Sudan Journal of Medical Sciences Volume 17, Issue no. 1, DOI 10.18502/sjms.v17i1.10683 Production and Hosting by Knowledge E Original Article The Effect of Neonatal Training Programs on NICU Nurses’ Knowledge and Practice in the Military and Police Hospitals of Khartoum State, Sudan Rabab.Mohamed Adam1* and Buthina Bassyonie Elssayed2 1Nursing Program, Kamllin Ahlia College, Al Kamlin, Sudan 2Faculty of Nursing, Albutana University, Rufaa, Sudan Abstract Background: Hypothermia in neonates is a life-threatening condition. It happens due to the extrinsic thermal variations that contrast the intrauterine area. Early detection methods such as increased awareness and good nursing care play an important role in the prevention of hypothermia in newborns and reduce the consequences and death resulting from it. This study aimed to evaluate the effect of training programs on nurses’ knowledge and practice with respect to caring for neonates with hypothermia. Methods: This quasi-experimental study was conducted in the military and police hospitals in Khartoum State, Sudan. A total of 47 nurses meeting the study inclusion criteria and agreeing to participate were included. The necessary research data were collected using a structured interview and a checklist pre and three months post intervention. Training program on neonatal hypothermia was offered to nurses which included the definition, causes, signs and symptoms, and treatment and prevention of neonatal hypothermia. Data were analyzed using the SPSS v.20; descriptive and inferential statistics (t-test and chi-squared test) were used with p-values < 0.05 considered as statistically significant. Results: All participants were female nurses aged 20–30 years, with a mean age of 27.7 ± 5.3 years. A majority of them (40 [85.1%]) had a BSc degree in nursing. Their experiences were varied, but the most common was 1–5 years, followed by 6– 10 years (15 [32%] and 14 [29.8%], respectively). Nurses’ knowledge about observing and monitoring temperature pre intervention was 73%, which increased to 94.3% post intervention with a P-value = 0.03. Additionally, nurses’ practice in cases of hypothermia pre intervention was 80.01%, which increased to 82.9% post intervention. Their pre intervention practice around placing the baby under radiant warmer was 72.3%, which changed to 93.6% post intervention with a P-value = 0.006. Conclusion: Implementation of the training program on neonatal hypothermia was very effective and significantly increased nurses’ level of knowledge and practices. We recommend similar training programs should be given to all nurses working in the neonatal intensive care units in Sudan. Keywords: training program, neonatal hypothermia, prevention How to cite this article: Rabab.Mohamed Adam* and Buthina Bassyonie Elssayed (2022) “The Effect of Neonatal Training Programs on NICU Nurses’ Knowledge and Practice in the Military and Police Hospitals of Khartoum State, Sudan,” Sudan Journal of Medical Sciences, vol. 17, Issue no. 1, pages 28–38. DOI 10.18502/sjms.v17i1.10683 Page 28 Corresponding Author: Author; email: rababi145@gmail.com Received 02 February 2022 Accepted 09 March 2022 Published 31 March 2022 Production and Hosting by Knowledge E Rabab.Mohamed Adam et al. This article is distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use and redistribution provided that the original author and source are credited. Editor-in-Chief: Prof. Mohammad A. M. Ibnouf http://www.knowledgee.com mailto:rababi145@gmail.com https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ Sudan Journal of Medical Sciences Rabab.Mohamed Adam et al 1. Introduction Hypothermia in neonates can occur at any time and is a crucial threat for newborn survival in the neonatal period, which is the period from 0 to up to 28 days of life [1]. Its incidence is higher in a period <24 hr of birth, and babies are more likely to die due to hypothermia as the neonate has at that moment to deal with the extrinsic thermal variations that contrast evidently the intrauterine area [2]. 1.1. Problem statement Worldwide neonatal deaths are unevenly dispensed around the world. Half of the world’s newborns die at home, and >99% of all deaths occur in developing countries, where the average neonatal mortality rate is 33 per 1000, compared with 4 per 1000 in high-income countries. Since neonatal deaths account for >40% of under-5 mortalities, reaching the Millennium Development Goal (MDG) will require a substantial reduction in newborn mortality. Although addressing neonatal hypothermia might promote this goal, so far little attention has been paid to it. Maintaining a normal body temperature is a critical function for newborn survival [3]. 