Nurses Practice in Leukemia
Nurses Practice in Leukemia
Nurses Practice in Leukemia
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Nurses Knowledge and Practice Regarding Educational Needs for Patients with
Leukemia
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Nurses Knowledge and Practice Regarding Educational Needs for Patients with
Leukemia
Nadia Mohamed Taha*, Howida Kameel Zatton2 and Hala Ibrahem Zatton3
Department of Medical Surgical Nursing, Faculty of Nursing Zagazig University, Zagazig, Egypt
*Corresponding author: Taha NM, Assistant Professor, Department of Medical Surgical Nursing, Faculty of Nursing, Zagazig University, Zagazig city 44511, Egypt, Tel:
0020224330793; Fax: 0020552312009; E-mail: [email protected]
Received date: March 31, 2017; Accepted date: June 26, 2017; Published date: July 4, 2017
Copyright: © 2017 Taha NM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited
Abstract
Aim: The aim was to assess nurses' knowledge and practice regarding educational needs for patients with
leukemia.
Methods: Two tools were used for data collection, namely as self-administered questionnaire and an observation
checklist. The study was conducted at the Oncology and Hematology Department in Zagazig University Hospital.
Sample: Convenience sample of 30 nurses with the only inclusion criterion of having at least one-year
experience in the study setting.
Results, conclusion and recommendations: The study demonstrates deficient knowledge and inadequate
practices of nurses providing care to patients with leukemia in the study setting. This is most evident in critical areas
such as infection control, skin care, and maintaining nutrition. There is also a shortage in training programs for these
nurses. Therefore, there is urgent need to arrange continuing education programs for nurses. The study findings
could be used as a basis for construction of training endeavors based on identified knowledge and practice gaps to
respond to their unmet needs. The main limitation of this study is its small sample size, which would hamper
generalization of its results, in addition to the possible observed bias.
Keywords: Leukemia; Knowledge; Practices over a period of months to years, and the disease trajectory can extend
for years [10]. Diagnosis is by symptoms [11], confirmed with
Introduction complete blood count, followed by bone marrow aspiration [12].
Treatment tends to destroy abnormal cells, but can also damage
Leukemia is a malignancy originating in the stem cells of the healthy cells and tissues, and it causes side effects [13].
hematopoietic system, which results in uncontrolled proliferation of
white blood cells (WBCs) [1]. The produced WBCs have different Since the patient with leukemia has many physical and
grades of immaturity, with inability to perform functions. The is also psychological needs, the nursing role is extremely challenging. The
decreased production of normal red blood cells, white blood cells, and diagnosis of leukemia can evoke great fear from death, which makes
platelets and infiltration of other organs [2]. Leukemia is fatal if left the patient difficult to manage, and increases his/her need for
untreated [3]. continued diligent support as well as teaching [14]. Added to this is the
patient family need to be informed about treatment and prognosis.
Leukemia estimated new cases in the United States in 2011 were Therefore, the nurse must develop a teaching plan with short and long-
44,600 and deaths 21,780 [4]. The number of new cases of leukemia term goals, specific nursing actions, and periodic evaluation of
was 13.7 per 100,000 men and women per year. The number of deaths progress toward goal achievement [15]. The satisfaction of basic
was 6.8 per 100,000 men and women per year. These rates are age- human needs enhance wellness conversely [16] whereas the unmet
adjusted and based on 2010-2014 cases and deaths [5]. In Egypt, a high needs can result in a client’s altered health status [17]. For nurses, it is
incidence was reported, especially in the pediatric population [6]. The imperative that these physical, psychological, social, and educational
National Cancer Registry Damietta Profile [7] registered 52 cases. The patients’ needs be met [18]. Moreover, they should be sensitive to the
cause of leukemia is not known, but multiple factors are thought to be information-seeking behavior of cancer patients and their families
responsible as age, radiation, chemicals, viruses, genetics, cigarette [19].
smoking and cancer therapy [8].
