, usually between the ages of 3 months and 3 years.(Cheikhrouhou T. et al, 2022).
The exact cause of intussusception is often unknown, but certain factors can increase the risk.Gastrointestinal infections caused by viruses like rotavirus or adenovirus, have Vol. 32.No. 1 (Supp 2) ,February 2024 been associated with intussusception.Structural abnormalities in the intestine, such as Meckel's diverticulum or polyps, can also act as lead points for intussusception.Additionally, previous abdominal surgeries and certain medical conditions, like lymphoid hyperplasia or immune-deficiency disorders, may increase the risk.(Ting X. et al 2022) Clinical manifestations of intussusception typically include severe, intermittent abdominal pain, vomiting (sometimes with bile-stained vomit), and bloody stools described as "currant jelly" stools.However, not all children present with this classic triad of symptoms, and the presentation can be atypical or incomplete.Other signs may include lethargy, irritability, abdominal distension, and a palpable abdominal mass.(Gumerov AA. et al, 2022) Nursing management of a child with intussusception involves comprehensive care, including pain management, fluid and electrolyte balance, emotional support for the child and family, monitoring the child's condition, and providing education about intussusception and its management.Nursing interventions aim to promote optimal child outcomes.

(Kelley-Quon LI. Et al, 2021)
The educational program should be designed to the learning needs of the nurses, with interactive sessions and handson training.The program can be delivered through various methods such as lectures, case studies, videos, and simulations.Nurses should be evaluated to assess the effectiveness of the program.(Kelley-Quon LI.Et al, 2021) Providing educational program for nurses help to promote early detection and quick care of intussusception by enhancing nurses' knowledge and practice, which will eventually improve child outcomes.Prompt actions can avoid the need for more invasive procedures, prevent serious consequences, and shorten hospital stays.(Issa K. et al, 2021).Providing nurses with more up dated information allows them to handle child care with more expertise, confidence, and clinical skills, which improves the efficiency and effectiveness of healthcare delivery.

Significance of the study
Intussusception is invagination of one segment into a distal segment of a bowel.It is the commonest cause of abdominal surgical emergencies in infants and children.The estimated global rate of intussusception is 74 cases per 100,000 children under one year of age, ranging between 9 and 328 cases per 100,000 depending on geographic location (Jiang J. et al, 2013).
Pediatric nurses provide vital role in children's care.
Continuing nursing education equips nurses with the knowledge and skills necessary to provide a better quality of care to children with intussciption.Nursing education for nurses careing of children with intussciption may enhance their performance and improve children's outcomes.

Aim of the Study:
The current study aims to evaluate the effect of educational program regarding care of children with intussusception on nurses' knowledge and practice.

4) Tools Validity:
The content validity index for the study's instruments was 98% after they were reviewed by five pediatric nursing specialists; changes were made as needed.5) A Pilot study: Apilot study was done on 10% (6 nurses) of the nurses who participated in study.The necessary adjustments were done.There was omission of the preliminary study from the final analysis.

6) Tools Reliability:
The research instruments were tested for reliability using Cronbach's Alpha test it was of 0.903.7) Phases of the study: The study was conducted on four phases: 1-Assessment phase: Nurses sociodemographic characteristics were assessed using (tool 1 part 1).Nuurses' knowledge about intussciption was assessed using ( tool 1 part II) .Nurses' practice was assessed using (Tool II ).Nurses' knowledge and practices were assessed pre, immediately and after one month from implementation of the educational program.

2-Planning phase:
The researcher set objectives, plan for educational sessions and prepare the educational materials according to the assessment phase.

