Sickle cell disease (SCD), or sickle cell anemia (SCA), is a serious, inherited group of blood disorders characterized by an abnormal form of hemoglobin molecule in red blood cells that transport oxygen throughout the body (Costa & Conran, 2016). The abnormal, sickle-shaped red blood cells can stick to blood vessel walls, causing occlusion and tissue ischemia. As a result, reduced tissue perfusion occurs, which can lead to attacks of sudden, severe pain, known as pain episodes or crises (Costa & Conran, 2016). SCD is a major public health concern and affects many individuals throughout the world. It is particularly common among individuals of African, Indian, Caribbean, Central and South American, and Mediterranean descent (Centers for Disease Control and Prevention, 2017). SCD is associated with significant morbidity and mortality. Individuals of all ages who are affected by SCD often present to hospitals with acute complications of the disease. Many acute and chronic complications affect individuals with SCD. Among the most commonly reported acute complications are acute pain crises (vasoocclusive crises), acute chest syndrome, and priapism (Lionnet et al., 2012). Chronic complications of SCD, which results from progressive damage to most body organs, include kidney dysfunction, pulmonary hypertension, heart disease, strokes, gallbladder stones, leg ulcers, retinal problems, and infections (Andong et al., 2017).
Optimal management of SCD requires a multidisciplinary approach. Nurses can have significant roles in enhancing the outcomes of individuals with SCD. The need for evidence-based nursing practices is emphasized to meet the quality of care needed for individuals with SCD (Matthie & Jenerette, 2015; Stevens, 2013). Therefore, nurses need to be familiar with evidence-based practices for management of individuals with SCD within the clinical setting (Wilson & Nelson, 2015). However, these practices have not been widely implemented in clinical practice. Therefore, the aim of this study was to determine the effectiveness of an educational program regarding SCD management on the knowledge and care practices of nurses who care for individuals presenting at the hospital with acute sickle cell crises.
Recommendations for the appropriate and timely management of individuals with SCD are included in published clinical practice guidelines (National Heart, Lung, and Blood Institute [NHLBI], 2014; National Institute for Health and Clinical Excellence [NICE], (2012). However, literature that documents the knowledge and practices of such clinical guidelines among nurses working in hospital settings is scarce. Moreover, limited efforts have been documented on improving the quality of nursing care for SCD individuals, such as children, compared with other chronic illnesses that occur in similar populations (Wang, Kavanagh, Little, Holliman, & Sprinz, 2011).
Research on the effectiveness of education programs on nurses' knowledge and practice regarding management of SCD is scarce. Gomes et al. (2017) examined the effectiveness of training program on childhood SCD for 263 community health agents and nursing technicians working in primary care in Brazil. Participation in the training program, which used active methodologies, significantly increased the percentage of correct answers on a knowledge questionnaire among primary care professionals in the intervention group.
Previous studies have shown evidence of deficiencies in SCD care that negatively affected the outcomes for individuals with SCD. Documented deficiencies included limited access to health care providers who are knowledgeable about the unique clinical needs of the population and inadequate treatment provided in hospital settings (Evensen et al., 2016). In addition, health system barriers such as difficulty in contacting health care providers, prolonged wait times, and inconvenient clinic hours were reported by parents of children with SCD (Jacob, Childress, & Nathanson, 2016).
Other barriers to effective SCD management were acquired from the perceptions that health care providers have regarding individuals with SCD. For example, several studies reported nurses had negative attitudes toward individuals with SCD. In one study, nurses perceived individuals with SCD as drug seekers and opioid addicts (Jenerette, Pierre-Louis, Matthie, & Girardeau, 2015). Another study found that nurses were hesitant to administer a high dose of analgesic to this population (Pack-Mabien, Labbe, Herbert, & Haynes, 2001). Negative attitudes toward individuals with SCD continued beyond the emergency department. Nurses working in intensive care and medical–surgical units exhibited negative attitudes with no significant differences in relation to those attitudes reported by nurses working in emergency departments (Jenerette et al., 2015). Negative attitudes exhibited by emergency providers were associated with lower adherence to national guidelines for the management of acute pain in SCD (Glassberg et al., 2013). However, efforts have been made to improve health care providers' attitudes toward individuals with SCD. Haywood, Williams-Reade, Rushton, Beach, and Geller (2015) assessed the effects of a video-based educational intervention designed to improve nurses' attitudes, among other health care providers, toward youth with SCD. An improvement in attitudes toward this population was expressed by participating pediatric health care providers.
