https://doi.org/10.15218/ejnm.2020.15 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov. 2020 Original Article Quality of Immediate Postoperative Nursing Care for Patients in Public and Private Hospitals in Erbil City, Iraq- Comparative Study ABSTRACT INTRODUCTION The postoperative time period is a critical phase that requires a highly standardized measure of care, starts where patients are admitted to the post anesthesia care unit (PACU) or a nursing unit and ends with the patient’s postoperative assessment in the physician’s office after 24 hours [1]. The immediate postoperative nursing care starts when the patient is finished follow- ing the surgery and includes a short time that remain after PACU for around 1 to 2 hours [2]. The World Health Organization (WHO) defined quality of care as a process that conveying effective delivering health care and medical services for people and networks, in light of need [3]. Nurses pro- vide the majority of immediate care for all the patients [4]. Since the 1970s, there is proof that nursing outstanding task is re- lated with the nature of patients; also nurse can be offered the best quality level in serious consideration especially in inten- sive care and subsequently critical care units [5].The main role of nurse Background and objective: The 1 to 2 hours for the first 24 hours after surgical operation is a crucial time to perform patient care. The study aimed to assess and compare quality of immediate post operation nursing care for patients undergoing surgeries in the public and private hospitals in Erbil City. Methods: A comparative study design was conducted on non-probability and purposive sample of 106 nurses (53 nurses of public hospitals and 53 nurses from private hospitals) in the surgical unit in all public and some private hospitals in Erbil city. The data was col- lected between February and July, 2019 by direct observation and using an observational questionnaire. Results: The majority of the nurses were young adults who had graduated from a nursing institute who were of middle income and lived in an urban area. The duration of experi- ence as a nurse was between 1 to 10 years. The majority of the nurses (98.1%) in the pub- lic hospitals they practiced poor nursing care practice, while most of the nurses (69.8) in the private hospitals practiced good nursing care practices. Very high significant differ- ence found between immediate post operation nursing care in public and private hospi- tals (P <0.000). Conclusion: The study concluded that; postoperative nursing care is very important to improve health services, but the quality of the nursing care in the public hospitals as a generally was very poor when compared with the private hospitals. We recommended improving their skills by implementation job description, opening training course and monitoring of the nurses as well as awareness and follow-up. Keywords: Quality of Immediate Postoperative; Nursing Care; Patient; Public Hospitals; Private Hospitals. Sideeq Sadir Ali; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: sideeq.ali@hmu.edu.krd) 126 Erbil Journal of Nursing & Midwifery Received: 28/11/2019 Accepted: 22/12/2019 Published: 30/11/2020 mailto:sideeq.ali@hmu.edu.krd https://doi.org/10.15218/ejnm.2020.15 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov. 2020 Original Article immediately after surgical operation are transferred patient from the operation room to the PACU, and doing critical care that includes maintaining an intact surgical incision, monitoring for potential vascular changes, keeping the patients tempera- ture, positioning of the patient, drains do not closed, and the vital signs are also very important [6]. The fundamental job of nursing care is centered around or depend- ent on the patients’ vital signs, torment evaluation, focal venous weight, implanta- tion rates and hourly pee yield [7], and agony evaluation and dispensing medica- tions [8]. A descriptive study about quality nursing care as perceived by patients in China were found that most of patients (83.69%) they had good perceptions about quality nursing care [9]. Another cross- sectional study was conducted at Kenyatta National Hospital showed that most mem- bers (40.5%) showed that they had a good perception of the nursing care and [10]. Also another study that conducted to ex- plore patients’ opinions of nursing care and to identify predictors of patients’ experi- ences of nursing care on 225 adult patients in medical-surgical in Jordan, The encoun- ters of nursing care all out