https://doi.org/10.15218/ejnm.2018.03 EJNM, Vol. 1, No. (1), May, 2018 Original Article Nurses’ Knowledge Regarding Heart Failure Education Principles in Erbil Teaching Hospital ABSTRACT INTRODUCTION Heart failure (HF) has become a major public health problems, with the preva- lence of over 23 million worldwide *1+. It is a condition in which the heart is unable to adequately pump blood throughout the body or unable to prevent blood from “backing up” into the lungs *2+. Most of HF patients are not looked after by specialists and have little knowledge of their condi- tion and its treatment *1+. Therefore, it is common reason for hospital readmissions, and subsequently, a major contributor to rising health care costs *3+. It has also been reported that Medicare spends more mon- ey on heart failure treatment than it does Background and objective: Heart Failure is a major public health problem often associated with a decreased quality of life and high mortality rate. To optimize the quality of manage- ment and support patients to care for themselves in their own home, they need to be well- educated about all aspects of the heart failure. This study aims to investigate nurses’ knowledge regarding the treatments that can be taught to heart failure patients to im- prove self-care. Methods: Cross-sectional study, 64 nurses out of 85 working at three public hospitals in Erbil City took part, the data was collected from 15th February to 15th March, 2017 through interviews using a questionnaire schedule. The data was analyzed using Statistical Package for the Social Science (SPSS) program version 20. Results: Majority of the participants were young (87.6% within the range of 21-40), male (62.5%), and graduated with a technical diploma (60.9%). More than half of them (53.1%) have between 1–5 years of nursing experience, 50% of the nurses work in the Surgical Spe- cialty Hospital - Cardiac Centre and 43.8% of them have general knowledge of Cardiac care. The majority of participants achieved a good knowledge score (70.3%). There was a significant association between level of knowledge of nurses working in the Surgical Spe- cialty Hospital - Cardiac Centre and Rizgary Teaching Hospital, while few of them are in Hawler Teaching Hospital (53.3%, 26.7% and 20% respectively P <0.002). Conclusion: The study concluded that the nurses have good knowledge score, but still need continuous knowledge and practical training to educate patients regarding heart fail- ure. High level of significance was found between the levels of knowledge and the working area. Keywords: Nurse; Knowledge; Heart failure; Education Principles. Bootan Hasan Ahmed ; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. Sideeq Sadir Ali; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: sideeq.sadir@nur.hmu.edu.krd) Vian Afan Naqshbandi; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. Ribwar Arsalan Mohammed; Department of Nursing, College of Nursing, University of Rparin, Sulaimaniya , Iraq. 15 Erbil Journal of Nursing & Midwifery Received: 2/9/2017 Accepted: 28/10/2017 Published: 5/5/2018 https://doi.org/10.15218/ejnm.2018.03 EJNM, Vol. 1, No. (1), May, 2018 Original Article on MIs and all forms of cancer combined *4+. Thirty to forty percent of HF patients are readmitted within six months of their previous hospitalization *5+. Hence, educa- tion of heart failure patients and their fam- ilies is critical. Failure of these patients to comply with physicians and other healthcare providers’ instructions is some- times a cause of heart failure exacerbation. A significant reason for patient’s failure to comply is lack of understanding as well as poor discharge planning that are associat- ed with improved patient outcomes *6+. Therefore, HF patients need to be well- educated on various aspects of HF so that they can be successful in their self- management of HF, this will enable them to manage their disease in their home envi- ronment. A number of studies have been conducted regarding guidelines and heart failure management among nurses. A study examined nurse’s knowledge of heart fail- ure education topics at a regional Midwest- ern Hospital *3+. In addition, six other stud- ies have assessed knowledge of nurse re- garding HF education principles *7, 8, 9, 10, 11, 12+. Although, such studies have pro- vided important