Evaluation of nurses' practice concerning pulmonary rehabilitation to remove secretions from the lungs of a person infected with covid-19

Evaluation of nurses' practice concerning pulmonary rehabilitation to remove secretions from the lungs of a person infected with covid-19

Ahmed Yassin Khadyer ¹, Sabah Abbas Ahmed ² *

1. Ministry of Health, Baghdad Health Directorate, Iraq;
2. Department of fundamental nursing, College of Nursing, University of Baghdad, City of Baghdad, Iraq.

Corresponding author: Ahmed Yassin Khadyer

Email: [email protected]

ORCID

ABSTRACT

The study to estimate of nurses' practice regarding pulmonary rehabilitation to take away secretions from the lungs of a person infected with covid-19 and to conclude the association between nurses’ practice and their socio-demographic characteristics. Methodology: A descriptive study was carried out at isolation units of Al-Hussein teaching hospital started from June 1^st ,2022 to January 27^th, 2023. A non-probability (purposively) sample of 41 nurses who were working in isolation units were selected from Al-Hussein teaching hospital located in Thi-Qar, Iraq. The data were collected through the use of observational checklist, which consists of two parts (1) Demographic data form that consists of a (8) items and (2) nurses practice checklists that consists of (3) parts contain (19) procedures, by mean of direct observational technique with isolation units nurses. The validity of the checklists was determined through presenting it to (13) specialist expert and its reliability were determined through a pilot study which was carried out through the period from April 1^st, 2022 to April 28^th, 2022. The data was analyzed through the use of descriptive and inferential statistical analysis approaches.  Results: The results of the study show that the majority of the study sample are within the age group of (20-30) years, female, married, have Bachelor in nursing, working for 6-12 hours, with 1 to 5 years of experience, and 56.1% (23/41) who did not participate in training sessions related to COVID-19. Also nurses' practice were insufficient, where the evaluation shows a clear fail in most responses for 19 procedures regarding pulmonary rehabilitation for patient with COVID-19. Conclusions: The study concluded that the nurses' practice toward pulmonary rehabilitation for patients with COVID-19 is inadequate during evaluation, also there is not statistical association between the nurses' practice and socio-demographic characteristics. Recommendations: The study recommend for the conduction of health intervention programs to raise nurses' practice and skills about pulmonary rehabilitation for patients with COVID-19.

Keywords: practice, pulmonary rehabilitation,  COVID-19

Received: 03 September 2021, Accepted: 15 December 2021, Available online: 20 January 2022

INTRODUCTION

A number of mysterious pneumonia cases have been recorded in Wuhan, China, as of late December 2019. A new coronavirus was found to be the etiologic agent of this mystery pneumonia a few days later. The relevant infected diseases have been given the temporary names coronavirus disease 2019 (COVID-19) and severe acute respiratory syndrome coronavirus 2, respectively, by the World Health Organization. Currently, the COVID-19 pandemic is spreading over the world and in China (He et al., 2020).

The virus that causes COVID-19 most likely originated from an animal source but is currently circulating among humans. When an infected individual coughs or sneezes, respiratory droplets are released, which are thought to be the major way the virus spreads, primarily amongst people who are in close proximity to one another (within roughly 6 feet). Although this is not believed to be the primary method of virus transmission, it is nevertheless possible for someone to contract COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or potentially their eyes (VDI, 2020).

The Iraqi Ministry of Health has verified that COVID-19 has infected a significant number of people—about 394,566, with 9,683 fatalities in May 2020. The average age of the deceased in Iraq is 71 years, and the majority of them also had other chronic conditions like diabetes, cardiovascular disease, cancer, or cigarette use. As a result, the fact that these individuals had pre-existing medical issues was evidence that they needed support for breathing due to respiratory distress syndrome (ARDS), which was caused by pneumonia caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Mohammed & Bakey, 2021).

Clinical COVID-19 symptoms have been described, ranging from asymptomatic infection to acute respiratory failure. The main symptoms include self-reported fever, fatigue, dry cough, myalgia, and dyspnea. Some of the odd symptoms include diarrhea, hemoptysis, headache, and sputum production. Only a few patients with SARS-CoV-2 infection reported pleuritic chest pain, despite the fact that the majority of patients had pneumonia (Li et al., 2020; Chan et al., 2020; Chen et al., 2019).