In summary, individuals affected by SCD are a unique population. Optimal management of SCD is a real challenge for health care providers. Providing an evidence-based standardized care for this population can improve management (Wilson & Nelson, 2015). Improving the knowledge and enhancing positive attitudes of health care providers toward patients with SCD is essential for good quality of care. Some interventions that have been suggested in the literature can offer benefits to health care providers for the appropriate management of SCD. Additional research is needed to further evaluate various interventions in improving the quality of care provided to individuals with SCD. This study was undertaken to assess the effectiveness of an educational program on managing acute sickle cell crises.
A pretest–posttest control group design was used to evaluate the effectiveness of an educational program on nurses' knowledge and practices regarding the management of acute sickle cell crisis. A total of four units were included in this study. After obtaining baseline measurements (pretest), these units were randomized into two groups. Two of these units were randomly assigned to be in the intervention group, and the other two units served as the control group. This randomization was performed to prevent contamination of the control group. The nurses in the intervention group received the educational program, and they were tested (posttest) directly after program implementation. The time interval between the preand posttest was 3 weeks. The nurses in the control group also were given a posttest at the same time while continuing to provide client care as usual without any exposure to the educational program. The results between the two groups were compared.
This study was conducted in hematologic and genetic units at two tertiary-care teaching hospitals located in the northern region of Egypt. These units provided a wide range of care services to individuals with SCD. Clients admitted with diagnoses of vasoocclusive crises and other complications associated with SCD frequently are treated in these units.
The sample for this study consisted of RNs working in the hematologic and genetic units. All of the RNs employed in the units were asked to participate voluntarily, and all of the RNs had the option to decline without consequence. A total of 77 RNs were recruited and composed the final study sample.
Members of the research team held meetings with the nursing administrative personnel at participating hospitals to explain the objectives of the research, to answer any questions, and to seek professional facilitation and support during the implementation process of the research. Nurses working in the selected units were approached individually and were invited to participate. After obtaining a completed consent form for participation, data collection began. A list of names for the nurses and their work schedules at the selected units were obtained to create a coding manual. To ensure the participants remained anonymous, each nurse who agreed to participate was assigned a unique, depersonalized code.
Data were collected in two phases. In the first phase, the pretest phase, baseline data concerning clinical practices and knowledge tests were collected for both study groups. In the second phase, the posttest phase, the same participants in both groups completed the knowledge test questionnaire (which included similar items as the pretest questionnaire but in a different order), and data concerning the participants' clinical practice were gathered.
The clinical practice data collection was conducted by trained research assistants using a clinical performance checklist. Nursing records for participants who were responsible for the care of newly admitted clients with acute sickle cell crises were evaluated after the end of their regular work shift. Documented practices performed by the nurses during that shift, which pertained to the items in the checklist, were abstracted from records and recorded on the checklist. Data concerning medication administration were abstracted from the medication sheet. Nursing assessments and interventions were obtained from the nursing process sheet. By referring to the created coding manual, a research assistant who was responsible for data collection had this code written in each completed clinical performance checklist for all of the nurses who participated in the study. The second phase (posttest) of data collection concerning clinical practices began 1 week after the standardized educational program was completed. Data collection occurred simultaneously for both groups.
The knowledge data were collected using a self-administered knowledge questionnaire. Upon enrollment, nurses from the participating units were asked to complete a baseline pretest knowledge questionnaire before the unit randomization process began. The questionnaires were distributed at clinical sites. After the questionnaires were completed, a research assistant collected the completed forms from the participants. Participants in the intervention group were asked to complete the posttest during the last session of their educational program. On the same day, participants in the control group were asked to complete the posttest. Participants from the control group were approached individually at their clinical units by a research assistant who was blinded to group assignment and were given a package containing a posttest knowledge questionnaire. The research assistant scheduled multiple visits to units to collect data from all of the participants. The same content on the pretest knowledge questionnaire was administered as the posttest questionnaire for both study groups. The questionnaire took approximately 20 minutes for participants to complete. To pair participants' responses on the pretest and posttest knowledge questionnaires, participants were asked to write their unique code in a specified place at the top of the first section each time they completed the questionnaire.