1.2. Definition Hypothermia is defined as a body core temperature of <35ºC (95ºF) in humans [4]. Symptoms depend on the temperature. In mild hypothermia, there is shivering and mental confusion. In moderate hypothermia, shivering stops and confusion increases [5]. In severe hypothermia, there may be paradoxical undressing, in which a person removes their clothing, as well as an increased risk of the heart stopping. 1.3. Causes Premature birth and low birth weight. Low birth weights run a higher risk of hypothermia due to lack of insulating body fat, immature nervous system, inability to efficiently conduct heat, cold birth environment, hypoglycemia, and infection. 1.4. Signs and symptoms Lethargy, poor feeding, cold extremities [6]. DOI 10.18502/sjms.v17i1.10683 Page 29 Sudan Journal of Medical Sciences Rabab.Mohamed Adam et al 1.5. Management and Prevention Hypothermia should be prevented through strict observance of chain of warmth includ- ing thermal control such as ensuring a warm area for delivery, keeping the baby warm and wrapping them in warm clothes, initiating early breastfeeding, delaying bathing, checking body temperature, and providing care during transport when returning back home or transferring the baby from one unit to another [7]. Hypothermia prevention in neonates is a key element to prevent child mortality as most of them are vulnerable to die within the neonatal period [8]. Another meaningful aspect of preventing neonatal hypothermia is keeping the baby and the mother together as the neonate body tem- perature depends significantly on the mother’s temperature. However, babies delivered by caesarian section (C/S) do not benefit from the usual maternal bonding, because they are usually separated from the mother and cared apart making them prone to hypothermia [9]. Midwives in healthcare facilities strive to adhere to the WHO guidelines regarding the prevention of hypothermia in the neonates from the delivery room to the postpartum ward but the gaps are more observed when the baby is discharged from the hospital, running into the burden of the means of transport that are most of the time inadequate for the newborn baby [8]. 1.6. Justification Neonatal hypothermia is a life-threatening disease, widespread especially in Africa, with a high mortality and morbidity rate. To reduce its incidence rate, safe care should be provided to neonates with hypothermia, and early detection methods such as increased awareness and good nursing care should be facilitated. 1.7. Objectives 1.7.1. General objective To evaluate the effect of training programs on nurses’ knowledge and practice with respect to the care of neonates with hypothermia in the obstetrics and gynecology hospitals in Khartoum State, Sudan (2019–2021). DOI 10.18502/sjms.v17i1.10683 Page 30 Sudan Journal of Medical Sciences Rabab.Mohamed Adam et al 1.7.2. Specific objectives (i) To assess nurses’ knowledge regarding the various aspects of caring for neonates with hypothermia such as defining causes, signs and symptoms, and its manage- ment in the obstetrics and gynecology hospitals in Khartoum State, Sudan (2019– 2021). (ii) To monitor nurses’ performance when caring for neonates with hypothermia in the obstetrics and gynecology hospitals in Khartoum State, Sudan (2019–2021). (iii) To evaluate the effect of implemented training program on nurses’ knowledge and practice when caring for neonates with hypothermia in selected areas for >1 year (2019–2021). 2. Materials and Methods 2.1. Study design This interventional hospital-based study aimed at assessing the effect of the training programs on nurses’ knowledge and practices regarding the nursing care of neonates with hypothermia in the obstetrics and gynecology hospitals in Khartoum State, Sudan. 2.2. Study area This study was conducted in the neonatal units of the police and military hospitals in Khartoum State, Sudan. Police hospitals are located in Bor. The hospital was built in 1996 and receives patients from different areas of the locality. It includes a clinical reference department, a medical department, a radiolofy department, a blood bank, a kitchen, a security unit, a pediatric ward, an obstetrics and gynecology department, and two neonatal intensive care units (septic and aseptic units) that have 15 incubators and 4 radiant warmers. The per day delivery rate of the hospital is 50 babies; in a month, it admits about 35–50 babies, and 24 nurses work in different shifts. 