https://doi.org/10.15218/ejnm.2024.02 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article Quality of Nursing Care for Neonates with Respiratory Distress Syndrome at Neonatal Intensive Care Unit in Teaching Hospitals in Erbil City ABSTRACT Background and Objective: Quality of nursing care has an important role in providing the highest care to neonates in the neonatal intensive care unit. Improvement in the quality of nursing care is a main goal of the nurses. The study aimed to assess the quality of nursing care for neonates with Respiratory Distress Syndrome. Methods: A descriptive cross-sectional study was conducted on 50 nurses at neonatal intensive care units in teaching hospitals (Rapareen Teaching Hospital for Children and Maternity Teaching Hospital) in Erbil city. A convenience sampling technique was used to collect the data. Two tools were used to collect the data which was developed by the researcher: the first tool was a self-administered questionnaire which contained two parts (socio- demographic characteristics, and questions related to neonatal respiratory distress syn- drome), and the second tool was an observational checklist that was used to assess the quality of nursing care for NRDS. The Statistical Package for Social Science was used to analyze the data (version 23) presenting descriptive and inferential statistics, including the chi-square test, Fisher exact test, frequency, and percentage. Results: More than half (54%) of the nurses were within the age group of 25-34 years. 62% of the nurses graduated from the college of nursing, 58% of the nurses were fe- male, and the majority (88%) of the nurses were married. The highest percentage (64%) of the nurses had a good level of knowledge, while the highest percentage (74%) of the nurses had a fair level of quality nursing care. A highly significant association was found between the quality of nursing care with educational level and the duration of the train- ing course. Also, there was a weak positive correlation between the level of nurses’ knowledge and the quality of nursing. Conclusion: Based on the study findings of the present study, it was concluded that the highest percentage of the nurses had a good level of knowledge, and the high percent- age of the nurses had a fair level of quality nursing care. Keywords: Quality of Nursing Care; Neonates; NICU; NRDS. Jihad Rasool Mamo; Department of Nursing, College of Nursing, Hawler Medical University, Kurdistan Region, Iraq. (Correspondence: jihadsenaway@gmail.com ) Norhan Zaki Shaker; Department of Nursing, College of Nursing, Hawler Medical University and Tishk International University, Kurdistan Region, Iraq. 10 Received: 31/08/2022 Accepted: 29/10/2022 Published: 30/05/2024 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:jihadsenaway@gmail.com?subject=jihadsenaway@gmail.com%20%20%20%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article Neonatal Respiratory Distress Syndrome (NRDS) is a potentially fatal condition caused by underdeveloped lungs and small alveoli in preterm infants that results from a surfactant deficiency and a decreased alveolar surface area available for gas ex- change [1]. Respiratory distress syndrome affects neonates born before 34 weeks of gestational age, and the most common causes of mortality rate among neonates in the first hours after birth are RDS, prema- turity and low birth weight [2]. Respiratory distress syndrome can injure a preterm in- fant's lungs, which increases their chance of developing bronchopulmonary dysplasia [14].In the neonatal intensive care unit, nurses play an important role in the care of neonates with RDS. Also with technical skills, the care of the neonate with RDS re- quires a high degree of interpersonal skills, and nursing services are the basis of the healthcare system [10].Within a few minutes after delivery, the symptoms of respiratory distress syndrome appear like the blush of the skin (cyanosis), grunting, nasal flaring, deep respiration, use of the chest muscles, dyspnea, and apnea. At that time, the preterm neonates need emergen- cy treatment in neonatal resuscitation healthcare [3].Neonatal respiratory distress syndrome affects about 50% of newborns which born between 26 and 28 weeks of