People can help protect themselves from lung illness with everyday preventive activities.  Avoid close contact with individuals who are sick. Avoid touching your eyes, nose, and mouth with unwashed hands. Wash your hands often with soap and water for at least 20 seconds. Use an alcohol-based hand sanitizer that contains at least 60% alcohol if soap and water are not presented (VDI, C. 2020).

There are many procedures to prevent spread of COVID-19, the nurses are using personal protective equipment for a prolonged period while providing care to COVID-19 patients; Despite the problems caused by personal protective equipment. Hence, constant  vigilance  regarding  infection control  and  follow-up  rehabilitative  procedures  are  essential  to  improve  the  morale  and  efficacy  of  the nurses (Ahmed, S. A. (2022).

Currently, a variety of therapeutic choices are available that include antiviral medications (e.g., molnupiravir, paxlovid, remdesivir), anti-SARS-CoV-2,monoclonal antibodies (e.g., bamlanivimab/etesevimab,casirivimab/imdevim,sotrovimab, bebtelovimab), anti-inflammatory drugs (e.g., dexamethasone), immunomodulators agents (e.g., baricitinib, tocilizumab) are available under FDA issued Emergency Use Authorization( EUA) or being evaluated in the managing of COVID-19 (Cascella et al., 2022).

The clinical utility of these treatments is specific and is based on the severity of illness or certain risk factors. The clinical course of the COVID-19 illness occurs in 2 phases, an early phase when SARS-CoV-2 replication is greatest before or soon after the onset of symptoms. Antiviral drugs and antibody-based managements are likely to be more effective during this stage of viral replication. The later phase of the illness is driven by a hyperinflammatory state induced by the release of cytokines and the coagulation system's activation that causes a prothrombotic state. Anti-inflammatory drugs such as corticosteroids, immunomodulating therapies, or a combination of these therapies may help combat this hyperinflammatory state more than antiviral therapies. Below is a summary of the latest potential therapeutic options proposed, authorized, or approved for clinical use in the management of COVID-19 (Cascella et al., 2022).

 Providing respiratory rehabilitation program (RRP) in patients with severe COVID-19 ARDS involves risks for operators and organizational problems, especially in rehabilitation centers; nevertheless, its continuity is important to prevent the improvement of permanent disabilities in previously healthy subjects. Limited to the practice of only one patient, we were able to carry out a safe RRP during the COVID-19 pandemic, promoting the complete functional recovery of a COVID-19 young patient (Pancera et al., 2020).

During hospitalization, patients with COVID-19 are mainly characterized by respiratory dysfunction. Rehabilitation intervention (including positioning and respiratory management, traditional Chinese medicine, physiotherapy, and psychological support) should be provided along with routine treatment, which can diminish hospital length of stay and improvement patient status and QoL (Sun et al., 2020).

Pulmonary rehabilitation should be provided throughout the illnesses controlling process, regardless of whether the patient is hospitalized or at home. In addition, rehabilitation preparations should be individualized based on the patient's specific condition. The effective incorporation of pulmonary rehabilitation into disease managing and a patient's daily life, so that it becomes a conscious behaviour, can provide long-term benefits to both the patient and his / her family. With the deepening of the understanding of COVID-19, an increasing number of patients have recovered. Pulmonary rehabilitation for these recovered patients has become a major challenge for medical staff, the resolve of which needs multidisciplinary collaboration and joint exploration so that evidence-based, high-quality support can be provided (Nanjappan et al.,2021).

METHOD

A descriptive study was carried out in order to achieve the early stated aims. The aim of this descriptive study was to conclude nurses' practice concerning pulmonary rehabilitation to remove secretions from the lungs of a person infected with covid-19 and find out the relationship between nurses' practice and their socio-demographic characteristics. The study was conducted in isolation units of Al- Hussein teaching hospitals located in Thi-Qar, Iraq for the period from June 1^st ,  2022 to January 27^th , 2023. These units were selected because they care for patients at risk for developing COVID-19. Non- probability (purposively) sample included 41 nurses. An observational checklist was developed depending on experts opinion and an concentrated review of any relevant literature and studies to measure nurses' practice concerning pulmonary rehabilitation to remove secretions from the lungs of a person infected with covid-19. The observational checklist was accessible to nurses who consented to contribute in the study; the nurses evaluated by the observational checklist in the presence of the investigator. The final study instrument consisted of two parts.

