Assessment Quality of Nursing Care Provided to Neonates with Respiratory Distress Syndrome at Intensive Care Unit in AL-Nasiriyah City Hospitals

Objectives: The study aims: To assess Demographic Characteristics like (age, level of nursing education and nurse's experience in the intensive care unit), To assess quality of nursing care and to detect the association between the quality of nursing care with Demographic Characteristics like (age, level of nursing education and nurses experience in the intensive care unit). Methodology: A descriptive quantitative design is carried out at Intensive Care Unit in AL-Nasiriya City Hospitals include Bent Al-Huda Teaching Hospital, Muhammad AL-Mawsawi pediatric Hospital and Al-Hububi Teaching Hospital, the study period from 19 Dec, 2016 to 16 Feb, 2017. A non-probability (Purposive) of (100) nurses at intensive care unit to provide care for neonate with respiratory distress syndrome. To achieve the objective of the study the researcher has established the constructed questionnaire, which consists of two part 1: which include sociodemographic data form that consist of 8-itemsand part 2 include quality of nursing care that consist of three domains. Reliability of this determined by using Cronbach reliability rate (0.81), also through a pilot study and the validity through a panel of (18) experts. The data were described statistically and analyzed through use of the descriptive and inferential statistical analysis procedures. Results: The findings of the present study indicate that assessment quality of nursing care in neonatal respiratory distress syndrome for nurses at intensive care unit, since their relative sufficiency (75%) were under cutoff point (1.5), There was significant relationship between quality of nursing care and demographic characteristics like (age, level of nursing education and nurses experience in the intensive care unit by P value < 0.05). Recommendations: The study recommended to providing educational program for nurses for improving quality of nursing care of neonatal respiratory distress syndrome and Providing updating booklets, pamphlets and boosters for nurses to upgrading their knowledge about neonatal respiratory distress syndrome.


Introduction
Newborn is delivered at preterm, term or full term and have no problems but some newborns may have medical problems related to factors that occur before birth such as any health problems or habits of the mother and certain birth defects are likely to lead to early delivery, the earliest premature infants are likely to have problems with transition to newborn life especially breathing problems caused by respiratory distress syndrome (1) . Neonatal respiratory distress syndrome or neonatal RDS, also known as Hyaline Membrane Disease (HMD) may occur if the lungs aren't fully developed in the preterm infant that causes a primary deficiency of surfactant and a reduced alveolar surface area available for gas exchange (2) .Surfactant is a substance produced in the lungs which lines the alveoli and prevents them from collapsing, it is not normally secreted in sufficient quantities until approximately the 29-30th week of gestation and as a result most preterm infants born before this gestation will be surfactant deficient (3) .
Respiratory distress is one of the most common reasons an infant is admitted to the neonatal intensive care unit, fifteen percent of term infants and 29% of late preterm infants admitted to the neonatal intensive care unit develop significant respiratory morbidity; this is even higher for infants born before 34 weeks' gestation it is seen almost exclusively in preterm infants but may also be associated with multifetal pregnancies, infants of diabetic mothers, cesarean section delivery, cold stress, asphyxia and a family history of respiratory distress syndrome (4) .Quality of care is probably much more complex, therefore as nurses who are involved in quality improvement or implementation of evidence-based practice, must be faced with the question of how to measure quality of care (5) .
Babies with respiratory distress syndrome have the best outcome, it is essential that they have optimal supportive care including maintenance of a normal body temperature, proper fluid management, good nutritional support and support of the circulation to maintain adequate blood pressure and tissue perfusion, temperature, fluid and nutritional management radiant warmers can be used for initial stabilization in the delivery suite and for accessibility in the neonatal intensive care unit optimal management depends on the diagnosis and the degree of prematurity, we would advocate a stepwise approach to respiratory support with frequent reassessment and a low threshold for escalation of treatment (6) .

Objectives:
To assess Demographic Characteristics like (age, level of nursing education and nurse's experience in the intensive care unit) 1. To assess quality of nursing care.

2.
To detect the association between the quality of nursing care with (age, level of nursing education and Nurses experience in the intensive care unit).