pregnancy, although fewer than 30% of preterm newborns are born between 30- 31 weeks of pregnancy [3]. Respiratory dis- tress syndrome is the main cause of admis- sion of neonates to the Neonatal Intensive Care Unit (NICU), the incidence rate of NRDS is approximately 7.8% among neo- nates. Also, respiratory distress syndrome was the main leading cause of mortality among 50% of premature neonates[4]. In Iraq, about 42% of infants die within the 28th day of life [5]. The incidence of NRDS decreases as the gestational age increases [6].Nurses have a critical role in decreasing the mortality rate among neonates with RDS, through physical examination, assessing the respiratory rate, observing for grunting, suctioning, using CPAP, using ventilator machines, and assessing the severity of RDS. Respiratory distress syndrome is more common in newborns born before 34 weeks of gestation. A family history of respiratory distress syndrome, neonates born by cesarean section, neonates with diabetic mothers, cold stress, hypoxia, and premature birth are the main attributed causes of NRDS [7]. There were studies carried out in non- developed countries, such as Egypt, Turkey, and Saudi Arabia, that discovered that nurses had weak knowledge and practice, and were responsible for providing care for premature neonates with RDS [8,9].The study aims to assess the quality of nursing care in NICUs at Rapareen Teaching Hospital for Children (RTHC) and Maternity Teaching Hospital (MTH), furthermore, until the quality of nursing care given to neonates with RDS is evaluated, nurses do not know how well they are doing. Good nurses’ knowledge and practice reduce their mortality and improve their outcomes [3].Previous studies regarding care for neonates with RDS had ignored important practices and procedures like suctioning, oxygen therapy, control of infection, and using CPAP machines. Neonatal respiratory distress syndrome is a significant factor in newborn mortality around the world [13]. Invasive respiratory support methods like nasal continuous positive airway pressure (CPAP) or non-invasive intermittent positive airway pressure (nCPAP) are used to treat NRDS. Other methods including mechanical ventilation, oxygen therapy, and surfactant therapy are used to treat NRDS. 11 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. INTRODUCTION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article based on the Likert scale as the follows the correct answer was rated (2), and the in- correct answer was rated (1). The level of nurses’ knowledge was scored by calcu- lating the total score of 24 items related to nurses’ knowledge as follows: low scores (24-32) represent a poor level, an average score (33–40) represent a fair level of knowledge, and high scores (41-48) repre- sent a good level of the nurses’ knowledge. The second tool was an observational checklist; it was developed based on the usual nursing care that nurses should offer in the NICU. This part consists of 63 items, which were divided into 14 domains as fol- lows: assessment ( 6 items), oxygen thera- py administration (6 items), suctioning (7 items), pulse oximetry (5 items), intrave- nous administration (6 items), cannulation (10 items), infection control (7 items), chest physiotherapy (1 item), incubator care (5 items), maintaining thermoregula- tion (2 items), psychological support (1 item), nasogastric tube insertion (8 items), NG tube feeding (6 items), and documen- tation (1 item). Regarding rating and scor- ing the quality of nursing care based on the Likert scale. It was scored as the fol- lows the completely done was given the score (3), the incompletely done was given the score (2), and the not done was given the score (1). The calculation of overall items regarding the quality of nursing care was categorized into three levels: low scores (63-104) represent a poor level of quality of nursing care, an average score (105–146) represents a fair level of quality of nursing care, and scores (147-189) rep- resents a good level of quality of nursing care. The total score of each domain relat- ed to nurses’ knowledge was calculated by the mean of the score and classified into three levels as follows: a low mean score (1-1.33) represents a poor level, an aver- age