Part I: Socio Demographic Characteristics: The socio demographic characteristic of nurses which include: Age, gender, educational level, work time, number of years of experience, nursing trainings session about COVID-19, and social status.

Part II: Observational checklists  related to nurses' practice about pulmonary rehabilitation to remove secretions from the lungs of a person infected with covid-19. The second part of the questionnaire was comprised of (19) items that are concerned with nurses practices toward pulmonary rehabilitation to remove secretions from the lungs of a person infected with covid-19 which included three section as following: Section one which includes (4) items related to evaluate of the passive techniques to remove secretions from the lungs, (4) items to evaluate of the Positive techniques to remove secretions from the lungs, and (11) items to the Evaluation of practices related to breathing strategies. These items were graded on a Liker's scale as follows: always (2), sometimes (1), and never (0). Three episodes of events were observed for each respondent to determine the scale's levels; Rating and scoring, the items were rated and score with (2) for correct done, (1) for sometime done (0) for incorrect done and not done. Therefore, the level of practice explained by the following: (Never)= 0 - 0.66, (Sometime)= 0.67 -1.33 and (Always) =1.34 – 2 with cut of point= 0.66.

Validity of the Study: The content validity of the study tool is determined through the panel of (13) experts and previous relevant literatures to inspect the clarity, suitability, and adequacy of the tool to achieve the objectives of the study.

Reliability of the Study: On five nurses, reliability testing was used as a statistical analysis method to determine the concordance between the observational checklist items using the reliability coefficient.

Data Analysis: The data of the present study is analyzed through using the Statistical Package of Social Sciences (SPSS), version (23). The researchers used descriptive and inferential data analysis to analyze the results.

Implication of the study

In an effort to address the gap in the management of corona virus disease, ensure that nurses are assessed about pulmonary rehabilitation for patient with COVID-19 and present the responsible health institutions to provide preventive and curative management of corona virus disease.

Ethical Considerations:  Ethical approval has been granted from the Scientific Research Ethical Committee at the College of the Nursing University of Baghdad before the initial conduct of the original study, also permission has been obtained from nurses at hospital in Thi-Qar city for data collection. To participate in the study, the nurses in isolation unit have been assigned a consent agreement. They have been introduced with the study objectives and they are presented with the opportunity of being aware of the study affairs. They also have the full right to withdraw from participation in the study.

RESULTS

The findings in Table (1) shows that most of the women in the present study are 20-30 years old (68.3%). Females are constituted the higher percentage (68.3%) of the study sample, and the remaining are males (31.7). Level of education among nurses presented (48.8%) have Bachelor in nursing. Duration of work time of the nurses in the hospital the present study showed that 70.7% were working for 6-12 hours. Regarding years of  experience 65.9 % of  them were working through the range of years from 1 to 5 years in the hospital. The above-mentioned table reveals that the majority of nurses in the study sample 56.1% (23/41) who did not participate in training sessions related to COVID-19. Social status showed the distribution of among nurses the finding were married (51.2%) and 48.8% of them single.

Table (2) reveals nurses' practice concerning pulmonary rehabilitation to remove secretions from the lungs of a person infected with covid-19. These results were categorized which include passive techniques to take away secretions from the lungs nurses practice; these include postural drainage, percussion and vibration. Practices concerning positive techniques to remove secretions from the lungs these include active cycle of breathing procedures and controlled breathing. Practice concerning practices related to breathing strategies concerning pursed lip breathing, segmental breathing, diaphragmatic breathing, slow and deep breathing and alternate-nostril breathing.

Table 3 shows the majority of nurses' practices were never in part1and part2, while the majority of nurses' practices were sometime in part3, totally, the majority of nurses' practices were never.

Table 4 validates that there is no statistically significant relationship between nurses' practice and their age, gender, social status, work time, level of education, years of experience, and number of training session at P-value of  more than 0.05, respectively. 