2.3. Study population The study included 47 nurses working in the neonatal intensive care units of the selected hospitals. DOI 10.18502/sjms.v17i1.10683 Page 31 Sudan Journal of Medical Sciences Rabab.Mohamed Adam et al 2.4. Data collection A questionnaire was designed by the researcher in English language that included nurses’ sociodemographic characteristics such as age, qualifications, years of experi- ence, and information on nurses’ knowledge and practice before and after the training program. An observational checklist was developed by the researcher to observe the actual performance of the nurses before and after the training program. It included all nursing care and procedures needed for the care of neonates with hypothermia. 2.5. Phases of the study: Phases of intervention 2.5.1. Pre intervention phase • Permission was taken from managers and directors of the two hospitals for data collection through official letters. • A questionnaire was distributed for each available nurse to be filled under the researchers’ guidance. • Each nurse was observed for her clinical skills when caring for neonates with hypothermia. 2.6. Program implementation The program was designed and offered to equip nurses with essential information and practice regarding the care of neonates with hypothermia and included informa- tion about hypothermia such as its definition, causes, signs and symptoms, treatment, prevention and related procedures. 2.6.1. Post intervention program A posttest was done using the same questionnaire and a checklist was used to evaluate the effect of program on nurses’ knowledge and skills. All nurses were observed by the researchers during their shift. A certificate and copies of the program was given to all participants. DOI 10.18502/sjms.v17i1.10683 Page 32 Sudan Journal of Medical Sciences Rabab.Mohamed Adam et al 2.7. Data analysis Data were coded, entered, and analyzed using the statistical package for social science (SPSS) to show the results of the hypothesis of the study by using frequencies and per- centages in tables and figures, and a suitable statistical method was used (descriptive and inferential). P-value, for statically significant 3. Results 0 0.5 1 1.5 2 2.5 3 3.5 20-30 31-40 > 40 A x is T it le Figure 1: Distribution of the study sample according to their age (yr), N = 47. Figure 1 shows that the majority of our study participants were in the age group 20–30 years. . 2.1 85.1 4.3 8.5 Diploma BSc High diploma MSc Figure 2: Distribution of the study sample according to education, N = 47. As seen in Figure 2, a majority of our participants (85.1%) had a bachelor’s degree in nursing. DOI 10.18502/sjms.v17i1.10683 Page 33 Sudan Journal of Medical Sciences Rabab.Mohamed Adam et al 19.1 32 29.8 19.1 < 1 5-Jan 10-Jun >1010 5 Figure 3: Distribution of the study sample according to the years of experience, N = 47. Table 1: Nurses’ knowledge about hypothermia (n = 47). Pre training Post training P-value F % F % Nurses’ knowledge about monitoring of temperature 37 78.7 43 91.5 0.031 Nurses’ knowledge about monitoring of neutral thermal environment 35 74.5 45 95.7 0.008 Nurses’ knowledge about incubator care 31 66.0 45 95.7 0.001 Average 73% 94.3% 0.013 Furthermore, Figure 3 shows that a majority of the study samples (32%) had one to five years of experience. 8.5 91.5 yes No Figure 4: Distribution of the study sample according to their attendance of a similar training program prior to previously. Figure 4 shows that 91.5% of our study participants had not attended any training programs regarding neonatal hypothermia. DOI 10.18502/sjms.v17i1.10683 Page 34 Sudan Journal of Medical Sciences Rabab.Mohamed Adam et al Table 2: Nurses’ practice of hypothermia management (n = 47). Pre intervention Post intervention P-value F % F % Nurses’ practice on observing signs of hypother- mia such as shivering, slow breathing, confusion, acrocyanosis 42 89.4 44 93.6 0.46 Nurses’ practice on covering head, hands, legs, and avoiding undressing the infant 37 78.7 39 83 0.60 Nurses’ practice on placing the baby under a radiant warmer or incubator 34 72.3 44 93.6 0.006 Average 80.01% 82.97% 4. Discussion The