information on nurse’s knowledge regarding HF topics that need to be taught to HF patients, however, HF patients are not homogenous in their de- mography, disease pathogenesis, treat- ment protocol, and side effects of the treatments and level of education. Nurses can play an essential role in educating HF patients on HF self-care. This education enables patients to successfully manage their HF at home and minimize hospital readmission *3+. Therefore, the aim of this study was to investigate nurses’ knowledge regarding self-care of patients with HF and to find out association between nurses' knowledge with their socio-demographic characteristics. This cross-sectional study was carried out in three public hospitals (medical word of Rizgary Teaching and Hawler Teaching Hospital also three units of the Surgical Specialty Hospital - Cardiac Centre; surgi- cal, cardiac catheterization and outpatient unit) at Erbil City/ Kurdistan Region during the period from 15th February to 15th March, 2017. Among the 85 nurses that worked at medical words of Rizgary Teach- ing Hospital, Surgical Specialty Hospital - Cardiac Centre and Hawler Teaching Hospi- tal, 64 participated. The first hospital was Rizgary Teaching Hospital, during con- ducting this study the hospital was under reconstruction and 18 nurses accept to participate in this study from 21. The se- cond hospital was Surgical Specialty Hospi- tal - Cardiac Center in which 45 nurses were asked to participate; 32 nurses here agreed to participate in this study. The third hospital was Hawler Teaching hospi- tal, in this hospital nurses who work in cor- onary care unit and medical ward were asked to be involved in this study, 18 nurs- es confirmed their participation out of 22. Inclusion criteria were; nurses who have experience in delivering direct care to HF patients, and have at least one of the fol- lowing levels of education Diploma, Bache- lor Degree, Master of Science or PhD in nursing. Nurses who did not agree to par- ticipate in this study or did not have expe- rience of caring of HF patients were ex- cluded. This study was approved by the Scientific and Ethics Committee of the Col- lege of Nursing at Hawler Medical Universi- ty. Institutional approval for conducting the study was also obtained from General Directorate of Health in Erbil and the three hospitals mentioned above. Confidentiality regarding personal issues of the persons was ensured. At first a self-assessment of the nurses’ knowledge of heart failure was METHODS 16 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2018.03 EJNM, Vol. 1, No. (1), May, 2018 Original Article patients in hospital were between 1 – 5 years. With regards to educational level, most of the study sample graduated from a nursing institute (60.9%) (Table 1). in ad- dition, half of the participants (50%) worked in the Surgical Specialty Hospital - Cardiac Centre. Finally 43.8% of nurses thought that they had good understanding of heart failure education topics. Table 2 shows the knowledge levels of the 64 participants regarding heart failure edu- cation principles. The highest correct knowledge score for the first section was for the question “Swelling of the abdo- men may indicate retention of excess fluid due to worsening heart failure” (75%), While the lowest knowledge score was for the question “Patients with heart failure should decrease activity and most forms of active exercise should be avoid- ed” (10.9%). Regarding second section the highest correct knowledge score was for the question “new onset or worsening of fatigue” (78.1%) while the lowest knowledge score was for the question “Dizziness or lightheadedness when arising that disappears within 10-15 minutes” (46.9%). Table 3 focuses on the overall knowledge of the nurses regarding heart failure; the table shows that majority of the nurses had a good knowledge and received aver- age score 70.3%, while 9.4% had poor knowledge. It also demonstrates that only 20.3% of the nurses had high knowledge levels. Table 4 illustrates relationships between the nurses overall knowledge levels and their socio-demographic data. In general, there was no significant association be- tween the level of knowledge and the so- cio-demographic characteristics of the nurses except “Place of work or hospital” which was significantly higher for those nurses