mean score (1.34-1.66) represents a fair level, and high mean score (1.67-2) A descriptive cross-sectional study was conducted on 50 nurses, 20 nurses from the NICU in RTHC, 11 nurses from the Pedi- atric Intensive Care Unit (PICU) in RTHC, and 19 nurses from the NICU in MTH in Erbil city/ Kurdistan Region, from 1st No- vember 2021 to 1st November 2022. A non -probability/convenience sampling tech- nique was used to collect the data. The Scientific and Ethics Committee of the Col- lege of Nursing at Hawler Medical Universi- ty gave its approval to the study (code 113) on 7/10/2021 before starting the research. The formal consent form was obtained from the General Directorate of Health in Erbil, Rapareen Teaching Hospital for Chil- dren and Maternity Teaching Hospital to conduct the study. The result of Cronbach's alpha was 0.92 for the first group of nurses, and 0.87 for the second group of nurses which was statistically ade- quate. These results reflected the reliabil- ity of the tools. A relevant questionnaire and observational checklist were devel- oped and designed based on a relevant literature review. Two tools were used for data collection: The first tool was a self- administered questionnaire, which consist- ed of two parts. The first part was com- posed of socio-demographic and profes- sional data of the nurses, including age, gender, place of work, educational level, attending training courses, and marital sta- tus. The second part consisted of 24 ques- tions related to nurses’ knowledge regard- ing NRDS. It was divided into eight do- mains as follows: definition (1 question), cause (1 question), risk factors (3 ques- tions), signs and symptoms (3 questions), complications (2 questions), surfactant(3), prevention(2 questions), and nurses’ knowledge regarding nursing care(9 ques- tions). Regarding rating and scoring of the scales, the nurses’ knowledge was scored 12 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. METHODS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article represents a good level. The total score of each domain related to the quality of nurs- ing care was calculated by the mean of the score and classified into three levels as fol- lows: A low mean score (1-1.66) represents a poor level, an average mean score (1.67- 2.33) represents a fair level, and a mean score (2.34-3) represents a good level. Nurses who agreed to participate in the study and who worked in NICUs for at least six months were required inclusion criteria. Volunteer nurses who worked in the NICU were among the study's exclusion criteria and were also nurses with less than six months of experience. The data were ana- lyzed using IBM's Statistical Package for Social Sciences (SPSS) version 23. Initially, to summarize numerical data, the mean was computed, and proportions were com- puted for categorical variables. To find out the association between the level of nurs- es’ knowledge, and practice with socio- demographic characteristics, the chi- square test was used. In cases, where 20% or more of the cells had less than five, Fish- er exact tests were used, and Spearman’s rank correlation coefficient was used to find out the direction and correlation be- tween the level of nurses’ knowledge and the quality of nursing care. Table 1 shows that more than half (54%) of the nurses were within the age group of 25 -34 years the mean and standard deviation for the age range were 37.4 ± 8.3. The highest percentage (62%) of the nurses graduated from the college of nursing, while more than half (58%) of the nurses were female, and the majority (88%) of the nurses were married. Also, table 1 shows that a high percentage (58%) of the nurses had the experience of 1-10 years in nurs- ing, less than half (44%) of the nurses par- ticipated in training courses regarding care for neonates, and more than half (59.1%) of the nurses participated in the training courses for more than 1 week. 13 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. RESULT Table 1: Socio-demographic characteris- tics of the nurses Items (n*= 50) Variables No.