3-Implementation phase:
The researcher classify the nurses into six groups each group comprised of five nurses.A combination of video lectures, PowerPoint presentations, and interactive posters made up the class sessions.The researcher conducted an educational program for nurses by holding a series of six sessions according to needs assessment.The researcher met the participated nurses twice weekly.Session length varied from 30 to 45 minutes, with discussion time varying based on nurses' input and progress.The content of the educational program was presented in the following: First session: It was focus on knowledge about intussusception definion, etiology and pathology.Second session: It started by revision for the knowledge given in the first session.Then the resercher moved on to cover knowledge related to clinical symptoms, Vol.32.No. 1 (Supp 2) ,February 2024 diagnostic procedures, and surgical treatment for intussusception.Third session: A practical session.It focus on nurses' practice of pre-operative care including children's preparation for intussusception surgery including the need to refrain from eating and drinking for a certain time before to the procedure, chart whether the child has passed urine and had a bowel movement, a water soluble contrast or air enema, administration of intravenous fluids and electrolytes, insertion of nasogastric tube and anti-shock measures, monitoring vital signs, urine output, avoid hypothermia, hypoxia and hypovolemia.Fourth session: Started by revision of the content in the previous session then focus on post-operative preparation for children undergoing intussusception operation by checking tubes, drains and equipment.Observation of drainage, care of wound, observation for passage of stools or barium, observation of character of stool, recurrence of previous symptoms, signs of infection (increasing redness occurs around the wound, pus or cloudy fluid drainage from the wound, pain and swelling, bad odour, elevated body temperature).Fifth session: It concentrated on postoperative problems of children with intussusception (constipation, abdominal distension and dehydration).Discussion of linked ideas provides the material to nurses.Sixth session: It focused on discharge and follow up plan.

Evaluation phase:
The participated nurses were evaluated immediately and one month after implementation of the educational program about children's intussciption and theses results were compared with the results of the pre educational assessment using tool (I part 2) & tool (II).Statistical analysis: The data was organised, tabulated, and analysed using SPSS, a statistical computer programme, version 25.Finding the mean, standard deviation, and range were all part of the calculations for numerical data.The qualitative data was analysed with the use of the Chi-square test (χ2).Using a T-test for independent to compare between the two groups' means.We compared the means of the group variables before and after the intervention using a paired sample T-test.If there were more than two variables or three intervention periods in a group, the F-value of analysis of variance (ANOVA) was calculated to compare the means.a Pearson correlation and Spearman's correlation coefficient, abbreviated as r were used to correlate between variables.A significance threshold of P<0.05 was used to interpret the results of the significance tests (*).The results of the significance tests were also interpreted using an extremely significant threshold of P<0.01 (**).(Gerstman B. 2018 and Petrie A. 2015).

Results: Table (1):
demonstrates Percentage distribution of the studied nurses regarding their socio demographic characteristics.The study revealed that 40% of them, their age range from 41 to less than 51 years old with the mean age ± SD (38.9±9.91).Regarding sex, it was also clear that the majority of nurse were females (81.7%), respectively.Regarding level of education, it was found that slightly less than half of Vol.32.No. 1 (Supp 2) ,February 2024 the nurses (46.6%) had technical instituted in nursing .It was observed that 46.6% of the nurses had more than 10 years of experience with the mean ± SD (7.47±4.89).The table also illustrated that all studied nurses (100%) had not attended training courses related to intussusception.

