Development Of A Nursing Care Protocol For Care Of Neonates With Esophageal Atresia/Trachea-Esophageal Fistula.

https://doi.org/10.33698/NRF0314-Liji George ,Sukhwinder Kaur,KLN Rao

Abstract: Specialized neonatal nursing care is a challenge in a developing country like India. The challenge is even greater in the absence of well-defined protocols and policies. As pediatric surgical nursing is an area where correct nursing practices are largely vague or unknown, this study aimed to bring out a reliable, feasible and acceptable protocol for the care of neonates with esophageal atresia (EA)/tracheo-esophageal fistula (TEF). In this study, a preliminary protocol and an observation checklist for implementing the protocol was prepared and sent to a Delphi panel of experts for assessment of the content validity of the protocol. Following consensus on the content validity of the protocol, the staff nurses were trained on its utilization. The internal consistency reliability of the protocol was assessed by try-out on 35 neonates with TEF/EA using the observation checklist prepared from the protocol. The Cronbach’s alpha for each section of the protocol ranged from 0.69 to 0.90 respectively. Of the nurses trained in the utilization of the protocol, 90% nurses reported that the protocol was beneficial to them and 96.7% nurses mentioned that the protocol was easy to use. The present study has thus provided a protocol that is valid, feasible, internally consistent and acceptable for utilization in practice.

Keywords:Nursing care protocol, Esophageal atresia, Tracheo-esophageal fistula

Correspondence at:Dr. Sukhwinder Kaur Lecturer, National Institute of Nursing Education PGIMER, Chandigarh

Introduction:Congenital anomalies are an important cause of neonatal mortality both in developed and developing countries. Congenital anomalies account for 8-15% of perinatal deaths and 13-16% of neonatal deaths in India.1 E s o p h a g e a l a t r e s i a / t r a c h e o – esophageal fistula has an overall incidence of approximately 1 in 3000-4500 live births.2 It is a fairly common congenital disorder with an incidence of 1 in 4000 live births in India.3 At PGIMER, Chandigarh, surgery for EA is the most common emergency surgery in neonates, with about 180 cases per year.4Despite advances in technology and care modalities for neonates with EA/TEF,management can reduce the stay in duration of mechanical ventilation, the intensive care unit and hospital lengths of stay in hospital.8 Studies have also pointed out that use of protocol-based care has the potential to impact on nurses’ roles, increasing their autonomy and subsequently impacting of there is an enormous difference in survival patient service delivery.9 Also, increased use rates of these neonates between developed and developing countries. In western countries, associated congenital anomaly is the main factor which affects the prognosis. But in India, the preoperative condition, intra-operative and postoperative condition and socioeconomic status along with congenital anomaly affects the prognosis.5 Inadequate nursing care is a factor that contributes to lower the survival of neonates with EA/TEF in developing countries. 6,7 Esophageal atresia is perhaps one of the most challenging pediatric surgery anomalies. Some argue that the ability to overcome this malformation, survival and quality of life for these children are indicators of the effectiveness of the hospital care. The prognosis largely depends on the quality of care that these patients are given during their hospitalization as well as the presented associated malformations. Therefore it is essential to provide quality nursing care for these children for optimal survival rate. Incidentally, there is severe dearth of an evidence-based body of literature available to pediatric surgery nurses to practice best possible care for neonates with such congenital anomalies. Neonates with TEF/EA require specialized care by nurses who need in-depth knowledge about the anomaly and the surgical correction performed. Evidence suggests that implementation of nursing protocols directed towards improving patient care and disease of protocols leads to higher survival rates for patients and decreases in ICU costs.10 Clinical protocols have also enhanced nursing efficiency, as nurses need to consult with physicians less frequently. Nursing protocols contain a comprehensive, up-to- date review of the disease process and provides rationale for each therapeutic decision. Protocols thus represent an important educational resource for clinical staff.In the Neonatal Surgical ICU (NSICU) of PGIMER, Chandigarh, there are no documented guidelines with respect to nursing care of admitted neonates with esophageal atresia/ tracheo-esophageal fistula. The need for a well-developed care protocol with a checklist for i ts implementation was an urgent requirement in a tertiary care centre like PGIMER, Chandigarh for providing best possible care. This study therefore aims to provide a solid body of literature for nurses to guide themselves while providing care to neonates with esophageal atresia / tracheo- esophageal fistula.