** (%)*** Places of work NICU- RTHC NICU-MTH PICU-RTHC 20 19 11 (40) (38) (22) Age group ( years) 25-34 yrs. 27 (54) 35-44 yrs. 11 (22) 45-54 yrs. 10 (20) ≥55 2 (4) Educational Level Nursing School Gradu- ate Preparatory Nursing School Nursing Institute grad- uate Nursing College Grad- uate 0 6 13 31 (0) (12) (26) (62) Gender Male Female 21 29 (42) (58) Marital Sta- tus Single Married 6 44 (12) (88) Are you satisfied with your Income Yes No 26 24 (52) (48) Years of experience in nursing 1-10 yrs. 11-20 yrs. 21-30 yrs. ≥31 yrs. 29 12 5 4 (58) (24) (10) (8) Years of Experience in NICU 1-5 yrs. 6-10 yrs. 11-15 yrs. ≥16 yrs. 22 19 5 4 (44) (38) (10) (8) Training Course Yes No 22 28 (44) (56) If yes: Dura- tion of Course < 1week >1week 9 13 (40) (59) Total 50 (100) • = Number of the study samples • **= Frequency • *** = Percentage https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article 14 mean score (1.82), while less than three- quarters (70%)of the nurses had a good level of knowledge regarding the compli- cations of NRDS, and there was a high total mean (1.83).Less than half (42%) of the nurses had a fair level of knowledge regarding surfactants; there was an aver- age total mean (1.55). Also, less than (48%) of the nurses had a fair level of knowledge regarding the prevention of NRDS, there was an average total mean (1.64). Regarding nursing care knowledge in the study a high percentage (64%) of the nurses had a fair level of knowledge, there was an average total mean (1.53). was a low total mean score (1.52). As re- gards infection control, half (50%) of the nurses had a fair level of quality nursing care, and there was an average total mean of scores (1.92)., More than half (54%) of the nurses had a fair level of quality of nursing care regarding intrave- nous administration, and there was an average total mean of scores in this do- main (2.12).Regarding cannulation, around half (52%) of the nurses had a fair level of quality nursing care, there was an average total mean of scores (2.23). Al- so, concerning NG feeding, a high per- centage (42%) of the nurses had a fair Table 2 shows the nurses’ knowledge re- garding NRDS. It shows that a high percent- age (94%) of the nurses had a good level of knowledge regarding the definition of NRDS, and there was a high total mean (1.94). Also regarding the causes, more than one-third (68%) of the nurses had a good level of knowledge. And there was a high total mean (1.86). Less than three- quarters (64%) of the nurses had a good level of knowledge regarding the risk fac- tors of NRDS, there was a high mean (1.83). The majority (92%) of the nurses had a good level of knowledge regarding signs and symptoms of NRDS ; there was a high Table 3 demonstrates that most (70%) of the nurses had a poor level of quality of nursing care regarding the assessment of the neonates with RDS; there was a low total mean score (1.43). Less than half (44%) of the nurses had a fair level of quali- ty of nursing care regarding oxygen therapy administration, there was an average total mean of scores (2.13). Concerning suction- ing, less than half (40%) of the nurses had a fair level of quality of nursing care, there was an average total mean (1.92). Also, nearly three-quarters (74%) of the nurses had a poor level of quality of nursing care regarding the use of pulse oximetry, there Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 2: Domains of Nurses’ Knowledge regarding NRDS Domains of Nurses’ Poor Fair Good Total M. Evaluation No. (%) No. (%) No. (%) Define 3 (6) 0 (0) 47 (94) 1.94 Good Causes 16 (32) 0 (0) 34 (68) 1.86 Good Risk factor 6 (12) 12 (24) 32 (64) 1.83 Good Sign and symptoms 0 (0) 4 (8) 46 (92) 1.82 Good Complications 2 (4) 13 (26) 35 (70) 1.83 Good Surfactant 15 (30) 21 (42) 14 (28) 1.55 Fair Prevention 9 (18) 29 (48) 12 (28) 1.64 Fair Nursing care 3 (6) 32 (64) 15 (30) 1.53 Fair Total nurses’ knowledge 0 (0) 18 (36) 32 (64) 1.75 Good Cut-off point: (1-1.33)= Poor, (1.34-1.66)= Fair, (1.67-2)=Good https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article of scores (2.03). As regards psychological support, a high percentage (56%) of the nurses had a poor level of quality of nurs- ing care; there was a low total mean of scores (1.56), regarding documentation, a high percentage (46%) of the nurses had a fair level of quality of nursing care; there was an average total mean (1.68). regarding NRDS, and more than one-third (36%) of the nurses had a fair level of knowledge regarding NRDS. 15 level, and there was an average total mean (2.01). physiotherapy, a high per- centage (90%) of the nurses had a poor level of quality of nursing care, there was a low total mean (1.12).Concerning incu- bator care more than one-third (68%) of the nurses had a poor level of quality nursing, and there was a low total mean Figure 1 shows the levels of overall nurs- es’ knowledge regarding neonates with RDS. The highest percentage (64%) of the nurses had a good level of knowledge Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 3 :Domains of quality of nursing care regarding NRDS Domains of quality of nursing care Poor Fair Good Total M.S Evaluation No. (%) No. (%) No. (%) Assessment 35 (70) 15 (30) 0 (0) 1.43 Poor O2 Therapy 12 (24) 22 (44) 16 (32) 2.13 Fair Suctioning 16 (32) 20 (40) 14 (28) 1.92 Fair Pulse Oximetry 37 (74) 11 (22) 2 (4) 1.52 Poor IV administration 2 (4) 28 (54) 20 (40) 2.12 Fair Cannulation 4 (8) 26 (52) 20 (40) 2.23 Fair Infection Control 16 (32) 25 (50) 9 (18) 1.92 Fair Incubator care 34 (68) 14 (28) 2 (4) 2.03 Fair Maintain Thermoregulation 14 (28) 21 (42) 15 (30) 2.06 Fair NG Feeding 9 (18) 21 (42) 20 (40) 2.01 Fair Documentation 23 (46) 20 (40) 7 (14) 1.68 Fair Psychological support 28 (56) 15 (30) 7 (14) 1.56 Poor Chest physiotherapy 45 (90) 4 (8) 1 (2) 1.12 Poor Total 12 (24) 35 (70) 3 (6) 1.82 Fair Cut-off point: (1-1.66)= Poor, (1.67-2.33)= Fair, (2.34- 3)=Good Figure 1: Overall nurses’ knowledge regarding NRDS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article nurses had a poor level of quality of nurs- ing care, and a minority (6%) of the nurses had a good level of quality of nursing care. Figure 2 shows overall the levels of quality of nursing care for NRDS. Less than three- quarters (70%) of the nurses had a fair lev- el of quality of nursing care, 24% of the 16 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Figure 2: Overall levels of quality of nursing care for NRDS. Figure 3: Correlation between the levels of nurses’ knowledge and the quality of nursing care for NRDS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article age group of the nurses, Almost all (100%) of the nurses who had a good level of qual- ity nursing care were in the age group 25- 34 years (p=0.005). Also, there was a high- ly statistically significant association be- tween the quality of nursing care and edu- cational level (p=0.001). And there was a statistically significant association between the quality of nursing care and the dura- tion of training courses (p=0.050). Table 4 shows that there was a statistically non-significant association between the level of quality of nursing care and places of work, gender, marital status, education- al level, experience in nursing, experience in the NICU and participation in training courses (p=0.110)(p=0.880)( p=1.000) ( p=0.526)( p=0.091)( p=0.794)( p=0.468). Also, table 4 shows that there was a statis- tically highly significant association be- tween the quality of nursing care and the 17 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 4: Association between the quality of nursing care and demographic characteris- tics Variables Poor Fair Good Total P-Value Sig. No. (%) No. (%) No. (%) No. (%) Places of work NICU in RTHC 5 (25) 15 (75) 0 (0) 20 (100) 0.110* N.S NICU in MTH 5 (26) 13 (68.4) 1 (05.3) 19 (100) PICU in RTHC 0 (0) 9 (81.8) 2 (18.2) 11 (100) Gender Male Female 5 (23.8) 5 (17.2) 15 (71.4) 22 (75.9) 1 (4.1) 2 (6.9) 21 (100) 29 (100) 0.880* N.S Age group 25-34 yrs. 1 (3.7) 23 (83.2) 3 (11.1) 27 (100) 0.005* H.S 35-44 yrs. 3 (27.3) 8 (72.7) 0 (0) 11 (100) 45-54 yrs. 6 (60) 4 (40) 0 (0) 10 (100) ≥55 yrs. 0 (0) 2 (100) 0 (0) 2 (100) Marital status Single Married 1 (16.7) 9 (20.5) 5 (83.3) 32 (72.7) 0 (0) 3 (06.8) 6 (100) 44 (100) 1.000* N.S Educational levels Preparatory nursing school Nursing institute graduate Nursing college graduate Socioeconomic status Satisfy with income Unsatisfied with income Experience in nursing 1-10 yrs. 11-20 yrs. 21- 30 yrs. ≥31 yrs. Experience in NICU 1-5 yrs. 6-10 yrs. 11-15 yrs. ≥ 15 yrs. Participation in the training course Yes No Duration of course <1 week >1 week 5 (83.3) 5 (38.5) 0 (0) 4 (15.4) 6 (25.0) 2 (06.9) 4 (33.3) 2 (40) 2 (50) 4 (18.2) 3 (15.8) 1 (20) 2 (50) 3 (13.6) 7 (25) 3 (33.3) 0 (0) 1 (16.7) 8 (68.5) 28 (90.3) 21 (80.8) 16 (66.7) 24 (82.8) 8 (66.7) 3 (60) 2 (50) 16 (72.7) 15 (78.9) 4 (80) 2 (50) 17 (77.3) 20 (71.4) 5 (55.6) 12 (92.3) 0 (0) 0 (0) 3 (9.7) 1 (3.8) 2 (8.3) 3 (10.3) 0 (0) 0 (0) 0 (0) 2 (9.1) 1 (05.3) 0 (0) 0 (0) 2 (9.1) 1 (3.6) 1 (11.1) 1 (7.7) 6 (100) 13 (100) 31 (100) 26 (100) 24 (100) 29 (100) 12 (100) 5 (100) 4 (100) 22 (100) 19 (100) 5 (100) 4 (100) 22 (100) 28 (100) 9 (100) 13 (100) 0.000* 0.526* 0.091* 0.794* 0.468* 0.050* VHS N.S N.S N.S N.S S Total 10 (20) 37 (74) 3 (6) 50 (100) N.S= Non-significant, S= significant H.S= highly significant VHS= very highly significant *=by fishers exact test https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article participate in the training courses, which may be due to a lack of training courses regarding care for neonates. This result was similar to a study done at Zagazig Uni- versity Children's Hospital in Egypt by Mo- hamed et al, who revealed that more than half of the study participants did not par- ticipate in the training courses [20]. Also, the result of the current study shows that among nurses who participated in training courses more than half of the study nurses participated in the training courses for more than one week, while less than half of them participated for less than one week. The findings of the present study disagree with a cross-sectional study done in Iraq by Alridh et al, who found that a high percentage of the nurses participated in training courses several times [19].The result of the present study shows that the nurses had a good level of knowledge re- garding the definition of NRDS. The result of the present study agrees with a cross- sectional study done in Sudan by Ahmad, which found that more than three- quarters of the nurses had a good level of knowledge regarding the definition of NRDS [14]. The result of the present study disagrees with a cross-sectional study done in Port Said city in Egypt by Loutfy et al, which found that the majority of the nurs- es didn’t know the definition of NRD [28]. Regarding causes of NRDS, the result of the present study revealed that most of the nurses had a good level of knowledge. However, the result of the present study was inconsistent with the result of the study done by Elsayed et al, conducted in Saudi Arabia, who found that less than half of the nurses had unsatisfied knowledge regarding causes of NRDS [29].The result of the study shows that less than two- thirds of the nurses had a good level of knowledge regarding the risk factors of NRDS. The result disagreed with the result of the study done at Khartoum State in The nurses in the NICU are frontline healthcare workers who provide care and prevention for neonates with RDS. The ability of the nurses to react to respiratory problems depend on their knowledge and practice. To find out the best understand- ing, this is the first study conducted in Erbil city to demonstrate nurses’ knowledge and quality of nursing care for NRDS. We conducted this study to fill a gap in the quality of nursing care and literature relat- ed to knowledge and quality of nursing care for NRDS. The findings of the present study show that more than half of the nurses were in the age group 25-34 years. The result of the present study was similar to a study done by Ali et al, conducted in Jordan, which found that most of the nurs- es were within the age group of 23-33 years old [17].Regarding the distribution of the study sample according to their hospi- tals and departments, the highest percent- age of the nurses were from the NICU in RTHC, more than one-third of them were from the NICU in MTH, and a minority of them were from the PICU in RTHC. The highest percentage of nurses graduated from the college of nursing. The findings of the current study were supported by a study conducted in Egypt by AL-Ziady et al. who found that a high percentage of nurs- es graduated from the college of nursing [18]. A high percentage of the nurses were female, this result was supported by a cross-sectional study done in Iraq by Alridh et al who found that the majority of the study samples were female [19].A high percentage of the nurses had experience