Evaluation of Nurses' Knowledge and Practices Concerning Nursing Care Guide in the Intensive Care Unit in Misan Governorate Hospitals

: Background: Intensive care nurses must possess good knowledge and high professional skills in everything related to the critical care environment such as tools and equipment for specialized technical devices and nursing care for critically ill patients whose cases require mechanical ventilation through endotracheal intubation.


INTRODUCATION
A critical care can be considered a complex specialty developed to serve the diverse health care needs of patients with actual potentially life-threatening conditions. Professional practice in a high risk critical care environment requires good specialized knowledge, efficient advanced skills, adequate clinical experience and problem-solving capabilities to assess, monitor and effectively assess, monitor and respond to the needs of seriously ill patients (1) . To meet the needs, comfort, and goals set for the patient undergoing ventilator or respiratory failure must be provide evidenced based standards to the nursing care for safe and efficient management with the mechanical ventilation patients (2) .
In intensive care units the critically ill patients with high symptomatic burdens and physiological functional impairments, So the care receive in critical care units are highly dependent on the level of knowledge and skills critical care nurse and comfort level of caring (3) .Commonly critical care nurses are also called ICU nurses. Because they treat patients with severe and unstable physiological diseases, they require more frequent nursing assessments of the patient's situation and knowledge of the use of life-saving medical technology and drugs. They apply their specialized knowledge base to care and maintain life support for critically ill patients, especially those who are verge of death (4) . Intensive care nurses are required training on variety technology and the uses its, such as equipment hemodynamic parameter, mechanical ventilation uses, and cardiac monitoring devices, intra-aortic balloon pumps, and ventricular assist systems, continuous renal replacement tools, extracorporeal membrane oxygenation turning and many other advanced life support systems (5) . The area of critical care nursing is the provision of specialized care for critically ill patients with life-threatening illnesses or critical injuries. These patients may be unstable, have complex needs and require intensive and careful nursing care. Thus, the nursing requirements in intensive care are high, including on the professional skills and expertized knowledge (6) . Intensive care is a system of care provided by a professional team of experts including physicians from various disciplines, professional nurses, pharmacists, respiratory therapists, microbiologists, physiotherapists and rehabilitation, as well as social workers, specialists, spiritual care and many other fields (7) .
There are many cases every day are admitting to hospitals, especially in critical care units such as cardiovascular and respiratory failures patients and who requirement to specialized high quality of critical care nursing, those require to adequate learning and training toward monitoring principles, application of systems, use devices technique and implement of nursing interventions (8) .When provide comprehensive, competent, and appropriate nursing care is required deep scientific knowledge to support their actions and great clinical expertise, to nursing professionals in critical care area (9) .The study aim to evaluate knowledge and practices of the nurses toward nursing care guide in the ICU, and found out the association between the nurses' knowledge, and practices with their demographic characteristics (age, achievement of educational, years of experience in nursing scope, experiences' years in the intensive care unit and training sessions).

AIM OF THE STUDY
The study aim was to evaluate knowledge and practices of the nurses regarding nursing care guide at the intensive care units in Al-Sadder teaching hospital and Al Zahrawi surgical hospital.

METHODOLOGY
To achieve aims of this study, it was utilizeda descriptive design study, with the application to evaluate the nurses' knowledge and practices concerning nursing care guide in the ICU. This study applied in critical care units at Shaheed Al-sadder teaching hospital and Al-zahrawi surgical hospital in Misan governorate. Started from the 25th of September 2018 to the 30th of October 2019.Purposivesample selecting is consisted of (60) nurses. The data collection process has been performed through the utilization of questionnaire in Arabic version. Instrument of study is adopted, and developed via researcher to evaluate nurses' knowledge and practices concerning nursing care, it contains three parts: Part I: Self-administered sheet include demographical characteristics of the nurses involved (6) variables, which included age, gender, achievement education, experiences' years in nursing field, and years of experience in the critical care units and training sessions.
Part II: questionnaire sheet which use to assessment of knowledge, it is consisted (30) questions. Each question comprised of (4) alternatives for multiple choice. The score of questions is recorded as correct (1)  Part III: questionnaire sheet is the practices checklist for nurses was composed of (65) items related to nurses' practices and divided into ten domains (Standard precautions when provide nursing care (6) items, nursing care of the respiratory tract (16) points, nursing care cardiovascular system (4) items, care of nursing with the nervous system (5) items, nursing care digestive tract (5) points, nursing care in the urinary system (5) points, nursing care for the integumentary (7) items, nursing care of the musculoskeletal system (4) items, psychosocial nursing care (6) items, and nursing documentation (7) points. According the Likers' scale, were rated these items into: always (3), sometimes (2), and never (1). Scale levels of were observed in a total of three episodes of events for each respondent evaluation of practices are rated according to three levels: (1.00 -1.66) inadequate practice, (1.67 -2.33) fair practice and (2.34 -3.00) adequate practice.
The content validity of the instrument for knowledge test and practices checklist was determined by the panel of 17 experts. Instrument reliability is determined via use of Alpha Cronbach's reliability is a high acceptance level (0.92). New line and write statistical analysis, SPSS version 20 was used through the descriptive statistical method which includes (frequencies, percentages, mean score, standard deviation), and a deductive statistical approach (Chi-Square test). The results were determined to be high significant if (P <0.01), was significant when (P <0.05) and not significant if the value (P> 0.05). The above table is revealed that majority of participants in the sample were from Al-Shaheed AL-sadder teaching hospital where included 44 (73.3%). The most of age group were 15 (25%) of nurses in the study within (36-40 years) while the majority of gender accounted 35 (58.3%) of nurses were male.