score in this ex- amination were relatively high 74% [11]. The immediate postoperative period is a critical phase of operation, because the patient requires closely monitoring and nurses can provide cares to patients to fa- cilitate good operative outcomes and de- crease the risks of post-operative complica- tions. Poor nursing care after operation in the hospitals lead to high re-hospitalization rates, complications and in some situations due to the death. For those reasons, this study assesses the immediate post- operation nursing care in the public and private hospitals in Erbil City. This direct observation and comparative study was conducted in all public and some private hospitals in Erbil City/ Kurdi- stan Region from February to July, 2019 by using a direct observation of the nurses during immediate post operation. The data was collected from 106 nurses who were doing immediate postoperative care. Inclu- sion criteria included nurses who were worked in surgical ward during morning shifts who provided post-operative nursing care. This study excluded all the nurses who were worked in the kidney transplan- tation unit. 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 to the public hospitals, and for private hospitals, permis- sion was provided by college of nursing registration departments. The data was collected through direct observational method by using observational checklist for assessing the nurses during doing im- mediate postoperative care for the pa- tients; each nurse was assessed by obser- vation individually, the questionnaire of the study consists of two parts based on the research objectives which are; socioec- onomic data sheet (age, sex, marital sta- tus, educational level, economic status, residential area, duration of experience in nursing, duration of experience as a nurse in surgical ward, training course related to postoperative nursing care and how many hours doing training course), take those information after observed the nurse from post operation procedure. The observa- tional checklist for immediate postopera- tive nursing care which consisted of 36 ob- servational procedure items with two op- tions: achieved (doing the procedure) and not achieved (not doing the procedure), 127 Erbil Journal of Nursing & Midwifery METHODS https://doi.org/10.15218/ejnm.2020.15 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov. 2020 Original Article was considered statistically significant. Table 1 shows socioeconomic characteris- tics of 106 nurses in private and public hos- pitals; regarding age group, it was ranged between 21-55 years old, in public hospi- tals nearly half of the of participants were young adults (52.8%), while in private hos- pitals nearly all of participants were young adults (98.1%). In public hospitals, most participants (56.6%) were males, but in private most (62.3%) were females. In pub- lic hospitals, the majority of participants (90.6%) were married, but in the private ones, 50.9% were single. The majority of participants in both hospitals had graduat- ed from Institute of nursing in the public 75.5% and in the private 71.7%. About in- come, majority of the nurses in both hospi- tals were in the level of middle income (public= 86.8%, private 81.1%). Most (90.6%) nurses in the both type of hospi- tals lived in an urban area. In public hospi- tals, less than half of participants (47.2%) had 1 -10 years of experience, while in pri- vate, the majority of participants (90.6%) had 1-10 years of experience. In public hospitals, less than half of them (47.2%) had 6-10 years of experience, while nurses in the private majority of them (88.7%) had 1-5 years of experience. Finally about training course related to postoperative nursing care which shows; in public hospi- tals, most (92.5%) hadn’t completed any training course, but in private hospitals, half (56.6%) hadn’t completed any training course, and only 47.8% nurses in private hospitals had completed a course of up to five hours. Table 2 explores the quality of immediate post-operation nursing care action in public and private hospitals. All nurses in public hospitals performed poor- ly practice while, in the private hospitals, above half of the nurses (52.8%) per- formed fairly. which was divided in to three actions steps including: pre-procedure actions, intra- procedure actions, and post-procedure ac- tions. Intra-procedure actions were divided into some subscales as followed; vital signs, neurological assessment, wound care, check intake and output and medica- tion. This observational procedure