Data were collected using a structured questionnaire and a clinical performance checklist. Both data collection tools were prepared by the authors for this study. The questionnaire contained two sections: the first section requested background information about nurses, and the second section included a knowledge test with multiple choice questions. The knowledge test included 20 items that measured nurses' level of knowledge about initial pain assessment, control of acute pain, reassessment of pain, and ongoing management and discharge. The scoring system for the knowledge test consisted of assigning each item on the test a score of 1 if the answer was correct and 0 if the answer was wrong. Higher scores indicated a higher level of knowledge regarding management of SCD. The total score for the knowledge test was the sum of the scores for all 20 test items.
The clinical performance checklist was designed to facilitate the collection of care practices that were performed and documented by participants. The checklist was developed by researchers and sourced from published evidence-based clinical guidelines for the management of hospitalized clients with sickle cell crises (NHLBI, 2014; NICE, 2012) and relevant nursing care and interventions (Gulanick & Myers, 2016). The clinical performance checklist was formed to address the nurse's performance of the assessment and reassessment of pain; time to initiate pain management; assessment and interventions related to oxygenation, hydration, and adverse pain medication effects; monitoring vital signs; documenting blood hemoglobin value and other clinical parameters; and use of nonpharmacological pain interventions. The scoring system for the observational checklist consisted of giving 1 point for the documented competency item and 0 for the items that were not documented. The total score for each nurse on the checklist was scored out of a possible 15 points.
To evaluate the psychometric properties and determine the feasibility of conducting the current research, a pre- and posttest pilot study was conducted. First, the developed knowledge questionnaire was tested for content validity and reliability with 21 RNs (none of whom were previously recruited for this study) working in a hematology unit in a tertiary hospital. To ensure content validity, the questionnaire was given to a panel of four experts (two hematologist-oncologist and two professional nurse researchers) to obtain their opinion about whether the questions were essential and relevant, and then to rate the questionnaire. The calculated content validity index was 0.95, and the computed average of content validity index of individual items was 0.99, which suggested evidence of good content validity (Polit, Beck, & Owen, 2007). Internal consistency reliability was estimated for question items using Kuder-Richardson coefficient of reliability for pilot data. The test items had reliability coefficients of 0.813, indicating a good estimate of the internal consistency of the knowledge test.
In addition, the clinical performance checklist was submitted to the panel of experts, who evaluated the appropriateness and relevance of each item. The checklist items achieved a high level of agreement. The calculated content validity index for items was 1.0. Two independent research assistants reviewed 13 randomly selected medical charts after they completed training on the use of the checklist. Agreement between the charting of two research assistants was assessed to ensure interrater reliability. The intraclass correlation coefficient (ICC) was calculated to estimate absolute agreement between two research assistants' rating on the checklist total score. An excellent degree of agreement between the two research assistants' rating was found (ICC = .94, 95% confidence interval [.82, .98], F [12, 12] = 18.57, p < .001).
The study was approved by the research and ethics committees of the university and the participating hospitals. The aims of the study were explained by a member of the research team. Nurses were informed that participation was voluntary. After that, written consent was obtained from nurses who agreed to participate in the current study.
The educational program was conducted in a large seminar room at the participating hospital. The program was delivered by a member of the research team who had prior nursing experience of working on a hematology and oncology unit. To accommodate participants' work schedules, the educational content was delivered in three group sessions. The same member was responsible for teaching each session. The teaching method for the educational program was didactic in nature, using PowerPoint® slides and multiple case study analyses. The nurses had the opportunity to work in small and large groups and to be involved in discussions. The educational content was delivered over 2 days. Clinical practice guidelines were introduced and explained to the RNs during these 2 days. The educational content addressed the guidelines that included recommendations on individualized assessment at admission, pain management and primary analgesia, reassessment and ongoing management, acute and chronic complications, nonpharmacological interventions, and discharge planning (NHLBI, 2014; NICE, 2012).