majority of our participants (74.5%) were aged 20–30 years. Similar findings were reported by another Sudanese study which showed that the majority of NICU nurses (60%) were in the similar age group [10]. All participants in this study were female which is similar to the findings of another study in Sudan which showed that all pediatric nurses (100%) in the NICU were female. This can be attributed to hospital polices [11]. Our finding is also similar to the findings of another study on ”nursing care for newborn infant with jaundice in a maternity hospital in Brazil,” which reported that all nurses included in the study were aged 25–35 years [12]. The study revealed that more than two-third (85.1%) nurses had a BSc degree in nursing science. However, this finding is in contrast to the findings of another study conducted to observe the effect of a designed nursing care protocol on the clinical outcomes of neonates with hyperbilirubinemia in NICU in Shebin–Elkom Teaching Hospital which found that half of the nurses in their study were qualified by only a diploma in nursing [13]. Similarly, another study conducted in Yemen showed that about 83% of their study participants had a nursing diploma and no degree; this is a serious indicator for Yemen which shows that the majority of their nurses are academically not qualified enough to bear their responsibilities [14]. Moreover, one- third (32%) of the study participants had about one to five years of experience. This is in contrast to the results of a study conducted to verify the seriousness of nursing and find an association with respect to nursing care (age, nursing education, and experience in intensive care unit) that show the majority of samples in years of experience group to the study sample where within (under 2 years) and (2–5 years) were 50% and 40%, respectively [15]. Moreover, it was found that 91.5% of the nurses had never undertaken a training course in neonatal care. This is similar to the result of another Sudanese study in which 56% of the nurses had never taken a course in neonatal care [16]. Moreover, in our study, nurses’ knowledge regarding neonatal hypothermia improved from 73% DOI 10.18502/sjms.v17i1.10683 Page 35 Sudan Journal of Medical Sciences Rabab.Mohamed Adam et al pre intervention to 94.3% post intervention with a p-value of 0.013. However, this is in disagreement with another study that found 57.5% of their respondents had adequate knowledge about risk factors and causes of neonatal hypothermia. The study also revealed that 89.4% and 93.6% of the study sample responded with correct answers regarding the warning signs of hypothermia pre and post intervention, respectively [17]. Nevertheless, the finding of the present study is better than the findings of an Egyptian research that showed most of the nurses (96.7%) at pretest had inadequate knowledge about preventing hypothermia in preterm infants, while in the posttest a majority (85%) had gained adequate knowledge [18]. Overall, nurses’ practice with respect to managing neonatal hypothermia had a little improvement – pre 80.01% and post 82.9%. 5. Conclusion The findings of the current study proved that training programs are effective and significantly increase the knowledge and improve the practice of the nurses with respect to neonatal hypothermia. Limitations The study had a few limitations such as lack of financial support to implement the intervention programs to cover all nurses in Khartoum state and low sample of nurses. Recommendations 1. Contentious educational programs for nurses to improve their performance in ICUs. 2. Further studies to assess nurses’ knowledge and practice in the management of neonates with hypothermia in other healthcare settings in Sudan and application of their recommendations into practice. Ethical Considerations Permission from managers, matrons, and head nurses of police and military hospitals was taken through official letters and verbal acceptance was obtained after explaining to them the purpose of the study. Participants had the right to withdraw at any time. Privacy and confidentiality was ensured by using coded questionnaire. DOI 10.18502/sjms.v17i1.10683 Page 36 Sudan Journal of Medical Sciences Rabab.Mohamed Adam et al Competing Interests None. Availability of Data and Material All relevant data of this study are available to any interested researchers upon reason- able request to the corresponding author. Funding