scale was developed and organized by two refer- ences; first WHO Department of Essential Health Technologies; Clinical Procedures Unit (WHO/EHT/CPR) 2004 reformatted 2007, with the aim of creating strategic choices in the health systems [2, 12], sec- ond one developed by Lynn and LeBon in the 2011 that organized procedures Skill Checklists for Taylor’s Clinical Nursing Skills (A NURSING PROCESS APPROACH) [13], those references are the same procedures that used in our hospitals (public and pri- vate hospitals) for caring patients post op- eration. The age group of the nurses was categorized as: 18 - 35 Years Old (Young Adult), 36 - 55 Years Old (Middle-Aged Adults) and 56 Years Old and above (Older Adult), but the range of the participants nurses of the study between 21- 55 years old. Regarding the observational check list, 36 items of questionnaire divided into three categories ‘Poor practice’, ‘Fair prac- tice’ and ‘Good practice.’ To calculate over- all practice, the score of poor practice ranged from 0-12, Fair practice ranged from 13-24 and good practice’ ranged from 25- 6. The data was analyzed by using the Statistical Package for Social Sciences (SPSS, Version 23), by applying two statisti- cal approaches: Descriptive data analysis (frequency and percentage) and for com- parative between both types of hospitals used independent samples t- test, mean and standard deviation, mean difference, 95% Confidence Interval of the Difference. For comparing between both hospitals re- garding the immediate post operation nursing care used A P-value of ≤ 0.05 128 Erbil Journal of Nursing & Midwifery RESULTS https://doi.org/10.15218/ejnm.2020.15 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov. 2020 Original Article All nurses in public hospitals performed taking of vital signs poorly (100%), but in the private hospitals, the majority of the nurses (69.8%) good performed the prac- tice well. Regarding neurological assess- ment, the majority of the participants in public hospitals (84.9%) performed poorly, while the nurses in the private hospitals performed well (77%). Regarding wound care; in public hospitals, the majority of participants (73.6%) performed poorly, and in private hospitals, the majority of partici- pants (98.1%) performed well. Regarding checking intake and output of the patients 56.6% of nurses in the public hospitals performed poorly, and all of the nurses in the private hospitals (100%) per- formed well. Regarding dismemberment of medication in both types of hospitals, nurses performed well. Finally the last ac- tions which include post procedure ac- tions; all of the nurses in the public hospi- tals (100%) performed poorly, but in pri- vate hospitals the majority of participants (66%) performed well. 129 Erbil Journal of Nursing & Midwifery Table 1: Socioeconomic Characteristics of the Nurses Socioeconomic characteristics Type of Hospital Public n=53 Private n=53 F (%) F (%) Age group (years) 21-35 (Young Adult) 28 (52.8) 52 (98.1) 36-55 (Middle-Aged Adults) 25 (47.2) 1 (1.9) Gender Male 30 (56.6) 20 (37.7) Female 23 (43.4) 33 (62.3) Marital status Single 5 (9.4) 27 (50.9) Married 48 (90.6) 26 (49.1) Educational levels Preparatory of Nursing school graduated 11 (20.8) 0 (0) Institute of Nursing graduated 40 (75.5) 38 (71.7) College of Nursing graduated 2 (3.8) 15 (28.3) Economic status Low income 4 (7.5) 10 (18.9) Middle income 46 (86.8) 43 (81.1) High income 3 (5.7) 0 (0) Residential area Urban 48 (90.6) 48 (90.6) Sub urban 5 (9.4) 5 (9.4) Duration of experience in nursing (years) 1-10 25 (47.2) 48 (90.6) 11-20 19 (35.8) 4 (7.5) 21-30 9 (17) 1 (1.9) Duration of experience in surgical word (years) 1-5 8 (15.1) 47 (88.7) 6-10 25 (47.2) 6 (11.3) 11-15 15 (28.3) 0 (0) 16-20 5 (9.4) 0 (0) Did you do any training course re- lated to post operation nursing care Yes 4 (7.5) 23 (43.4) No 49 (92.5) 30 (56.6) (If yes) How many hours did you do training (*No.