in nursing for 1-10 years, the findings of the present study agreed with a study done in Al- Nasiriyah in Iraq by Aziz and Mansi; they found that the majority of the nurses had experience 1-10 years [21]. More than half of the nurses did not 18 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. DISCUSSION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article limited number of nurses. The result was similar to a study done in the Kurdistan region/Iraq b Jamshir KM, who mentioned that the nurses had a poor level of quality nursing care for the assessment of neo- nates [28].As regards oxygen therapy ad- ministration, less than half of the nurses had a fair level of quality nursing care.The result of the study agrees with a study done by Alfadil and Elnageeb, who found that the majority (76%) of the nurses had provided oxygen therapy as needed [22]. Concerning suctioning, less than half of the nurses had a fair level of quality nursing care. The result of the current study was supported by the study done in Egypt by Elsayed, who found that more than half of the nurses had incompetent practice re- garding suctioning[9]. Also, nearly three- quarters of the nurses had a poor level of quality of nursing care regarding the use of pulse oximetry, the result of the study was inconsistent with a study done by Masood [23].As regards infection control, half of the nurses had a fair level of quality nurs- ing care. This result was supported by the results of the study done in Egypt by Mo- hamad et al in 2019 who found that more than half of the nurses had satisfied prac- tice regarding infection control [24]. The nurses had a fair level of quality nursing care regarding the intravenous administra- tion of medication, and the result of the present study was supported by the result of the study carried out by Aziz and Mansi, conducted in Al-Nasriayah in Iraq, who found that the majority of the nurses know the way to administer the medication as prescribed [21]. Regarding cannulation, more than half of the nurses had a fair lev- el of practice, and only less than one- quarter of the nurses wash their hands after cannulation, which may be due to the unavailability of the washbasin in the NICU. Also, concerning NG feeding, 42% of the nurses had a fair level; this result Sudan by Alfadil MA and Elnageeb MM, who found that less than two-thirds of the nurses had a poor level of knowledge re- garding the risk factors of NRDS[22]. Re- garding the sign and symptoms, the result of the present study shows that the major- ity of the nurses had a good level of Knowledge. The result disagreed with the result of the study done by Elsayed et al, who found that more than half of the nurses had unsatisfied knowledge regard- ing NRDS [9].The findings of the present study show that less than half of the nurs- es had a fair level of knowledge regarding prevention and Surfactant. This result was supported by the results of the study con- ducted in Saudi Arabia by Elsayed et al who found that most of the nurses had unsatisfactory knowledge regarding the prevention of NRDS and surfactant [9].Regarding the knowledge of the nurses about nursing care for neonates with RDS, the result of the study revealed that more than two-thirds of the nurses had a fair level of knowledge. This result agrees with the result of the cross-sectional study done by Alfadil MA, conducted in Sudan, who found that more than one-third of the nurses had a fair level of knowledge regarding nursing care [22].Overall levels of nurses’ knowledge regarding NRDS; a high percentage of the nurses had a good level of knowledge, which may be due to the high number of nurses who graduated from the college of nursing and participa- tion in training courses regarding neo- nates. The result of the study was similar to a study done in Iraq by Alridh et al, who found that a high percentage of the nurses had a good level of knowledge regarding NRDS [19].The findings of the present study demonstrate that more than two- thirds of the nurses had a poor level of quality of nursing care regarding the as- sessment domain for NRDS, which may be due to a large number of patients, and a 19 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article association between the