working in the Surgical Specialty Hospital - Cardiac Centre and Rizgary conducted. The questionnaire consisted of 19-question with two options “true” and “false” which measured nurses’ knowledge of heart failure topics *5+. Questions were about diet (3 questions), fluid or weight monitoring (6 questions), signs and symp- toms of worsening heart failure (6 ques- tions), medications (2 questions), and exer- cise (2 questions). Socio-demographic char- acteristics of the study sample were col- lected including age, level of education and years of experience working with heart fail- ure patients. The final question was an open-ended question to explore the topics related to heart failure for which nurses would like more education. As a compara- tive measure of the knowledge of heart failure education principles, the overall true score was expected to be 87.5% or greater for nurses who regularly cared for heart failure patients—this means 17 to 18 correct answers out of 20 possible *7+. For the first the questions regarding HF knowledge nurses' responses to the ques- tions were divided into three categories ‘Poor knowledge’, ‘Good knowledge’ and ‘High knowledge’. The score of poor knowledge ranged from 1% - 33%, good knowledge ranged from 34% - 67%. High knowledge’ ranged from 68% - 100%. Data was then entered into Statistical Package for the Social Science (SPSS), version 20 and analyzed by applying two statistical approaches: Descriptive data analysis (frequency, percentage, mean) and infer- ential data analysis (Chi-square test). The majority of the study samples (43.8%) were within the both ranges 21-30 and 31-40 years old. The mean age and standard deviation (M ± SD) of the nurses were 32.47 ± 7.176. Majority of the study participants were male (62.5%). The years of experience of more than half of the nurses (53.1%) with the heart failure 17 RESULTS Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2018.03 EJNM, Vol. 1, No. (1), May, 2018 Original Article and Rizgary Teaching Hospital than Hawler Teaching Hospital (53.3%, 26.7% and 20% respectively P-value <0.002). This study assessed the level of knowledge of sixty four nurses in three public hospitals in Erbil City. Educational support by a nurse for heart failure patient in a hospital and at home significantly in- creases self-care behavior *13+. Out of 19 questionnaire items; the highest knowledge scored was for the question “If patients take their medications as di- rected and follow the suggested lifestyle” in part one and the lowest score was in the question “Patients with heart failure should decrease activity and most forms of active exercise should be avoided” also from part one. In general, the participants answered most of the questions in part one (Knowledge regarding heart failure education principles) incorrectly and an- swered part two of the questionnaire (Knowledge regarding some of the signs and symptoms significant or not significant for heart failure patient) mostly correctly. The fact that more questions were an- swered incorrectly than correctly, may be because the nurses did not do any training courses to improve their knowledge or ne- glected to obtaining the knowledge, be- cause most of them (43.8%) were happy with their level of knowledge, or it could be due to the fact that most of them (53.1%) had low levels of experience work- ing with heart failure patients in hospital. Standfuss, (2012), reported; Nurses have important position in educating patients regarding heart failure, also they are in a key position to educate patients to effec- tively manage their heart failure inde- pendently *3+. The results of this study was supported by the cross-sectional, descrip- tive study that conducted by Knopp, (2009) in a western Montana at US, which 18 Table 1: Sociodemographic characteristics DISCUSSION Erbil Journal of Nursing & Midwifery Socio-demographic characteristics N= 64 F % Age group (years) 21-30 28 (43.8) 31-40 28 (43.8) 41> 8 (12.5) M ± SD 32.47± 7.176 Gender Male 40 (62.5) Female 24 (37.5) Years of experience with heart failure 1 – 5 years 34 (53.1) 6 – 11 years 19 (29.7) 12-17 years 9 (14.1) Above 18 years 2 (3.1) Educational levels Associated nurse 5 (7.8) Technical Diploma 39 (60.9) Baccalaureate 17 (26.6) Master 3 (4.7) Place of work Rizgary Teaching Hospital 18 (28.1) Hawler Teaching Hospital 14 (21.9) Surgical Specialty Hospital - Cardiac Centre 32 (50) Good understanding of heart failure educa- tion topics Strongly Agree 2 (3.1) Agree 28 (43.8) Neither Agree or Disagree 24 (37.5) Disagree Strongly 6 (9.4) Disagree 4 (6.3) Total 64 (100) https://doi.org/10.15218/ejnm.2018.03 EJNM, Vol. 1, No. (1), May, 2018 Original Article 19 Table 2: Knowledge of nurses regarding heart failure education principles Erbil Journal of Nursing & Midwifery Knowledge of nurses False True F % F % Knowledge regarding heart failure education principles If patients feel thirsty, it is OK to remove fluid limits and allow them to drink. 