=4, 23) 1-5 0 (0) 11 (47.8) 6-10 3 (75) 6 (26.1) 11-15 1 (25) 3 (13) 16-20 0 (0) 3 (13) Total 53 (100) 53 (100) https://doi.org/10.15218/ejnm.2020.15 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov. 2020 Original Article 130 Erbil Journal of Nursing & Midwifery Table 2: Quality of immediate post operation nursing care in public and private hospital Main domain of item Type of Hospital Public Private F (%) F (%) Pre procedure actions Poor Practice 53 (100) 13 (24.5) Fair Practice 0 (0) 28 (52.8) Good Practice 0 (0) 12 (22.6) Intra procedure actions A- Vital signs Poor Practice 53 (100) 0 (0) Fair Practice 0 (0) 16 (30.2) Good Practice 0 (0) 37 (69.8) B- Neurological assessment Poor Practice 45 (84.9) 2 (3.8) Fair Practice 6 (11.3) 10 (18.9) Good Practice 2 (3.8) 41 (77.4) C- Wound care Poor Practice 39 (73.6) 1 (1.9) Fair Practice 9 (17) 0 (0) Good Practice 5 (9.4) 52 (98.1) D- Check intake and output Poor Practice 30 (56.6) 0 (0) Fair Practice 12 (22.6) 0 (0) Good Practice 11 (20.8) 53 (100) E- Medication Poor Practice 0 (0) 0 (0) Fair Practice 4 (7.5) 0 (0) Good Practice 49 (92.5) 53 (100) Post procedure actions Poor Practice 53 (100) 3 (5.7) Fair Practice 0 (0) 15 (28.3) Good Practice 0 (0) 35 (66) https://doi.org/10.15218/ejnm.2020.15 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov. 2020 Original Article standard deviation of public hospitals were 3.792 ± 2.213, while the mean and standard deviation of private hospitals were 26.23 ± 3.528. The mean difference between public and private hospitals was (-22.434). The confidence interval of the difference practice of the nurses lower was -18.147 and the upper was -12.519. The difference in quality between the two types of hospitals varied significantly (P <0.001). 131 Erbil Journal of Nursing & Midwifery Level of nursing care Type of Hospital Public Private F (%) F (%) Poor Practice 52 (98.1) 0 (0) Fair Practice 1 (1.9) 16 (30.2) Good Practice 0 (0) 37 (69.8) Total 53 (100) 53 (100) Table 3 illustrates the overall immediate post operation nursing care practice in public and private hospitals. Nearly all nurses in the public hospitals provided poor nursing care practice for patients immediately after operation. In private hospitals most of the nurses (69.8%) per- formed well. Table 4 compares quality of care between both public and private hospitals regarding immediate post oper- ation nursing care practice; the mean and Table 3: Level of immediate post operation nursing care Table 4: Comparative between public and private hospitals regarding immediate post operation nursing care practice Total Practices of the nurses Public *M ± SD Private M ± SD Mean Difference 95% Confidence Interval of the Difference P value Lower Upper < 0.001 **VHS 3.792± 2.213 26.23± 3.528 -22.434 -23.568 -21.299 *M±SD= Mean and Standard Deviation. **VHS= Very Highly Significant. https://doi.org/10.15218/ejnm.2020.15 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov. 2020 Original Article in the different physiological systems [17]. Regarding neurological assessment majori- ty of nurses in public hospital achieved poor practice while in private hospitals the majority of nurses achieved fair practice; the result was supported by the study of postoperative pain assessment in hospital- ized patients National survey and second- ary data analysis which suggests that the implementation of measuring pain in hos- pitals is still insufficient [18]. Regarding wound care parts majority of the nurses in public hospital was done poor practice, while in private hospitals the majority of nurses they do good practice, this result was supported by that study of Maurya and Mendhe in the Maharashtra, India; which was showed in their study the nurs- es in the private hospitals performed good practice for wound after operation [19]. About medication, majority of nurses in both public and private hospitals was per- formed good practice, the result was simi- lar of the cross sectional study in Tigray, Ethiopia; the quality of nursing care gener- ally in the high level during medicine ad- ministration in public and private hospitals [20]. Regarding last part, post procedure actions, majority of nurses in private they were performed good practice while in public hospitals they were do poor prac- tice, this result, partially supported by the descriptive study of Merkouris et al, in Cy- prus, which founded overall patients they were satisfied with the post operation nursing care in their hospitals [21].As a generally, all of the nurses in the public hospitals they were done poor nursing care for patients immediately after opera- tion, while mostly nurses in the private hospitals they were done good nursing care practice, the main standpoint of re- searcher behind these results was some point; majority of the nurses in the private hospitals younger than the nurses in the public hospitals, so the younger person are This study observed and compares immedi- ate post operation nursing in public and private hospitals in Erbil City. The monitor- ing and caring of the patient is the one of the main duties of the nurse [14]. When nurses neglect to provide care, there are opportunities for post-operation