Data entry and statistical data analyses were performed using SPSS® version 20.0 software. Descriptive statistics were used to report demographic data. Pretest and posttest data were analyzed using analysis of covariance (ANCOVA). Correlation coefficient (r) tests were used to compare means and proportions as appropriate. McNemar's test was used to assess whether a statistically significant change in proportions had occurred on knowledge scores and practices performed by nurses prior to and following the implementation of the educational program. The level of statistical significance was set as α < .05.
A total of 77 RNs were enrolled in the study (intervention group = 37 nurses; control group = 40 nurses). The pre- and posteducational program data obtained for all of the participants were analyzed. The majority of participants were women; had completed a 3-year program nursing degree; and had not received any education or attended programs, seminars, or training courses regarding the management of individuals with SCA in the prior 24 months. Demographic data for the two study groups are shown in Table 1.
Characteristics of Study Sample (N = 77)
Effect of Implementing Clinical Guidelines on Nurses' Knowledge and Care Practices
One-way ANCOVA was used to determine whether there was a statistically significant difference between nurses in the intervention group and nurses in the control group on the mean knowledge scores after controlling for pretest knowledge scores (as a covariate). Results indicated the educational program had a significant effect on knowledge scores after controlling for participants' pretest scores (F [1, 74] = 24.69, p < .001). Similarly, one-way ANCOVA was used to compare the mean scores obtained by nurses after providing care for a newly admitted patient to a unit with a documented clinical diagnosis of sickle cell crisis during the period before and after implementing the educational program (controlling for baseline practice scores). Results indicated a significant increase in the mean scores for correct practices after the educational program was implemented (F [1, 74] = 30.04, p < .001). Table 2 reports descriptive statistics for nurses' knowledge and practices scores before and after implementing the educational program.
Descriptive Statistics for Knowledge and Practice Scores Before and After Intervention
Areas of Improvements Regarding Nurses' Knowledge and Care Practices
Participants in the intervention group had a pretest pass rate of 46.1% on the knowledge test, with scores increasing to 81.1% after implementation of the program. Areas in which participants demonstrated the highest gains in scores after implementing the educational program are presented in Table 3. The highest changes in correct nursing care practices performed by nurses in caring for persons with acute episode of sickle cells crises before and after implementing the educational program are reported in Table 4.
Highest Gains in Knowledge Scores for Nurses in the Intervention Group
Changes in Practice Performed by Nurses in the Intervention Group
Association Between Nurses' Demographics and Knowledge Scores and Care Practice
Pearson's correlation coefficients were used to analyze the relationship between nurses' age, years of nursing experience, and years of nursing experience at current hematological and genetic units and nurses' knowledge regarding management of acute sickle cell crises. The nurses' baseline knowledge score was not correlated with age or with years of nursing experience and current unit experience (p > .05). Similarly, participants' care practice score was not significantly correlated with age or with years of nursing experience (p > .05).
This study was conducted among RNs caring for individuals admitted to hospital settings with acute complications of SCD. The influence of providing an educational program on the clinical guidelines regarding the management of acute crises associated with SCD for RNs was evaluated. Results revealed that nurses' knowledge and practices regarding the management of SCD acute crises can be improved by the use of a structured educational program.
Nurses caring for individuals with SCD can play a fundamental role in the introduction of evidence-based practice within the clinical setting. The improvement in nurses' knowledge and practices after implementing an educational program highlights the need for such efforts that orient nurses about evidence-based guidelines in clinical settings. This study is congruent with what is emphasized in the literature regarding the continuing efforts needed to support nurses' knowledge to be able to perform an assessment of the needs for individuals with SCD and to intervene in an optimal manner. Ultimately, disseminating updated knowledge and applying the best practices could aid in reducing morbidity and mortality in individuals with SCD (Wilson & Nelson, 2015).
Several areas of knowledge deficits among nurses in the intervention group were improved in the current study. Areas of knowledge deficit concerning pain management and primary analgesia included dosages for commonly used analgesic drugs, the optimal time to initiate opioid therapy, recommended ways of opioids administration, and recommended time period to reassess pain after drug administration.