Methodology
A descriptive quantitative design is carried out at Intensive Care Unit in AL-Nasiriya City Hospitals include Bent Al-Huda Teaching Hospital, Muhammad AL-Mawsawi pediatric Hospital and Al-Habobi Teaching Hospital, from 19 Dec, 2016 to 16 Feb, 2017.
The data were described statistically and analyzed through use of the descriptive and inferential statistical analysis procedures.
Self-administrative questionnaire was constructed by the investigator for the present study through the review of available literature and related previous studies. The constructed questionnaire consisted of two parts: The Part 1 include sociodemographic data which consist of 8-items; the part 2 that include quality of nursing care which consist of three domains. These items were rated to two levels of Likert scale and scored as follows: I know (2), Don't know (1). Nurses' knowledge toward respiratory distress syndrome was calculated as two levels and scored as follows: Pass = (1.50-2.00) and Fail = (1-1.49) with cutoff point (0.05) with pass score with relative sufficiency R.S (75%).
Relevancy, and adequacy of the questionnaire were done by using (18) of a panel of experts to determine the content validity of the instrument in order to achieve the present study's objectives.
The internal consistency of the instrument was determined through a pilot study and the computation of Alpha Correlation Coefficient (Cronbach's Alpha). The result of the reliability was (r = 0.810) and such an estimation was statistically adequate which means that the questionnaire had adequate level of internal consistency and equivalence measurability.
The data were collected through the utilization of the self-administrative questionnaire; the data were collected from (100) nurses at intensive care unit to provide care for neonate with respiratory distress syndrome.
The data is analyzed through the application of descriptive and inferential statistical approaches, which were performed through the computation of the following: frequencies, percentage, and means of scores, standard deviation, relative sufficiency, alpha correlation coefficient and chi-square test.        Table ( 5) reveals that there is a (significant) association between (age factor, level of education and years of experience in the field of pediatric nursing and in the neonatal intensive care unit)and nurses' knowledge toward quality of nursing care in neonatal respiratory distress syndrome by p-value ≤ 0.05. It reveals that there is a (no significant) association between (marital status, residency factor and the nurse was participating in the training of neonatal intensive care unit and neonatal respiratory distress syndrome care) and nurses' knowledge toward quality of nursing care in neonatal respiratory distress syndrome by p-value ≤ 0.05.

Part-Ι: Discussion of the Demographic Characteristics Related to Nurses.
The results of the study had shown in the table (1) the majority of the study sample at age (21)(22)(23)(24)(25) years. And they are accounted for (61) nurses with percent (61%). This result agrees with Loutfy et al., (2014), Who find that the majority of study sample with age (20-30) (7) .
Concerning to the educational levels, the greater number in the secondary nursing school. the majority of the sample (57) nurses and they accounted for (57%) of the total sample. This result disagrees with Loutfy et al., (2014), that reveals the majority of study sample with bachelor's degree in nursing (7) .According to the subject's marital status, the majority of the sample are married for (57%) of the total sample. This result agrees with Elsayed et al., (2013), that show the majority of study sample with married nurses (8) .
Regarding to residency, results greater number of study sample were living in urban (99.0 %)nurses.
Related to years of experience in the neonatal intensive care unit, the results indicated that a highest percentage of the study sample are under 2 years and they are (50.0%) nurses. This result agrees with study done by Ahmed &Abosamra, (2015).This study shows the majority of study sample (68%)have less five years of experience (9) .
Related to years of experience in the field of pediatric nursing, the results indicated that a highest percentage of the study sample are under 2 years and they are (50.0%)nurses. This result agrees with Elsayed et al., (2013), that show highest percentage of the study sample are under 5 years for nurses (8) .
Concerning to the nurseparticipation in the training courses about of neonatal intensive care unit, around 82% of the sample have been participated in these courses. The majority of sample 51% participate in the training courses that focused on neonatal respiratory distress syndrome care. This result was in disagrees with Elsayed et al., (2013), that show participate in the training program with sample group (No) and they are (41%) nurses (8) .