complica- tions, including postoperative morbidity and mortality [15]. The main fact that was founded in the table two; was about the quality of immediate post operation nurs- ing care in both hospitals as a domain; as a generally the nurses in the public hospitals in general domain they were done poor practice except in the medication domain, but nurses in the private hospitals in gen- eral domain they were done good practice except in the pre procedure actions do- main they were done fair practice, the rea- sons behind that, could be because of the policy of hospitals; in the private hospitals distributes the job description between the health staff, so the nurses in the private they were done mostly of immediate post operation care, while in the public hospi- tals most of the immediate post operation care done by the physicians because of in the public hospitals they was no any dis- tributes of the job description between the health staff. The result was unsupported by cross-sectional study that conducted in Nairobi, Kenya about Examining Surgical Patients’ Expectations of Nursing Care which was finding that there was good care present for postoperative patients [16]. The result of the study regarding intra- procedure actions in public hospitals per- formed taking of vital signs poorly, but in the private hospitals, performed the prac- tice well, the result was supported by cross sectional study that conducted by Serra et al. 2015, about nursing care in the immedi- ate postoperative period, it was observed that nursing care is not fully offered 132 Erbil Journal of Nursing & Midwifery DISCUSSION https://doi.org/10.15218/ejnm.2020.15 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov. 2020 Original Article participation of nurse in training [24]. While the result of the study disagree with the cross-sectional survey study that con- ducted by Rahman et al on 652 nurses in Kedah, Malaysia, that working in the medi- cal and surgical wards in 12 private hospi- tals, reported in their study; Nurses with higher education were not significantly as- sociated with both quality of care and pa- tient safety [25]. Another main reason could be about the style of working in the hospitals, generally the nurses in public hospital was formal employed (permanent) they do not get the sack if they neglected or don’t doing work well, but the nurses in the private hospital was temporary employed if they do well work they became continuing on work contrarily may become get the sack. Also another important thing behind this reason the nurses in the private hospital are continu- ously invigilated on them if they don’t work well also get the sack or punished, per contra that, the nurses in the public hospital very rarely invigilated. The other cause could be due to certification of the nurses. Some of the nurses in the private hospitals had graduated from nursing col- leges, while the majority public hospital nurses graduated from nursing institute, this result was supported by the Doctoral dissertation study of Wulff 2019; majority of public nurses was less actives because of graduated majority nurses from insti- tute [26]. Regarding mean difference that illustrated in this table, there were found- ed that the practice of the nurses from pri- vate hospitals larger than the practice of the nurses from public hospital, so the re- sult was explored as a minus, because of practice minus private the results became minus. Also very high significant relation- ship was founded between public and pri- vate hospitals, because the practice of post operation nursing care from private was more than from the public. Silva et al, more active than the older one. This result was agreed with the previous Cross sec- tional study that conducted by Serra et al. 2015; majority of the nurses that was par- ticipated in their study young and very ac- tive during post operation [17]. Also the result was supported by descriptive study that conducted in selected private and public hospitals at Ludhiana, Punjab; it was founded the majority of the patient satis- faction with nursing care score was signifi- cantly higher in private hospitals as com- pared to public hospitals [22]. Another rea- son could be the different point in the mar- ital status, majority of the nurses in the public hospital was married, but nearly half of percentage of the nurses in the private was single, so the married person in our society was more devoir in general sector of the life than the un married persons, so the devoir persons are less than active