RESULTS:
Concerning to the achievement educational showed majority of the nurses 26 (43.3%) were graduated of nursing institute. In relation subject, the years of experience in nursing area 18 (30%) of nurses have service (1-5 years) in the nursing field. In regarding years of expert in the ICU, the majority for sample as they showed 23 (38.3%) have years of expert were (1-5 years). Concerning training courses concerning the work in the intensive care unit, 20 (33.3%) of nurses in research sample, have (1-3 sessions).   Table (2) displays that majority of the participants nurses' knowledge related to nursing care guide have fair level of knowledge evaluation 45(75%), and while the level of evaluation related to practices is showed that all nurses participants were have fair level 60(100%).

Nitroglycerin is used in cases of angina and in cases
of high blood pressure before or during surgery and given intravenously using the solution pump best nursing intervention:    Findings of the table -5-showed that there is no significant association between the nurses' knowledge with their demographic characteristics at (p value > 0.05), while pointed out that there is significant and highly significant relationship between nurses' practices and demographic characteristics at ( p value > 0.01), except (age) is showed that non-significant differences with their practices.

DISCUSSION:
-Part I: Discussion of the demographical characteristics for intensive care unit nurses.
When the results finding revealed that majority of participants in the sample were from Al-Shaheed AL-sadder teaching hospital where included 44 (73.3%). The most of age group were 15 (25%) of nurses in the study within (36-40 years) while the majority of gender accounted 35 (58.3%) of nurses were male. Concerning to the achievement educational, majority of the nurses 26 (43.3%) were graduate of nursing institute. Intervention to improve intensive care nurses' knowledge of sedation assessment and management, Results showed that most of the nurses (82%, n=54) owns nursing certificates were diploma (10) . Regarding the years of experience in the nursing area 18 (30%) of nurses in the study have service (1-5 years). More than one third of them in these hospitals their years of experience range between 5-10 years with the mean 5.7 and 9.9 respectively (11) . In regarding experiences' years at unit of the intensive care, the majority for sample as they showed 23(38.3%) have years of expert were (1-5 years). Concerning training courses concerning the work in the intensive care unit, 20(33.3%) of the study sample have (1-3 sessions).The majority of study (59.5%) of the respondents had less than two years of service experience and most of respondents had been less than 2 years' experience as nurse in (ICU) (12) . The vast majority of participants concerning specific years of experience in the study group had 1 -5 years (n = 32; 80 %). The participants in the control group also had 1 -5 years but in a smaller proportion (n = 27; 67.5%). Additionally, in both of study and control groups more than two third of participants reported that they had 1-3 times (n =31; 77.5%) (n =30; 75%) regarding specific training courses in ICUs (13) . Agree with study by (Hiba & suad, 2016), which collects basic sociodemographic characteristics obtained from the nurses via questionnaire sheet which contains [age of nurse, gender, level of educational, experience s' years, and years of experience in the ICU, and participation in training courses] (14) .
-Part II: Overall evaluation of knowledge and practices for the nurses toward nursing care guide in the intensive care unit.
The study displays that majority of the participants nurses knowledge about nursing care guide have fair level of knowledge evaluation 45 (75%), while the level of evaluation related to practices is showed that all nurses participants were have fair level 60 (100%). From the findings of the study, nurses had a deficient of knowledge and some unsound practices regarding enteral feeding in the critical care department (15) . Many studies had similar results related to the level of knowledge. In general, nurses' knowledge about enteral feeding in the critical care area was low and inadequate. Where the level of knowledge ranges from moderate to low, and none of the nurses had completely well knowledge (16,17) . Results of study is demonstrated that participants' knowledge for overall items and more than two-thirds of items are fair level except the items 2 (0.7 ± 0.446), 4 (0.23 ± 0.427), 14 (0.30 ± 0.462), 16 (0.25 ± 0.437), 17 (0.30 ± 0.462), 19 (0.32 ± 0.486), 22 (0.30 ± 0.462), 23 (0.28 ± 0.454), 24 (0.32 ± 0.469), 28 (0.28 ± 0.454) ) respectively, showed that in poor level of evaluation. In the analysis came out of this study was noticed that intensive care nurses had a lack of knowledge (18) . To determine quality of care for ICU patients is depending on the critical care nurses' knowledge, and the assessment of pain and as well as management skills applicable. Where, it has been showed that ICU nurses lack knowledge in pain assessment and interventions (19) . The results of this study reported that more than three quarter of critical care nurses in medical and oncology ICUs, (77.1%) and (48.6%) respectively, to have the unsatisfactory degree of knowledge. While practices showed an increase of half (51.4%) and 25.7% of nurses had poor practice (20) .