Regarding
nurses' total knowledge levels , It was observed that the majority of the studied nurses had a low level of knowledge pre the educational program.This may be attributed to insufficient information related to intussusception and its complications, pre & post-operative preparation and lack of continuous education pre implementation of the educational program.While more than three quarters and two thirds of the nurses had high level of knowledge immediately and post one month of the educational program respectively.The improvement in the study nurses' knowledge indicates that the planned teaching sessions were effective and enhanced nurses' knowledge post education.The study result was in the same line with Hassan Y. et al (2023) who reported that more than half of study sample had fair knowledge followed by one third of them had poor knowledge and one fifth of the study sample had a good knowledge concerning pre implementation of the educational program.This result disagrees with the study conducted in Nineveh Governorate by Hameed and Mohammed, (2018) who found that more than half of pre-program knowledge as excellent and more than one third of knowledge was acceptable.
Concerning the mean scores of nurses' practices regarding Preoperative nursing care intervention for children with intussusception.It was found that there was a positive statistically significant difference between pre, immediate, and post one It was observed that the most of nurses had unsatisfactory level of practice pre the educational program respectively, while the majority of them with satisfactory level of practice had immediate and post one month educational programs.This result may be attributed to lack of training courses as all of the nurses in the current study didn't attend any training courses and nearly one third of them had less than 5 years of experience.
A study done by (Mahmoud N. and Hamed S. 2021) was in harmony with the current results.They found that all of studied nurses didn't assess children's vital signs, assess hypo &hyperthermia at preprogram implementation, while more than two third of them performed it immediately post-program, and about two third of studied nurses completely performed it after one month of program implementation.Another study by Slagle, (2017), who found was agreed with the current results.They found that all of studied nurses didn`t have satisfactory level of practice regarding assess patients' sign and symptoms of hyper& hypothermia and also concluded that change in nursing practice to best is difficult due to time constraints.Additionally, the result was in the same line with ( Jeesh Y.A.A. et al, 2021) who found that there were variations of the nurses' improvement in all practice after the program, and the percentage of the nurses that implement the steps correctly shifted from the minority to the majority.
Concerning to the mean score of nurses' practice regarding postoperative care, the current study proved that the majority of nurses practice was improved immediately and one month after educational program compared to nearly one third of them before education.This may be attributed to the effectiveness of the educational program in improving nurses' practice.A study conducted by (Hanaa A. et al. 2020) was in agreement with the present findings as they found highly statistically significant difrences between nurses' practice pre, immediately and one month after education.(2018), who also noted that nurses are expected to engage in continuous learning and that wound care nursing practice requires specialized knowledge and abilities.The current findings highlighted the need for maintaining up-to-date skills and having enough knowledge while dealing with children in clinical practice.
The findings of the current study revealed a significant association between nurses' knowledge and their socidemographic characteristics especially level of education and experiences.
The significant associations found between age groups and the level of knowledge, that a nurse younger age was a good level of knowledge than older age in contrast to with the study done by"AL-Simady (2006)" which found that the results indicate that younger nurses possess ahigher degree of knowledge compared to their more seasoned counterparts, despite the fact that the former should be knowledgeable of many practical steps to minimize difficulties and provide the best nursing care for children.The claims made in the research are contradicted by this.
The findings indicated a strong relationship between gender and knowledge level, indicating that males had average knowledge.Also, there were very strong correlations between education and knowledge, suggesting that nurses with bachelor's degrees or above had a wealth of information.In line with a prior research carried out by "Hospitals with a larger percentage of direct-care registered nurses with bachelor's degrees showed a significant survival benefit over hospitals with a lower proportion of staff nurses with bachelor's degrees, according to Aiken et al. (2003).In a similar vein, institutions with a larger percentage of registered nurses with bachelor degrees had a far better chance of surviving severe complications encountered by surgical children while hospitalized.

Moreover,
there was a statistically significant relationship between years of experience and degree of expertise in this study; specifically, nurses with eleven to fifteen years of practice exhibited a moderate degree of expertise.With this outcome, we concur "Nursing practice time was the primary emphasis of AL-Simady (2006) and Shayma'a (2004) in their efforts to improve nurses' performance.There was a strong correlation between the nurses' education and years of experience providing post-operative care for children, as well as their entire understanding of the topic, according to a previous study Except for sex and locality, A statistically significant difference was discovered in the total number of nurse practices and sociodemographic factors according to the present study (P value < 0.05).These findings ran counter to those of "Hanaa A., et al 2020," which found There was no statistically significant correlation between the sample's age, education level, or years of experience and their degree of practicing.Initial stages and subsequent results Instantly & The amount of post-operative wound care after three months was significantly related to the degree of practice before the educational program this relationship persisted regardless of educational status (pvalue = 0.038).

Conclusion:
Nurses' receiving an educational program about children with intussception had improved in their level of knowledge and had satisfactory practice immediately and one month post educational program compared to pre-educational program.Statistical significant difrences were found between nurses' sociodemographic characteristics and their knowledge &practices.
Recommendations: The current study recommended the following:  In-service training program should be conducted for nurses to update their knowledge and practice regarding care of children with intussciption. Booklet and pruchours about preand post-operative nursing care for children with intussciption should be available at Pediatric Surgical units. Further studies are needed to improve nurses' practices for caring of children with intussusception before and after surgery.

Further
support for these findings came from a research in Jordan (Richboarg, et al., 2017), which found that children fared better when postoperative care nurses had expert wound care and training.The findings were corroborated by Golik et al.

Table ( 5): Relation between nurses' socio demographic characteristics and the main level of knowledge pre, immediately and one month post educational program(n= 60).
t: Student t-test F: F for One-way ANOVA test *: Statistically significant at p < 0.05