Leukemias are classified according to cell line involved lymphocytic Significance and of the Study
or myelocytic, and according to maturity of the malignant cells as
Cancer occupies the second place after heart disease as a cause of
acute (immature cells) or chronic (differentiated cells) [9]. In acute
death. The researchers observed that a large number of leukemia
leukemia, the onset of symptoms is abrupt, and without treatment, it is
patients are admitted to the hematology unit where they work. Those
fatal within weeks to months. In chronic leukemia, symptoms evolve
Page 2 of 7
patients have knowledge deficit about the disease manifestation, Control bleeding and prevent injury: 10 items such as “Instruct
treatment and follow-up care. This indicates a need to know how far patient to avoid gum bleeding hygiene by using soft tooth brushes,”
the nurses in the setting know and fulfill their roles towards these “Teach client to avoid forceful coughing, sneezing, and nose blowing.”
patients to optimize independence in daily living activities, prevent
Maintaining adequate balanced nutrition: 16 items such as “Provide
complications of the disease and its treatment, and attain remission.
liquids with different textures and tastes,” “Offer small frequent meals
including low-fat high-calories foods throughout the day.”
Aim
Control of side effects of lines of treatment: These included small
The aim was to assess nurses' knowledge and practice regarding checklists for dealing with anemia (4 items), fatigue (6 items),
educational needs for patients with leukemia. diarrhoea (10 items), constipation (6 items), alopecia (5 items) and
stomatitis (5 items).
Methods The checklist items were checked as either “done” or “not done.” For
scoring, the items observed “done” were scored one and the items “not
Design done” were scored zero. For each area, the scores of the items were
A descriptive cross-sectional design was used which was conducted summed up and the total divided by the number of the items, giving a
in Oncology and Hematology Department at Zagazig University mean score of this part. These scores were converted into percent
Hospital. scores. The nurse’s practice was considered adequate if the percent
score was 60% or more and inadequate if less than 60%.
Sample Upon preparation of the checklists, they were presented to a panel
of five experts (three professors in Medical-Surgical Nursing, Faculty of
The study involved a convenience sample of 30 nurses with the only Nursing, Ain Shams University, and an assistant professor and a
inclusion criterion of having at least one-year experience in the study lecturer of Oncology Medicine and Hematology, Faculty of Medicine,
setting. Since these were all the nurses available in the setting, no Zagazig University) for face and content validation. They reviewed the
sample size could be calculated. tools for clarity, relevance, comprehensiveness, understanding,
applicability and ease of administration. Minor modifications were
Data collection required.
Two different tools were used for data collection, namely as self-
administered questionnaire and an observation checklist. Pilot study
The self-administered questionnaire was designed by the researchers A pilot study was conducted on five nurses from another setting for
for assessment of nurse's knowledge of the educational needs of the testing clarity, arrangement of items, content applicability, and
patient with leukemia. It was constructed in Arabic language based on timeframe. The necessary modifications were done. The pilot subjects
pertinent literature [20]. It included a section for nurse’s demographic were not included in the main study sample.
characteristics as age, gender, nursing qualification, years of experience
both total and in oncology department, and previous attendance of Study manoeuvre
training in leukemia. The second section consist of 63 multiple-choice
After securing all necessary permissions using official channels, the
question assessing nurse’s knowledge of blood components, definition
researchers visited the setting and met with the administration to
of leukemia, its causes, types, clinical manifestations and treatment, as
explain the purpose of the study and its procedures. Then, they met
well as nurses’ role in management of the patient and in meeting
with the eligible nurses, explained to them the aim and process of the
patient needs. For scoring, each correct response was scored one and
study and invited them to participate. Those who consented to
the incorrect zero. For each area of knowledge, the scores of the items
participate were handed the self-administered questionnaire with
were summed-up and the total divided by the number of the items,
instructions in filling it. This took 20 to 30 min from each nurse. Once
giving a mean score of the part. These scores were converted into
completed, the form was collected and the nurse was instructed that
percent scores. The nurse was considered to have satisfactory
she will be observed during her routine daily work.
knowledge if the percent score was 60% or more and unsatisfactory if
less than 60%. Participant observation technique was used to avoid any observer
bias. The process of observation was done during the morning shift
The observation checklist was also designed by the researchers to
and lasted for many days for each nurse to complete all the checklists.
assess nurse’s performance of her role in meeting daily needs of the
Morning shift was suitable for the researchers because it was easy to
patient with leukemia. It was based on pertinent literature [21]. These
find the nurses on this shift. Moreover, follow-up and basic care and
needs included the following.
procedures to patients are mostly done during this shift, and there was
Personal hygiene and skin care: 12 items such as “Use warm water no interruption from visitors. Data collection was carried out over
and mild soap for skin care,” “Use only approved lotions and creams on three months from August to October 2010.
the skin.”