than the other. The result was supported by the descriptive study that conducted by the Devi and Saju among staff nurses and the nursing students in Narayana Medical Col- lege Hospital, Nellore, they were explore socioeconomic character such as educa- tional status, age, sex and year of experi- ences was significantly associated for in- creasing level of knowledge as well as source of information, association with it in the other hand [23]. So the researcher commented on that was additional fac- tored may be affected; was about training course related to postoperative nursing care which was founded in the table one; most of the nurses in the private hospital was participated training course, while very low percentage of the nurses in the public hospitals doing training course. This result was supported by the descriptive study that conducted by Qadir and Younis in the Erbil City; There was a significant relation- ship was founded between the levels of quality of nursing care with age, gender, levels of education, nurse’s experience and 133 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2020.15 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov. 2020 Original Article [Accessed: 29th Jan 2019]. [5] Padilha KG, Stafseth S, Solms D, Hoogen- doom M, Monge FJ, Gomaa OH, et al. Nurs- ing Activities Score: an updated guideline for its application in the Intensive Care Unit. REVISTA DA ESCOLA DE ENFERMAGEM DA USP· 2015; 49 (Esp): 131-7. Available from: DOI: 10.1590/S0080-623420150000700019 [Accessed: 30 th Jan 2019]. [6] Timby BK, Smith NE. Introductory medical- surgical nursing. US Philadelphia: 10th ed. Wiley-Blackwell Publishing; 2010. [7] Liddle C. Principles of monitoring postopera- tive patients. Nursing Times. 2013; 109 (22): 24-6. Available from: http// www.nursingtimes.net [Accessed: 1st Jan 2019]. [8] Dumolard P, Gök M, Le N. Nurses' responsi- bilities in postoperative pain management following total hip arthroplasty. Bachelor’s thesis. JAMK University of applied science. 2017; Available from: https:// www.theseus.fibitstreamhandle/10024/131 818/Dumolard_Pierre.PDF? sequence=1&isAllowed=y [Accessed: 3rd Jan 2019]. [9] Zhao SH, Akkadechanunt T. Patients percep- tions of quality nursing care in a Chinese Hospital. International Journal of Nursing and Midwifery. 2011; Sep 30; 3(9): 145-9. [10] Shawa E, Omondi L, Mbakaya B. Examining Surgical Patients’ Expectations of Nursing Care at Kenyatta National Hospital in Nairo- bi, Kenya. European Scientific Journal. 2017; Available from: doi: 10.19044/ esj.2017.v13n24p344 [Accessed: 3rd Jan 2019]. [11] Ahmad MM, Alasad JA. Predictors of pa- tients’ experiences of nursing care in medi- cal-surgical wards. International Journal of Nursing Practice. 2004; 10 (5): 235-41. [12] World Health Organization. Best Practice Protocols: Clinical Procedures Safety. WHO Surgical Care at the District Hospital 2003. Geneva 27, Switzerland. Available from: https://www.who.int/surgery/publications/ BestPracticeProtocolsCPSafety07.pdf [Accessed: 3rd July 2019]. [13] Lynn P. LeBon M. Skill Checklists for Taylor’s Clinical Nursing Skills, A NURSING PROCESS APPROACH. 3rd ed. London: Wiley-Blackwell Publishing; 2011. [14] Sun H, Okochili M. Patients' perceptions of the nurse patient relationship in postopera- tive care. Bachelor’s thesis. JAMK University reported in their study; nursing care should be developed in immediate post-operative period with quality and competence by nurses and all team [27]. The result was supported by a comparative study in Cy- prus that about assessment of patients' satisfaction with care provided in public and private hospitals, which show, those patients hospitalized in private hospitals seem to be more satisfied than those who were admitted to the public hospital [28]. While the quality of postoperative nursing care is important, the quality of immediate post operation nursing care in the public hospitals in Erbil city is insufficient. To im- prove quality in the public hospitals, high quality guidelines regarding post operation nursing care should be implemented. Final- ly monitoring the nurses during any proce- dure, especially post operation practice are very important, as well as should be imple- mented policy program for awareness and punishment. The author declares no any conflicts of in- terest. [1] Williams LS, Hopper PD. Understanding Med- ical-Surgical Nursing. 2nd ed. US, Philadelph- ia: F.A. Davis Company Publishing; 2003. [2] Lynn P. Taylor's clinical nursing skills: a nurs- ing process approach. 