Analysis data of study reveals that participants' practices are fair level in the all domains, except domain 4. Nursing care cardiovascular system (1.57 ± 0.588) is showed that poor level. Frequencies and percentages distribution of the nurses' practices level toward body fluid balance assessment was unsatisfactory at preprogram implementation (n=60; 55 (91.7%) (21) . -Part III: Discussion association between the nurses' knowledge and practices with their demographic data (age, gender, achievement education; experiences' years of in the nursing scope; experiences years in ICU and participation in training sessions) The results showed that there is none statistical significant correlation between nurses' knowledge with their demographic characteristics at (p value > 0.05). This result is identical with the study achieved by (Sulekha & Sarala, 2017) reported that there is no association with the knowledge level of the respondents and their age groups (p=0.107), and nurses' level of education (p=0.160) (22) .This was supported by (Morsy et al, 2014) who stated that there is no significant statistical relationship between years of experience and knowledge scores. This finding was supported by (Morsy et al, 2014) which stated revealed that there are no important statistical rapport between the years of experience and overall knowledge scores (23) .
Current study is agree with study by (Hiba & Suad, 2016), which showed there are no statistical significance correlation between nurses knowledge with their sex (p = 0.647), and year of the service in ICU (P = 0.632) {14}.Low training courses and don't in participation can be impact on nurses knowledge, therefore we need more participation in courses to promote nurses' knowledge (24) . Also, finding showed that there is significant and highly statistical importance rapport with nurses' practices and demographic characteristics at (p value > 0.01), except (age) is showed that non-significant differences with their practices. With regard to age, the result showed no correlation between age, practice and degrees of knowledge. This may be because of palliative care, a novice in Egypt protocol, especially in University of Tanta (20) . Researcher reveals according the study sample that there is a statistically significance correlation between nurses gender and their practices, because most of women have more compassionate and emotional feelings than males towards the patients undergoing ventilator in ICU. This study was supported by Ayed et al., (2015) reportedly, (2018) nurses with a higher degree education such as an academic certification, they had higher mean scores of the knowledge and practices compared with graduates of nursing institutes (25) .
The current study is agree with study by AQEEL & Suad, (2019) disclosed there was no statistically significant relevance with experiences' years and total knowledge scores; however, there was an association between years of experience and total scores of practices. May be due to the fact that nurses with more than 5 years of experience do not update their information and/or may have not enough time to research and increase their knowledge, therefore some nurses provide some aspects of care without knowing (26) . Results of study are reported that years of experiment in the ICU significantly correlated to increased knowledge, attitudes and practices among the various categories of staff (15) . Training courses especially in the critical care units can improve the scientific and practical framework of the nurses whose working there, so the enhancement and the will is toward increasing the number of provided training courses inside and outside the country specifically regarding ICUs, will lead to a dream of comprehensive care that can be given (13) .

CONCLUSIONS:
1. Illustrated from this study not all intensive care unit nurses were trained adequately on the nursing care guide at the intensive care unit approved via the Health Ministry of Iraqi which was prepared by Hammam Mithaq (2017).

2.
The results of the current study are showed that knowledge and practices of nurses were moderate level.

RECOMMENDATIONS:
1. Assert to update nurses' knowledge and current skill set in critical care units in hospitals to provide nursing care through adequate and high practices by training continuously. 2. As for nurses who have less than five courses must intensify and double the number of training courses for their.