Prevention and control of infection: 9 items such as “Maintain Data analysis
protective isolation,” “Maintain meticulous hand washing before and Data entry and Statistical analysis were done using SPSS 20.0
after every procedure.” statistical software package. Data were presented using descriptive
statistics in the form of frequencies and percentages for qualitative
variables, and means and standard deviations for quantitative
Page 3 of 7
variables. Qualitative categorical variables were computed using chi- Functions of WBCs 9 30
square test. Whenever the expected values in or more than one of the
cells in 2 × 2 tables was less than 5, Fisher exact test was used instead. Causes natural increase of WBCs count 26 86.7
Statistical significance was set at p<0.05.
Definition of increase immature WBCs count 27 90
The nurses in the study sample were mostly (53.3%) in the age Functions of Platelets 26 86.7
group 30-<40 years (Table 1). Only 2 (6.7%) were having a bachelor
Leukemia
degree in nursing. Their total experience years ranged between two
and 29 years, with mean 12.7 years. The majority (76.7%) was working Definition 26 86.7
in oncology for more than three years. Only about one-fourth (26.7%)
had previous training in leukemia. Risk factors 25 83.3
Table 2 demonstrates a wide variation in nurses’ knowledge of blood Role of the nurse in blood transfusion 26 86.7
components and functions. While 90.0% of them had correct
knowledge of the definition of increased immature WBCs count, only Table 2: Knowledge of blood components and functions and of
20.0% knew the number of platelets, and 30.0% knew the functions of leukemia among nurses in the study sample (n=30).
WBCs. As regards nurses’ correct knowledge of leukemia; it was
generally high reaching 100.0% for primary diagnosis, side effects of As illustrated in Table 3, nurses’ knowledge of their role in the care
chemotherapy, and aim of repeated blood transfusion. Conversely, only of patient with leukemia was generally high. The areas with highest
13.3% correctly knew the purpose of chemotherapy, and 26.7% knew percentages of correct knowledge were those of general nursing care
gender susceptibility. (100.0%), nursing role in oral complications (100.0%), nursing care of
hyperthermia (96.7%), nursing care of alopecia (96.7%), definition of
Correct knowledge of Frequency Percent
anemia (96.7%), and patient and family education (96.7%). On the
blood components and functions: contrary, the lowest percentages of correct knowledge were related to
precautions to prevent infection (6.7%) and nursing care for skin
Number of WBCs 13 43.3 complications (23.3%).
Page 4 of 7
Correct knowledge of nurse role Frequency Percent while the highest was related to nursing role (83.3%). Overall, 70.0% of
the nurses had satisfactory total knowledge.
General care
Total satisfactory (60%+) knowledge Frequency Percent
Nursing care 30 100
Blood components and functions 18 60
Pain relief 27 90
Leukemia 23 76.7
Prevention of infection
Nursing role 25 83.3
Causes of increase infection susceptibility in
leukemia 27 90 Total knowledge
Nutritional requirements for patient with leukemia 28 93.3 Maintaining personal hygiene and skin integrity 21 70
Improving nutritional status of patient with leukemia 27 90 Measures for controlling bleeding tendency 10 33.3
Types of skin complications in leukemia 25 83.3 Controlling the side effects of medications:
No. % No. %
Table 3: Knowledge of nurse role in leukemia among nurses in the
study sample (n=30). Age (years)
Page 5 of 7
Page 6 of 7
age and gender susceptibility, as well as the purpose of chemotherapy. Totally, two-thirds of the nurses in the study sample demonstrated
The lack of knowledge about susceptibility is not as important for these adequate practice. Their practice was not significantly related to any of
nurses as the lack of knowledge about the purpose of chemotherapy their personal characteristics. Moreover, it had no significant relation
since this is a major part of their care, and they should have better to their total knowledge. Again, this might be due to the small sample
knowledge of it. Nonetheless, the lack of knowledge about size in our study. However, the findings are in congruence with
susceptibility, causes, and risk factors of leukemia is not directly Mohammed [36] and Saleh [37] who, in two studies at Zagazig
influencing the quality of care these nurses provide to patients who University Hospital, found no significant relation between nurse's
already have the disease. Moreover, the etiology of leukemia and many knowledge and practice. On the same line, studies in Jordan [38] and
other chronic diseases is still not well-established [28]. in Nigeria [39] demonstrated a gap between nurses’ knowledge and
practice.