The nurses' correct responses significantly increased after implementing the educational program regarding opioid dosage escalation in individuals who reported undercontrolled pain level. Enhancement of nurses' knowledge regarding this matter has an important clinical implication. If nurses anticipate that an increment in opioid dose usually is required, this will help in reducing any negative perceptions of viewing individuals they care for as being drug seekers or addicted to opioids (Nelson & Hackman, 2013). During group discussions with nurses in the interventional educational program, nurses raised their concern about the frequent administration of opioid analgesics to their patients and noted they were hesitant in responding to such requests made by patients.
Despite the challenges in assessing pain in SCD populations (Adegbola et al., 2012), nurses in clinical settings should be capable of frequently assessing pain correctly. It is imperative for nurses to carefully observe both nonverbal pain cues and physiological manifestations of acute pain. Published guidelines recommend initiating analgesic therapy within 30 minutes after admission and conducting a reassessment of pain every 15 to 30 minutes after administering opioids. A substantial improvement was made by nurses both in the posttest scores and during observation after implementing the educational program. Prompt initiation of analgesic and frequent pain assessment could aid in achieving optimal pain control associated with SCD. However, individuals with SCD experienced longer delays in the administration of initial analgesic compared with other patients, despite having higher arrival pain scores and triage acuity levels (Lazio et al., 2010).
To aid in optimal pain management, nurses need a good understanding of both pharmacological and nonpharmacological therapies. In the current study, the baseline assessment of knowledge regarding pharmacological treatments used to reduce pain severity such as hydroxyurea indicated that nurses lacked knowledge in certain concepts such as the side effects and contraindications associated with this therapy. Future educational programs designed to improve nursing knowledge are encouraged to incorporate pharmacological treatments used in SCD management. It is crucial for nurses to be ready to provide safe medication practices and to effectively instruct patients about medication that will continue to be used after hospital discharge.
The use of nonpharmacological pain comfort measures and complementary approaches such as massages and other distractions are essential. Nevertheless, current findings show little emphasis by nurses regarding the use of nonpharmacological pain management. Several studies have documented that use of nonpharmacological interventions in SCD demonstrated success in alleviating pain and lead to good health (Williams & Tanabe, 2016). In addition to the lack of knowledge, nurses' personal beliefs about the effectiveness of nonpharmacological measures could explain the reason behind the lack of value and significance given to such interventions in the current study sample.
This study revealed there were no statistically significant relationships in the nurses' knowledge and care practices with their personal demographics such as nursing experience and age. Thus, the lack of knowledge and inadequate performance of care practices found before implementing the educational program could be attributed, in part, to the lack of opportunity for continuing education available for nurses to improve their knowledge and practices. Unfortunately, less than a quarter of participants in the current study received continuing educational programs in the past 2 years. Therefore, nurses caring for individuals with SCD are in need of continuing education and support (Jenerette et al., 2015). Particularly, the goals of continuing training for nurses are to enhance their knowledge, attitudes, and practice. Ultimately, nurses' ability to promote quality health care to their patients will be enhanced significantly (Jenerette et al., 2015).
This study provides an opportunity to evaluate short-term improvements that occurred in nurses' knowledge and practice as a result of providing an educational program regarding the management of sickle cell crises. One value of this study lies in its ability to link knowledge and practice among nurses who participated in this study. However, researchers were unsure whether knowledge and practice gains would be sustained for a longer period of time. Longitudinal studies would be particularly useful for providing insight on how educational programs have influenced outcomes in the future.
Implications for Nursing Education, Practice, and Research
The findings of this study have important educational implications and point to the requirement of the effective integration of education about sickle cell management, especially pain crises, in the teaching curriculum for nursing students. To accomplish this, students require a sufficient amount of teaching hours dedicated to pain assessment and management to be better prepared to provide quality patient care. Nursing curricula need to be evaluated continuously to ensure standardized care practices are updated and to be aligned with the clinical setting to ensure that graduates are equipped to face the challenges of caring for vulnerable populations such as those affected by SCD.