level of quality of nursing care and place of work, gender, marital status, experience in nursing, soci- oeconomic status, experience in the NICU, and participation in the training course. The result of the current study revealed that there was a statistically significant as- sociation between the quality of nursing care and age group (p=<0.05). These find- ings disagreed with a study done by Ab- dullatif AL, who found that there was a non-significant association between the quality of nursing care and a group of nurs- es [8]. Also, there was a very highly signifi- cant association between the quality of nursing care and the educational level of the study nurses (p=0.00). These results agree with the results of the study by Aziz and Mansi (2017), who found that there was a significant association between nurs- es’ practice and the educational level of the nurses [21]. There was a statistically significant association between the quality of nursing care and the duration of training courses. the results was supported by the results of Aziz and Mansi, who found that there was a non-significant association be- tween nurse practice and the number of training courses [21].Concerning the corre- lation between the total level of knowledge and the total level of quality of nursing care of the study participants about the care of neonates with respirato- ry distress syndrome; the result of the pre- sent study shows that there was a signifi- cant positive correlation between nurses’ knowledge and the quality of nursing care (rho=0.361). This result agrees with the result of a study done in Egypt by Hegazy (2019), who found that there was a posi- tive correlation between nurses’ knowledge and nurses’ practice [27]. disagrees with a study done by Osti et al [25]. As regards chest physiotherapy high percentage of the nurses had a poor level of quality nursing care; this result was sim- ilar to the result of the study done by Elsayed[9]. Concerning incubator care more than one-third of the nurses had a poor level of quality nursing care; The re- sult of the current study was inconsistent with a study done by Mohamed et al [24]. As regards psychological support, a high percentage of the nurses had a poor level of quality nursing care. Concerning docu- mentation, a high percentage of the nurs- es had a fair level of quality nursing care. These findings disagree with a study done by Elnageb [22].Figure 2 shows the overall levels of quality of nursing care for NRDS. Less than three-quarters of the nurses had a fair level of quality of nursing care, a mi- nority of the nurses had a good level of quality of nursing care and 24%of the nurses had a poor level of quality of nurs- ing care. The result of the present study agrees with a study conducted by Elsayed et al, who found more than two-thirds (69.2%) of the nurses had an incompetent level of practice for NRDS [9].Also, the re- sult of the present study shows that there was a statistically significant association between nurses’ knowledge and (participation in the training course, and the duration of training courses). It was evident that a majority of the nurses who participated in the training course had a good level of knowledge. These findings disagree with a study done by Alridh et al, who found that there was a non- significant association between the level of nurses’ knowledge and participation in training courses and the duration of train- ing courses [19]a. Regarding the associa- tion between quality of nursing care and socio-demographic characteristics, the re- sult of the present study shows that there was a statistically non-significant 20 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article [6] Lovrenski J. Lung ultrasonography of pulmo- nary complications in preterm infants with respiratory distress syndrome. Upsala Jour- nal of Medical Sciences. 2012 Mar 1;117 (1):10-7. Available from: https:// www.sciencedirect.com/science/article/pii/ S0378603X15000066. [7] Reuter S. Moser C Baack M. Respiratory dis- tress in the newborn. Journal of Pediatr Re- view. 2014;35(10):417-29. [8] Abdullatif AL. Quality of Nursing Care provid- ed for Preterm Infants Suffering from Respir- atory Distress Syndrome. 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