Objectives

• To develop a nursing care protocol for neonates with Esophageal Atresia / Tracheo-esophageal
• To develop an observation checklist for implementation of the protocol

Materials and Methods

A methodological study design was adopted to carry out the study. The Neonatal Intensive Care Unit (NSICU) where this study was conducted has a capacity of 25 beds and is staffed by nurses and resident surgeons.Neonates and children with various congenital anomalies are admitted to this unit. In the year 2013 alone, the ICU admitted around 270 neonates with EA/TEF.The present study was carried out in four phases.

Phase I – Preparation phase: This phase comprised of review of literature and preparation of the preliminary draft of nursing care protocol and the observation checklist for implementation of the protocol. This draft comprised of the domains ‘Definition and types of esophageal atresia/ tracheo-esophageal fistula’, ‘Antenatal diagnosis of EA/TEF’, ‘Symptoms following birth of neonate with EA/TEF’, ‘Nursing management of EA/TEF in the labour room nursery’, ‘Preoperative nursing management of EA/TEF in NSICU’, ‘Surgical procedure in EA/TEF’ and ‘Post – operative nursing management of EA/TEFin NSICU’.

Phase II – Validation phase: A Delphi panel was selected which comprised of 10 members (6 members from the field of nursing education, 1 member from Nursing staff and 3 surgeons from Dept of Pediatric Surgery, PGIMER, Chandigarh). The face and content validity of the nursing care protocol and checklist for implementation of the protocol was assessed using Delphi rounds. Two Delphi rounds were conducted in this phase.

Modifications following 1st Delphi round:

Following the first Delphi round, sections on ‘Transportation of neonate from labor room nursery/ pediatric emergency to NSICU’, ‘Fluid and electrolyte management’, ‘Pre-operative Oro-pharyngeal suctioning’, ‘Post-operative oral suctioning’, ‘Pain management with Neonatal pain, agitation and sedation scale (NPASS scale)’ and a photograph on the cover page were added. The section on ‘Surgical procedure in EA/TEF’ was removed as suggested by the Delphi panel members. Also, the domain on ‘Nursing management of neonate with EA/TEF in labor room nursery’ was organized into sections and specific procedures in the protocol were presented in a tabulated form.

Modifications following 2nd Delphi round:

Following the second Delphi round, sections on ^Sham feeding’, ^Therapeutic positioning’, ^Postural drainage’ were added and photographs in each domain. Modifications were made in the content and layout of the protocol with each Delphi round.

Phase III – First try out: In this phase, the researcher applied the guidelines of the protocol on 5 neonates with EA/TEF to assessits feasibility. The procedures and nursing care methods given in the protocol were found to be feasible in the NSICU setting. Following this, a final Delphi round of the protocol was conducted. Consensus was reached between all experts regarding content of the protocol and no modification was further suggested by any Delphi panel member.

Phase IV – Final try out: Training of 30 NSICU nurses in the care of neonates with EA/TEF was conducted using a laptop with MS Power Point presentations made from the protocol content. A total of 8 training sessions were held for the nurses in over a period of two weeks. Each session was of 30 minutes duration.The training was held in groups of of 4-5 members and each staff nurse was given one round of training along with a printed copy of the prepared protocol.To assess the internal consistency reliability of the checklist prepared for implementation of the protocol, 30 Bedside nurses working in NSICU, Advanced Pediatric Centre, PGIMER, Chandigarh and 35 neonates diagnosed with congenital EA/TEF were taken as the try-out sample (30 neonates who underwent primary repair and 5 neonates who underwent cervical esophagostomy and gastrostomy). All 30 bedside nurses available during the study period were included in the study and the sampling of neonates with EA/TEF was done using total enumeration i.e. neonates with EA/TEF admitted from mid-August to mid- October (two months).Following the training on utilization of the protocol, observation of nursing care provided by the 30 trained nurses for 35 neonates was done using observation checklist prepared for implementation of the protocol. The data was collected by observation of the nurses from 8 am to 8 pm everyday till the discharge of the neonate. This data was collected over a period of two months.The prepared final protocol was made available for use in the NSICU. The final draft consisted of  8  domains which  were

^Definition of esophageal atresia/ tracheo- esophageal fistula’, ^Types of esophageal atresia/ tracheo-esophageal fistula’,

^Antenatal diagnosis’, ^Symptoms following birth’, ‘Nursing management of EA/TEF in the labour room nursery’, ^Transportation from labour room nursery/ pediatric emergency to N S I C U ‘ , ^ P r e – o p e r a t i v e n u r s i n g management’ and ^Post operative nursing management’.