The present study findings have also demonstrated generally high
nurses’ knowledge of their role in the care of patient with leukemia.
Few areas had low percentages of correct knowledge, and these were Conclusion and Recommendations
concerning the precautions to prevent infection, and nursing care for The study demonstrates deficient knowledge and inadequate
skin complications. These two areas are critical given the high practices of nurses providing care to patients with leukemia in the
susceptibility of the patients with leukemia to infection and skin study setting. This is most evident in critical areas such as infection
problems. In congruence with this, Lachance et al. [29], in a study in control, skin care, and maintaining nutrition. There is also a shortage
Canada, reported that the patients with chronic lymphocytic leukemia in training programs for these nurses. Therefore, there is urgent need
are highly susceptible to infections, which would have negative impacts to arrange continuing education programs for nurses. The study
on their morbidity and mortality. Therefore, these authors suggested findings could be used as a basis for construction of training endeavors
immunoglobulin replacement therapy for prevention and management based on identified knowledge and practice gaps to respond to their
of infections. In agreement with our finding, a recent study in South unmet needs. The main limitation of this study is its small sample size,
Africa reported a similarly low level of knowledge about infection which would hamper generalization of its results, in addition to the
control among nurses [30]. possible observed bias.
Overall, almost three-fifth of the nurses in the current study had
total satisfactory knowledge. This is not very comforting finding since Ethical Aspects and Conflict of Interest
still two-fifth have unsatisfactory knowledge, which could have a
negative impact on the quality of care they provide to their patients All necessary permissions were obtained from the hospital director
with leukemia. This is why the Leukemia and Lymphoma Society in the and nursing director of Zagazig University Hospital. Official letters
United States is deploying efforts in improving professionals’ were issued to them from the Faculty of Nursing explaining the aim of
knowledge of leukemia s and other malignant blood diseases. It offers the study to obtain permission for collection of data. The study
free professional development and education seminars to nurses and proposal was approved by the research ethics committee at the Faculty
other professionals [31]. of Nursing, Zagazig University. An oral informed consent was obtained
from nurses to participate in the study. They were assured about their
Moreover, the lack of knowledge was universal among the nurses in rights to refuse or withdraw at any time. Complete privacy total
the present study sample regardless age, qualification, experience, or confidentiality of any obtained information was ensured. The study
previous training as shown by the lack of significant associations with procedure could not have any harm on participants.
any of these variables. In agreement with this, Sarani et al. [32], in a
study in Iran, found no significant relations between nurses’
Author Contribution
knowledge and any of their personal characteristics. Moreover,
Maghawry [33] in a study at Zagazig University Hospital reported that The first author (correspondent author): contributed to the
years of experience had no significant relations with nurses’ conception of the research, the development of the tools, statistical
knowledge. Conversely, El Sayed [34] reported a significant association analysis, and commentary on the tables, wrote the discussion and
between nurses' knowledge and their years of experience. The lack of references, prepared the patient protocol and help in data collection.
significant relation in our study could be due to the small sample size, The second author contributed to the sample collection, provided the
which is a main study limitation. pre, post and follow-up test, applied the protocol on patients, and
participated in the reference collection and analysis data. The third
The present study has also investigated nurses’ practice of their role
author contributed to the translation of the tools and booklet into
in caring for patients with leukemia. The main deficient practice was
Arabic, participated in the reference collection and data collection and
related to their role in the control of infection. This is an alarming
administered the protocol.
finding given the high susceptibility of these patients to infection. This
is certainly due to their deficient knowledge in this area as the study
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