34 (53.1) 30 (46.9) As long as no salt is added to foods, there are no dietary re- strictions for patients with HF. 26 (40.6) 38 (59.4) It is OK to use potassium-based salt substitutes (like “No- Salt” or “Salt Sense”) to season food. 32 (50) 32 (50) Lean deli meats are an acceptable food choice as part of the patient’s diet. 46 (71.9) 18 (28.1) Coughing and nausea/poor appetite are common symptoms of advanced heart failure. 22 (34.4) 42 (65.6) Patients with heart failure should decrease activity and most forms of active exercise should be avoided. 57 (89.1) 7 (10.9) When patients have aches and pains, aspirin and non- steroidal anti-inflammatory. 26 (40.6) 38 (59.4) If patients take their medications as directed and follow the suggested lifestyle. 13 (20.3) 51 (79.7) If a patient adds extra pillows at night to relieve shortness of breath, this does not. 48 (75) 16 (25) If a patient wakes up at night with difficulty breathing, and the breathing difficulty is relieved by getting out of bed and moving around, this does not mean that the HF. 40 (62.5) 24 (37.5) Swelling of the abdomen may indicate retention of excess fluid due to worsening HF. 16 (25) 48 (75) Once the patient’s HF symptoms are gone, there is no need for daily obtaining. 32 (50) 32 (50) If the patient gains more than 3 pounds in 48 hours without other HF symptoms, they should not be concerned. 35 (54.7) 29 (45.3) When assessing weight results, today’s weight should be compared with the patient’s weight from yesterday, not the patient’s ideal or “dry” weight. 17 (26.6) 47 (73.4) Knowledge regarding some of the sing and symptom sig- nificant or not significant for heart failure patient. BP recording of 80/56 without any HF symptoms. 27 (42.2) 37 (57.8) Weight gain of 3 pounds in 5 days without symptoms. 28 (43.8) 36 (56.3) Dizziness or lightheadedness when arising that disappears within 10-15 minutes. 30 (46.9) 34 (53.1) New onset or worsening of fatigue. 14 (21.9) 50 (78.1) New onset or worsening of leg weakness or decreased ability to exercise. 18 (28.1) 46 (71.9) https://doi.org/10.15218/ejnm.2018.03 EJNM, Vol. 1, No. (1), May, 2018 Original Article demonstrated that nurses working in a western Montana hospital may not be sufficiently knowledgeable regarding the HF education guidelines *5+. The results of this study do not correlate with the study of Fowler, (2012), where the mean score of nurses’ knowledge was 80% on the pretest with 16 correct answers out of 20 (80%) *14+. the nurses had a good knowledge 20 Erbil Journal of Nursing & Midwifery Table 3: Overall knowledge of the nurses regarding heart failure Overall Knowledge N= 64 F % Poor knowledge 6 (9.4) Good knowledge 45 (70.3) High knowledge 13 (20.3) Table 4: Association between nurses' overall knowledge and socio-demographic data Socio-demographic characteristics Overall knowledge To- tal P- value Poor Good High No. (%) No. (%) No. (%) Age group (years) 21-30 4 (66.7) 22 (48.9) 2 (15.4) 28 0.153 31-40 2 (33.3) 17 (37.8) 9 (69.2) 28 41> 0 (0) 6 (13.3) 2 (15.4) 8 Gender Male 3 (50) 28 (62.2) 9 (69.2) 40 0.722 Female 3 (50) 17 (37.8) 4 (30.8) 24 Years of expe- rience with heart failure patients in hos- pital? 