Table 1. Participants’ sociodemographic characteristics (N = 41) 

Table 2. Evaluation of nurses' practice concerning pulmonary rehabilitation to remove secretions from the lungs of a person infected with covid-19

Table 3. Association between Socio-demographic characteristics and Nurses’ practice about pulmonary rehabilitation

DISCUSSION

The result of data analysis that were shown in table 1 distribution of the study sample according to socio-demographic characteristics presented the distribution of the study sample exposed 68.3% are 20- 30 years old and they constitute the majority of 28/41. This result was consistent with a survey Joseph, (2011) conducted to ascertain knowledge, attitudes and practices of physiotherapists regarding their role in health promotion in Gauteng Province, South Africa  which found that the uppermost response rate of 45.1% (73/162) was from the age group 21-30 years. The result of  the present study indicates that the majority 68.3% (28/41) of nurses in the study sample were females, and remaining were males 31.7% (13/41) (Table 4.1). Saadeh et al, (2020), who researched "Knowledge, attitudes, and behaviors about the coronavirus disease 2019 (COVID19) among 311 nurses in Lebanon" reported that about three-quarters of them were female 79.4% (247/311). This study present that the educational level of the study sample 48.8% of the 41 nurses were from Bachelor’s in nursing and 26.8% were from a secondary school of nursing. The findings of level of education with Jasem & Al-Jubouri, (2021), who found that majority of the health care providers 39.9% (99/248) in intensive care unit for patient with COVID-19 were from Bachelor’s in nursing. The study found that the majority of nurses 70.7% (29/41) working for 6-12 hours daily in the isolation unit. Another research conducted in Australian by Newstead et al. (2017) to determine critical care nursing professionals’ attitudes towards the use of traditional “chest physiotherapy” techniques found that 76 (53%) of nurses were working full time, while 59 (42%) working part time. The researcher’s opinion is that most employees work in private clinics, so they prefer work part time. Regarding the years of experiences, most of the nurses (65.9%, 27/41) had experience ranged between 1–5 years. Also, this result agrees with a study done by Abd ElAziz., et al. (2021), who showed that most of the nurses (60%, 18/30) had experience between 1- 5 years and 20% (6/30) from 5-10 years and remaining 20% (6/30) had experience between less than 5 years. The findings of the study reveals that the majority of nurses in the study sample 56.1% (23/41) who did not participate in training sessions related to COVID-19. Study results are agreed with those results of Mohammed & Atiyah, (2022) who do not participate in any training courses in the control group (100%, 25/25). Finally, regarding demographic characteristics marital status showed the distribution of among health care providers the finding were married (51.2%, 21/41) and (48.8%, 20/41) of the single. These findings are also agreed with Mohammed & Atiyah, (2022) results revealed that (55%) were married.

Table 2  demonstrates the mean score for nurses' practice according to evaluation 19 procedure, fail or inadequate information which indicates a low level of procedure. This result supported by Mohammed & Atiyah, (2022), who showed in submitted study “effectiveness of an educational program on nurses’ practice towards physical therapy for patients with COVID-19” that the majority of nurses reflected a fair practice during pretest.

Table 4 Findings show that there is no statistical significant between nurses practice and their age, gender, social status, work time, level of education, years of experience, and number of training session interventional program at p-value > 0.05.  Resham et al.,  (2021), founded in their study “evaluation nurses' knowledge and attitudes about the prevention of the Coronavirus disease 2019 at emergency units in government hospitals in  Baghdad city / Iraq” that were a  no significant relationship between nurses' knowledge and socio- Demographic characteristics such as gender, sites of hospitals, level of education and social status except age group and experience in work where there is significant relationship at p-value < 0.05.

CONCLUSIONS

The study concluded that the nurse's practice toward pulmonary rehabilitation for  patients with COVID-19 is inadequate, also no statistical association between the nurses' practice and their socio-demographic characteristics. 

ETHICAL CONSIDERATIONS COMPLIANCE WITH ETHICAL GUIDELINES

Ethical approval has been granted from the Scientific Research Ethical Committee at the College of the Nursing University of Baghdad before the initial conduct of the original study, also permission has been obtained from nurses at hospital in Thi-Qar city for data collection. To participate in the study, the nurses in isolation unit have been assigned a consent agreement. They have been introduced with the study objectives and they are presented with the opportunity of being aware of the study affairs. They also have the full right to withdraw from participation in the study.

FUNDING
This research did not receive any grant from

funding agencies in the public, commercial, or

non-profit sectors.

AUTHOR’S CONTRIBUTIONS

Study concept, Writing, Reviewing the final

edition by all authors.

DISCLOSURE STATEMENT:

The authors report no conflict of interest.

ACKNOWLEDGEMENTS

We thank the anonymous referees for their useful suggestions.