None. References [1] Boundy, E. O., Dastjerdi, R., Spiegelman, D., et al. (2016). Kangaroo mother care and neonatal outcomes: a meta-analysis. Pediatrics, vol. 137, no. 1, p. e20152238. [2] Qazi, M., Saqib, N., and Raina, R. (2019). Knowledge regarding prevention of hypothermia in newborns among mothers in Northern India. International Journal of Research in Medical Sciences, vol. 7, no. 5. [3] Lunze, K. and Hamer, D. (2012). Thermal protection of the newborn in resource-limited environments’ perinatol. Journal of Perinatology, vol. 32, no. 5, pp. 317–324. [4] Brown, D. J., Brugger, H., Boyd, J., et al. (2012). Accidental hypothermia. The New England Journal of Medicine, vol. 367, pp. 1930–1938. [5] Fears, J. W. (2011). The pocket outdoor survival guide: the ultimate guide for short- term survival. Stoeger Publishing Company. [6] Qazi, M., Saqib, N., and Raina, R. (2019). Knowledge regarding prevention of hypothermia in newborns among mothers in Northern India. International Journal of Research in Medical Sciences, vol. 7, no. 5. [7] Lunze, K., Yeboah-Antwi, K., Marsh, D. R., et al. (2014). Prevention and management of neonatal hypothermia in rural Zambia. PLoS One, vol. 9, no. 4, p. e92006. [8] Mc call, E., Alderdice, F., Halliday, H. L., et al. (2018). Interventions to prevent hypothermia at birth in preterm and/ or low birth weight infants (Review). Cochrane Systematic Reviews, vol. 2018, no. 2, p. CD004210. DOI 10.18502/sjms.v17i1.10683 Page 37 Sudan Journal of Medical Sciences Rabab.Mohamed Adam et al [9] Sacks, E., Moss, W. J., Winch, P. J., et al. (2015). Skin thermal and umbilical cord care practices for neonates in southern, rural Zambia: a qualitative study. BMC Pregnancy and Childbirth, vol. 15, article 149. [10] Altun, I. and Karakoc, A. Management of hypothermia impact of lecture-based interactive workshops on training of pediatric nurses. Pediatric Emergency Care, vol. 28, no. 5, pp. 455–459. [11] Babeker, Z. A. (2015). Assessment of nurses knowledge and practice regarding care of premature baby in neonatal intensive care unit at Omdurman Maternity Hospital and Alribat University Hospital in pediatric nursing. Faculty of Graduate Studies and Scientific Research, The National Ribat University. [12] Moula, W. I. and Kambal, I. I. A. E. Pediatric nurses knowledge and practices regarding nursing management of premature babies in neonatal intensive care unit at Soba University Hospital, Khartoum State, Sudan. International Journal of Recent Research in Life Sciences, vol. 3, no. 4, pp. 1–9. [13] Samar, D. R., AnaPaula, N. L., Lisane, K. S., Maria, A. S., Francisca, W. B. (2013). Nursing care for the newborn infant with jaundice in a maternity hospital. Journal of Nursing, vol. 7, no. 1, pp. 7017–7025. [14] Ashor, G. M., Khalifa, M., El-gendy, et al. (2016). Effect of a designed nursing care protocol on clinical outcomes of neonates with Hyperbilirubinemia (NICU) in Shebin El-kom teaching hospital. International Journal of Novel Research in Health Care and Nursing, vol. 3, no. 3, pp. 70–76. [15] Bash, N. (2016). Patterns of nursing knowledge in identification of neonatal sepsis in NICU. Sana’a, Yemen: Nursing Department, Sanaa University. [16] Mansi, Q. and Aziz, A. (2017). Assessment nursing care in neonatal respiratory distress. International Journal of Science and Research, vol. 6, no. 5, pp. 550–553. [17] Ashor, G. M., Khalifa, M. I., El-Gendy, F. M., et al. (2016). Effect of a designed nursing care protocol on clinical outcomes of neonates with hyperbilirubinemia. International Journal of Novel Research in Healthcare and Nursing, vol. 3, no. 3, pp. 62–76. [18] Bourgault, A., Ipe, L., Weaver, J., et al. (2015). Development of evidence-based guidelines and critical care nurses knowledge of enteral feeding. Critical Care Nurse, vol. 27, no. 4, pp. 17–29. DOI 10.18502/sjms.v17i1.10683 Page 38 Introduction Problem statement Definition Causes Signs and symptoms Management and Prevention Justification Objectives Proxima-Nova-Bold-Italic.otfGeneral objective Proxima-Nova-Bold-Italic.otfSpecific objectives Materials and Methods Study design Study area Study population Data collection Phases of the study: Phases of intervention Pre intervention phase Program implementation Post intervention program Data analysis Results Discussion Conclusion Limitations Recommendations Acknowledgements Ethical Considerations Competing Interests Availability of Data and Material Funding References