Part-ΙΙ.: Discussion of Quality Nursing Care Related to Respiratory Distress Syndrome:
In regarding to the table (2) knowledge of the nurse's practice about use personal protection equipment and tools domain, the sub domains (hand washing) in the light of item (wash hands with soap and water before and after the completion of the tasks and duties) they had pass assessment, this result agrees with study done by Ekwere&Okafor, (2013) (10) . While the item (time of hand washing (40-60) second) they had fail assessment, this result agrees with study done by Ekwere&Okafor, (2013) (10) . Regarding to hand washing we can see that item responses (unnecessary to wash hands when touching surfaces and solids, necessary of wash hands before wearing gloves & does not need nurse to wash hands after removing gloves) had fail assessment. This result agrees with study done by Mahmood et al., (2015) (11) . While the subject (wash hands when touching blood, body fluids and secretions and contaminated materials). They had pass assessment, this result disagrees with study done by Mahmood et al., (2015) (11) .
In regarding to the table (2) knowledge of the nurse's practice to use personal protection equipment and tools domain, the sub domains (wear the gloves) in the light of item (necessity of wear the gloves before touching the patient) they had pass assessment, this result agrees with study done by Iliyasu et al., (2016) (12) . While the subject (we should not wear the gloves for the purpose of avoiding touching contaminated surfaces and materials & Is not advisable to wear gloves when cannula and the suction of fluids procedure) they had fail assessment, this result agrees with study done by Kołpa et al., (2015) (13) . Regarding to wear the gloves we can see that item responses (preferably wearing gloves when touching blood, body fluids and secretions) they had pass assessment, this result agrees with study done by Iliyasu et al., (2016) (12) . While the item (removal and exchange gloves after the completion of the tasks and duties before leaving nurse the baby bed) they had fail assessment, this result agrees with study done by Kołpa et al., (2015) (13) .
Also the table (2)Indicated that knowledge of the nurse's practice to use personal protection equipment and tools domain, the sub domains (Mask) in the light of item (wearing mask when begin to work) they had pass assessment, this result agrees with study done by Iliyasu et al., (2016) (12) . While the item (Unnecessary to wear the mask when approaching the child) they had fail assessment, this result agrees with study done by Egwuenu&Okanlawon, (2014) (14) .
In regarding to the table (2) knowledge of the nurse's practice to use personal protection equipment and tools domain, the sub domains (waste management) in the light of items (It should not be disposed of waste safely & Unnecessary to sort the waste into general, medical, sharp and chemical) they had fail assessment, this result agrees with study done by Enwere& Diwe (2013) (15) . While the item (Dispose of waste contaminated with blood and body fluids and secretions in their allocated places) they had pass assessment, this result agrees with study done by Mathur et al., (2011) (16) . Often patients need to quick procedures and because of the large numbers that are treated by one nurse, leading to the nurse's neglect of personal protective equipment (Researchers).
The  (7) , this result also agrees with study done by Mohammed, (2010), that show poor nurse knowledge about care of respiratory distress syndrome (17) . In this table the sub domains (Oxygen therapy) show poor nursing care and nurse knowledge, this result agrees with study done by Mahmood et al., (2015) (11) .
In this table the sub domains (CPAP therapy) show that the poor nursing care and nurse knowledge. The fact that the work on the new machine, in addition to the failure of the company equipped to train a sufficient number of nurses, as well as did not lack the Continuing Education Unit training courses or nurses (Researcher). this result agrees with study Chen et al., (2016), that show NCPAP education was only (69.2) points (18) . In this table the sub domains (Assist the doctor in give surfactant substance) show (60%) that lead to fail assessment, this result agrees with study Mikšová et al., (2014) (19) . In regarding to this table the sub domains (provide mouth care and around) show (72.5) that lead to fail assessment, this result agrees with study Afera, (2015) (20) . In regarding to this table the sub domains (Provide a child with i.v fluids to avoid dehydration and as needed) show (84.5%) that lead to pass assessment, this result agrees with study Ahmed et al., (2014), that show good nursing knowledge about intravenous therapy (21) . In regarding to this table the sub domains (Administer of medication as prescribe) show (93%) that lead to pass assessment, this result agrees with study Tembo, (2016), that show good nursing knowledge about Administer of medication (22) . In regarding to this table the sub domains (Preferably the child in supine position) show (55.5%) that lead to fail assessment, this result agrees with study Tembo, (2016) (22) . Related to the table (5), age groups, the results show a significant relationship between the age and nurses' knowledge toward quality of nursing care in neonatal respiratory distress syndrome domains. These results agree with Ahmed, (2013), who found significant relation between age and nurses' knowledge (23) . These results also agree with Ahmed et al., (2014), who found significant relation between age and nurses' knowledge (21) . These results also agree with Ahmed &Abosamra, (2015), who found highly significant relation between age and nurses' knowledge (9) . These results also agree with Aferu, (2015), who found significant relation between age and nurses' knowledge (20) . While this result disagreement with Elsayed et al., (2013), who reported that there is a non-significant relation between age and nurses' knowledge (8) . Regarding level of education, the results show that there is a significant relationship between the level of education and nurses' knowledge toward quality of nursing care in neonatal respiratory distress syndrome domains. These results agree with study done by Loutfy et al., (2014), who found highly significant relation between level of education and nurses' knowledge (7) . These results also agree with Ahmed, et al, (2014), who found significant relation between level of education and nurses' knowledge (21) . These results also agree with Aferu, (2015), who found significant relation between level of education and nurses' knowledge (20) . While this result disagreement with Elsayed et al., (2013), who reported that there is a non-significant relation between the level of education and nurses' knowledge (8) .
Concerning years of experience in the field of pediatric nursing, the results show that there is a significant relationship between years of experience in the field of pediatric nursing and nurses' knowledge toward quality of nursing care in neonatal respiratory distress syndrome domains. These results agree with Ahmed et al., (2014), who found significant relation between years of experience and nurses' knowledge (21) . These results also agree with Aferu, (2015), who found highly significant relation between years of experience and nurses' knowledge (p.value = 0.000) (20) . While these results disagreement with study done by Loutfy et al., (2014), who found a nonsignificant relation between years of experience and nurses' knowledge (7) .
Related to years of experience in the neonatal intensive care unit, the results show that there is a significant relationship between years of experience in the neonatal intensive care unit and nurses' knowledge toward quality of nursing care in neonatal respiratory distress syndrome domains. These results agree with study done by Ahmed &Abosamra, (2015), who found a highly significant relation between years of experience and nurses' knowledge (p.value = 0.000) (9) . While these results disagreement with study done by Hammod& Mohammed, (2016), who found a no significant relation between years of experience and nurses' knowledge (24) .