The results also indicated a call for continuing education and professional development opportunities for nurses working in clinical settings that admit individuals with SCD. Adopting and implementing clinical guidelines could serve as a tool to promote wellness and provide standards of care for individuals with SCD. Nurses should be engaged in implementing clinical practice guidelines as a professional responsibility. Clinical guidelines exist to provide guidance and recommendations for use by health care providers regarding standards of care and management for individuals with SCD (NHLBI, 2014; NICE, 2012). Although there may be difficulty in changing practices and a general lack of adherence to guidelines, hospital administrators must facilitate the implementation of guidelines and provide support for the implementation and evaluation process. Nurse managers need to be aware of the complexities of caring for such a vulnerable population and act to support the educational needs of their nursing staff and to ensure adequate fulfillment of such needs. Further studies are needed to confirm and expand on the current findings. Moreover, research is required to explore the educational needs of nursing staff and to evaluate the effect of various interventions that aim to improve the knowledge and practices in the treatment of individuals with SCD.
The implementation of an educational program regarding the management of individuals affected by sickle cell crises was useful in improving the knowledge and practice of nurses who participated in this study. Positive changes in the nurses' knowledge and practice scores were observed in the intervention group who received education. Knowledge and practice deficits among nurses in areas such as pain management and primary analgesia, reassessment and ongoing management, and nonpharmacological interventions of pain management were enhanced significantly after implementing an educational program. Nurses are integral in assisting and aiding with the quality of health care provided for individuals with SCD. Educational interventions to enhance knowledge developments and clinical practices need to be continued along with concomitant evaluations of its desired outcomes.
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Characteristics of Study Sample (N = 77)
|Variable||Intervention Group (n= 37)||Control Group (n = 40)|
|Age (years)||34.95||6.49||24 to 49||35.28||5.65||27 to 52|
|Total nursing experience (years)||12.76||3.83||4 to 19||13.73||4.16||7 to 20|
|Experience on hematological and genetic unit (years)||9.76||5.07||2 to 19||10.42||4.41||3 to 18|
|Estimated number of patients with acute painful crises per month||7.16||1.77||3 to 9||7.38||1.51||4 to 9|
| Associate (3 years)||29||37.7||35||45.4|
|Previous training or education regarding care for individuals with sickle cell disease in past 2 years|
Descriptive Statistics for Knowledge and Practice Scores Before and After Intervention
|Variable||Group||Before Educational Program|
|n||M||SD||Mean Difference||95% CI of Difference|
|Variable||Group||After Educational Program|
|n||M||SD||Mean Difference||95% CI of Difference|
Highest Gains in Knowledge Scores for Nurses in the Intervention Group
|Knowledge Categories||Before Educational Program||After Educational Program||Increase in Correct Response (%)||p|
|Correct Response (%)||Correct Response (%)|
|Anticipated dose escalation in case pain is not well controlled with current dose||10.8||94.6||83.8||<.001|
|Primary toxicity associated with hydroxyurea therapy||18.9||94.6||75.7||<.001|
|Recommended ways of opioids administration||16.2||86.5||70.3||<.001|
|Symptoms associated with acute chest syndrome||18.9||81.1||62.2||<.001|
|Nonpharmacological approaches that can be offered||16.2||75.7||59||<.001|
|Recommended time period to conduct reassessment of pain after administering opioids||27||83.8||56.8||<.001|
|Time of initiating analgesic therapy after admission||32.4||89.2||56.8||<.001|
|Hydroxyurea therapy in adult woman (during pregnancy)||29.7||78.4||48.7||<.001|
|Saturation level and administering oxygen||35.1||78.4||43.3||<.001|
Changes in Practice Performed by Nurses in the Intervention Group
|Practice Categories||Before Educational Program||After Educational Program||Increase in Performance of Correct Nursing Practice (%)||p|
|Performance of Correct Nursing Practice (%)||Performance of Correct Nursing Practice (%)|
|Perform gentle massage to affected areas and encourage range of motion exercises||24.3||86.5||62.2||<.001|
|Apply warm, moist compresses to affected joints and other painful areas||29.7||81.1||51.4||<.001|
|Encourage use of incentive spirometry||32.4||81.1||48.7||<.001|
|Monitor for adverse effects after each dose||27||75.7||48.7||<.001|
|Encourage ambulation and activity during period of maximum analgesia||29.7||75.6||45.9||<.001|
|Reassess pain intensity every 15 to 30 minutes until satisfactory pain relief has been achieved||27||67.6||40.6||<.001|
|Perform auscultation of breathing sounds||29.7||67.6||37.9||<.001|