3rd ed. London: Wiley- Blackwell Publishing; 2011. [3] World Health Organization. Quality of care: a process for making strategic choices in health systems. Geneva Switzerland: WHO Library Cataloguing Publishing; 2006. Available from: http://www.health.org.uk/qquipp [Accessed: 18th Sep 2018]. [4] Renganayaki S, Sugunakumari S. Quality of Post-Operative Nursing Care among Patients Subjected to Cardiac Surgery. Journal of Nursing and Health Science (IOSR-JNHS). 2016; 5 (1): 71-3. Available from: DOI: 10.9790/1959-05137173 134 Erbil Journal of Nursing & Midwifery CONCLUSION CONFLICTS OF INTEREST REFERENCE https://doi.org/10.15218/ejnm.2020.15 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov. 2020 Original Article [22] Sharma SK, Kamra PK. Patient satisfaction with nursing Care in Public and Private Hos- pitals. Nursing and Midwifery Research Journal. 2013; 9 (3): 130-41. [23] Devi A, Saju A. Knowledge regarding post- operative care in adult, among the staff nurses and nursing students. International Journal of Applied Research. 2017; 3 (4): 674-7. [24] Qadir DO, Younis YM. Quality of nursing care for patients with acute myocardial infarction at coronary units of Erbil city hos- pitals. Zanco Journal of Medical Sciences. 2015; 19 (2): 1011-8. [25] Rahman HA, Mu’taman Jarrar MS. Nurse level of education, Quality of care and pa- tient safety in the medical and surgical wards in Malaysian private hospitals: A cross-sectional study. Global Journal of Health Science. 2015; 7 (6): 331-7. Available from: doi:10.5539/gjhs.v7n6p331 [Accessed: 2nd Mar 2019]. [26] Wulff T. Knowledge and clinical practice of nurses for adult post-operative orthopedic pain management (Doctoral dissertation, Stellenbosch: Stellenbosch University). 2012; Available from: http://www schol- ar.sun.ac.za [Accessed: 2nd Mar 2019]. [27] Silva KA, Medeiros SM, Paulino TS, da Costa Pereira FC, da Rocha KD, de Sousa Rosso IC, et al. Nurses’ Role in Post-Operative Imme- diately Myocardial Revascularization in In- tensive Care Unit. International Archives of Medicine. 2016; 9 (199): 1-7. Available from: doi: 10.3823/2070 [Accessed: 2nd Mar 2019]. [28] Charalambous M, Sisou G, Talias MA. As- sessment of Patients' Satisfaction with Care Provided in Public and Private Hospitals of the Republic of Cyprus: A Comparative Study. International Journal of Caring Sci- ences. 2018; 11(1):125-35. of applied science. 2018; Available from: https://www.theseus.fi/bitstream/ handle/10024/141453/THESIS%20Okochili% 20Sun%20Bachelors%20Final%20BN..pdf? sequence=1&isAllowed=y. [Accessed: 4th Jul 2018]. [15] Jammer Ib. Perioperative interventions and postoperative outcomes (Doctoral disserta- tion). University of Bergen. University of Ber- gen, Norway. 2015; Available from: https:// pdfs.semanticscholar.org/c399/ beb4033a7afc0f4ddebad45f1676584b10ac.p df [Accessed: 3rd Feb 2019]. [16] Shawa E. Patients' perceptions regarding nursing care in the general surgical wards at kenyatta national hospital (Doctoral disserta- tion). University of Nairobi, School of Nursing Sciences. Kenyatta. 2012; Available from:https://www.nursingrepository.org/ bitstream/handle/10755/621210/ Shawa_Thesis.pdf;jsessionid=A3E9E5369F69 986A9BA776C716C974F0?sequence=1 [Accessed: 30 th Jan 2019]. [17] Serra MAAO, Filho FFS, Albuquerque AO, Santos CAA, Carvalho Junior FA, Silva RA. Nursing Care in the Immediate Postoperative Period: A Cross-sectional Study. Online Bra- zilian Journal of Nursing. 2015; 14 (2): 161-7. Available from: http:// www.objnursing.uff.br/index.php/nursing/ article/view/5082 [Accessed: 30 th Jan 2019]. [18] Hoogervorst-Schilp J, Van Boekel RL, De Blok C, Steegers MA, Spreeuwenberg P, Wagner C. Postoperative pain assessment in hospital- ised patients: National survey and secondary data analysis. International Journal of Nurs- ing Studies. 2016; Nov 1; 63: 124-31. [19] Maurya A, Mendhe S. Prevention of Post- Operative Wound Infection in Accordance with Evidence Based Practice. International Journal of Science and Research (IJSR). 2014; 3 (7): 1173-7. [20] Gerensea H, Solomon K, Birhane M, Medhin BG, Mariam TH. Quality of nursing care among in-patient of medical-surgical ward in Axum St. Marry Hospital, Tigray, Ethiopia. Enzyme Engineering. 2015; 4 (2): Available from:doi:10.4172/23296674.1000132 [Accessed: 2nd Mar 2019]. [21] Merkouris A, Andreadou A, Athini E, Hatzim- balasi M, Rovithis M, Papastavrou E. Assess- ment of patient satisfaction in public hospi- tals in Cyprus: a descriptive study. Health Science Journal. 2013; 7 (1). 27-40. 135 Erbil Journal of Nursing & Midwifery