1 – 5 years 5 (83.3) 22 (48.9) 7 (53.8) 34 0.626 6 – 11 years 1 (16.7) 15 (33.3) 3 (23.1) 19 12-17 years 0 (0) 6 (13.3) 3 (23.1) 9 Above 18 years 0 (0) 2 (4.4) 0 (0) 2 Educational levels Associated nurse 1 (16.7) 3 (6.7) 1 (7.7) 5 0.613 Technical Di- ploma 5 (83.3) 28 (62.2) 6 (46.2) 39 Baccalaureate 0 (0) 12 (26.7) 5 (38.5) 17 Master 0 (0) 2 (4.4) 1 (7.7) 3 Hospital Rizgary Teach- ing Hospital 2 (33.3) 12 (26.7) 4 (30.8) 18 0.002 Hawler Teach- ing Hospital 0 (0) 9 (20) 5 (38.5) 14 Surgical Spe- cialty Hospital - Cardiac Cen- tre 4 (66.7) 24 (53.3) 4 (30.8) 32 Feeling of the nurses regard- ing good under- standing of heart failure education top- ics Strongly Agree 1 (16.7) 1 (2.2) 0 (0) 2 0.136 Agree 2 (33.3) 21 (46.7) 5 (38.5) 28 Neither Agree or Disagree 1 (16.7) 17 (37.8) 6 (46.2) 24 Disagree Strongly 2 (33.3) 2 (4.4) 2 (15.4) 6 Disagree 0 (0) 4 (8.9) 0 (0) 4 Total 6 45 13 64 https://doi.org/10.15218/ejnm.2018.03 EJNM, Vol. 1, No. (1), May, 2018 Original Article of knowledge and the nurses educational level in the study groups *3+. overall level of knowledge with socio-demographic characteristics except place of work, This may be due to the low number of the nurs- es who participated in this study from Rizgary and Hawler Teaching hospital. In addition, 50% of the participants were in the Surgical Specialty Hospital - Cardiac Centre. The results correlate with the study conducted by the Standfuss (2012); where no statistically significant difference found between overall mean score. Limitations of the study The result of the study showed no sta- tistically significant relationship between the level of knowledge and majority of the variables. This may be due to limitations such as; low sample size of participants due to some of the eligible nurses refusing to participate in the study. In addition it was difficult on occasions to arrange ap- pointments with the nurses. Finally, the nurses had insufficient information due to lack of resources for receiving information. The study concluded that the nurses had a good level of knowledge, but gener- ally did not have enough information about heart failure. Most of the nurses did not interact well with the patients in giving information, and generally no significant relationship was found between the nurse’s level of knowledge and other char- acteristics, except from the place of work. There are no conflicts of interest and sources of financial support for any of the authors. in relation to the signs and symptoms of HF, but in terms of how to education the patients the knowledge level of partici- pants was low. With reference to the knowledge of the participants regarding heart failure (table 3); the majority of them had a good level of knowledge at 70.3%, 20.3% had high knowledge and only 9.4% of them had poor knowledge. This could be due to fact that the majority of the nurses were interested in receiving HF infor- mation, but don’t have opportunities to improve their knowledge. It also could be due to the level of education of majority of participants which was at the level of nurs- ing institute (60.9%). The study revealed that nurses are key providers of patient education during admission and pre- discharge, as well as through directed teaching sessions which in turn improve clinical outcomes and reduce cost of care *15-17, 7+. The result of this study is sup- port that of Garris (2014) a quasi- experimental program development with a pretest, intervention, and post-test to in- crease nurses’ knowledge regarding HF ed- ucation; pre-tests scores ranged from 60- 90 out of possible 100, with a mean score of 73.3% *18+. The results also agree with the study conducted by Willette et al. (2014) which surveyed 49 nurses who regu- larly provided care to patients with HF at a hospital in the southeastern United States; here the mean HF self-management knowledge score was 15.97 (79.85% cor- rect) *19+. Conversely, the results are be- low that of the study by Hart et al. 2010 on 122 nurses from a healthcare system locat- ed in the Southeastern USA, where the nurses were highly knowledgeable about multiple areas of HF with, 90% of the sam- ple correctly answering the item *20+.Regarding the relationship between the overall knowledge of the nurses with socio-demographic data; there was no any significant association noticed between 21 Erbil Journal of Nursing & Midwifery CONCLUSION CONFLICTS OF INTEREST https://doi.org/10.15218/ejnm.2018.03 EJNM, Vol. 1, No. (1), May, 2018 Original Article (4):371-7. *11+ Lakasing E, Francis H. Diagnosis and management of heart failure: Edin Lakasing and Heather Francis dis- cuss the causes, features, investigation and manage- ment of heart failure. Primary Health Care. 2006 Jun 1; 16(5):36-9. *12+ Nicholas M. Heart failure: pathophysiology, treat- ment and nursing care. 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