REFERENCES

He, F., Deng, Y., & Li, W. (2020). Coronavirus disease 2019: What we know?. Journal of medical virology, 92(7), 719-725.

https://doi.org/10.1002/jmv.25766

VDI, C. (2020). Coronavirus disease 2019 (COVID-19).

Mohammed, D., & Bakey, S. (2021). Detection of Depression among Nurses Providing Care for Patients with COVID-19 at Baqubah Teaching Hospital. Iraqi National Journal of Nursing Specialties, 34(1), 86-94.

https://doi.org/10.58897/injns.v34i1.464

Li Q, Guan X, Wu P, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med. 2020. https://doi.org/10.1056/NEJMoa2001316.  [published online ahead of print January 29, 2020].

Chan JFW, Yuan S, Kok KH, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet. 2020;395(10223):514-523.

https://doi.org/10.1016/S0140-6736(20)30154-9

Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395(10223):507-513.

https://doi.org/10.1016/S0140-6736(20)30211-7

Ahmed, S. A. (2022). Evaluation of nurses' practices related to personal protective equipment Regarding Preventive Measures of Transmission of COVID-19 in Baghdad Teaching Hospital. Texas Journal of Multidisciplinary Studies, 11, 63-67.

Cascella, M., Rajnik, M., Aleem, A., Dulebohn, S. C., & Di Napoli, R. (2022). Features, evaluation, and treatment of coronavirus (COVID-19). Statpearls [internet].

Pancera, S., Galeri, S., Porta, R., Pietta, I., Bianchi, L. N. C., Carrozza, M. C., & Villafañe, J. H. (2020). Feasibility and efficacy of the pulmonary rehabilitation program in a rehabilitation center: case report of a young patient developing severe COVID-19 acute respiratory distress syndrome. Journal of cardiopulmonary rehabilitation and prevention, 40(4), 205.

https://doi.org/10.1097/HCR.0000000000000529

Sun, T., Guo, L., Tian, F., Dai, T., Xing, X., Zhao, J., & Li, Q. (2020). Rehabilitation of patients with COVID-19. Expert review of respiratory medicine, 14(12), 1249-1256.

https://doi.org/10.1080/17476348.2020.1811687

Nanjappan, D., & Jeya Amutha, J. (2021). PULMONARY REHABILITATION FOR COVID 19.

Joseph, P. M. (2011). Knowledge, attitudes and practices of physiotherapists regarding their role in health promotion in Gauteng Province, South Africa (Doctoral dissertation, University of Limpopo (Medunsa Campus)).

Saadeh, D., Sacre, H., Hallit, S., Farah, R., & Salameh, P. (2021). Knowledge, attitudes, and practices toward the coronavirus disease 2019 (COVID‐19) among nurses in Lebanon. Perspectives in psychiatric care, 57(3), 1212-1221.

https://doi.org/10.1111/ppc.12676

Jasem, S. S., & Al-Jubouri, M. B. (2021). Obsession with COVID-19 among health care providers. Turkish Journal of Physiotherapy and Rehabilitation, 32, 3.

Newstead, C. J., Seaton, J. A., & Johnston, C. L. (2017). Australian critical care nursing professionals' attitudes towards the use of traditional "chest physiotherapy" techniques. Hong Kong Physiotherapy Journal, 36, 33-48.

https://doi.org/10.1016/j.hkpj.2016.08.001

Abd ElAziz, A., Abd Elhafez, N. G. E., & Sayed, S. Y. (2021). Effect of Nursing Educational Program on Nurses′ Knowledge and Practices regarding Pandemic Covid-19 in Isolation Unit. Egyptian Journal of Health Care, 12(4), 248-63.

https://doi.org/10.21608/ejhc.2021.198442

Mohammed, Q. D., & Atiyah, H. H. (2022). Effectiveness of an Educational Program on Nurses' Knowledge towards Physical Therapy for Patients with COVID-19. Pakistan Journal of Medical & Health Sciences, 16(03), 928-928.

https://doi.org/10.53350/pjmhs22163928

Resham, A., Qassem, W., & Mohammad, W. (2021). Evaluation Nurses' Knowledge and Attitudes about the Prevention of the Coronavirus Disease 2019 at Emergency Units in Government Hospitals in Baghdad city/Iraq. Kufa Journal for Nursing Sciences, 11(2), 17-29.

https://doi.org/10.36321/kjns.vi20212.2007