Following two months of try-out, the acceptability of the developed nursing care protocol amongst the nurses was evaluated through a feedback questionnaire.

Reliability of Checklist prepared for implementation of the ‘Nursing care protocol for neonates with EA/TEF’

Table 1 to Table 6 depicts the item statistics of the Checklist prepared for implementation of the ^Nursing care protocol for neonates with EA/TEF’.Table 1-2 shows the item-total correlation and Cronbach’s alpha values of the checklist on deletion of each item in the domain ^Pre-operative care’. Many items show corrected item-total correlation of <0.2(poor discrimination) but when these items were deleted one by one, the value of Cronbach’s alpha did not increase significantly, therefore it is evident that all the items had significant contribution. The highest value of alpha that could be obtained on deletion of an item was 0.767 and the lowest was 0.730. Deletion of any item did not significantly increase the overall value of alpha from 0.760. Therefore, none of the items were deleted.

Table 1: Item statistics of Checklist for implementing ‘Nursing care protocol for care of neonates with EA/TEF’– Pre-operative care                                                              N=30

Sr. No.	PRE-OPERATIVE CARE	Corrected Item- Total Correlation	Cronbach’s Alpha if item Deleted
	Preparation for receiving child in NSICU
1.	Receives prior information from paediatric emergency regarding shifting of neonate to NSICU	.402	.750
2.	Keeps ready clean radiant warmer with autoclaved linen	.432	.745
3.	Pre-warms radiant warmer	.483	.740
4.	Keeps articles for suction ready (suction unit, appropriate catheter etc.)	.402	.750
5.	Keeps ready an oxygen source with adequate distilled water	.402	.750
	Receiving child in NSICU
6.	Verifies documents and census entry done	.000	.760
7.	Weighs the child	.000	.760
8.	Shifts the child under prepared radiant warmer	.000	.760
9.	Places the child in a lateral/prone position	.291	.753
10.	Assesses neonate for color and respiratory status	.000	.760
11.	Clears airway of secretions	.000	.760
12.	Keeps child NPO	.000	.760
13.	Keep the child’s head covered	.286	.755
14.	Keep the newborn’s head elevated at 30-45°	.000	.760
15.	Places identification card with details of the neonate	.027	.764
	Pre-operative oral/upper pouch suctioning
16.	Assesses the need for upper pouch suctioning	.402	.750
17.	Places the child in a lateral position with the head turned to one side	-.046	.764
18.	Uses a size 6F/7 F suction catheter	.000	.760
19.	Wears a pair of gloves	.191	.758
20.	Gently passes the suction catheter into the esophagus until resistance is felt	.391	.747
21.	Withdraws the suction catheter by 0. 5 cm and applies suction	.623	.730
22.	Limits each attempt of oral suctioning to 5-7 seconds	.409	.745
23.	Provides sufficient time between each attempt to help in re-oxygenation of the infant	.518	.738
24.	Performs suctioning within 30 mins intervals	.181	.767
25.	Performs gentle suctioning	.000	.760
	Assessment of the respiratory status/ distress of the child
26.	Assesses the child’s respiratory status correctly using a neonatal respiratory distress score	.362	.748
	Oxygen therapy
27.	Administers oxygen as prescribed	.000	.760
28.	Administers humidified oxygen	.000	.760
29.	Documents rate of oxygen flow hourly	.000	.760

– Overall Cronbach’s alpha for the checklist section ‘Pre-operative care’ was 0.76

Lowest Value                                   Highest Value

Table 2 (Contd. from previous): Item statistics of Checklist for implementing ‘Nursing care protocol for care of neonates with EA/TEF’– Pre-operative care                                                        N=30

Sr. No.	PRE-OPERATIVE CARE	Corrected Item- Total Correlation	Cronbach’s Alpha if item Deleted
30. 31.   32. 33. 34.   35. 36. 37.   38. 39. 40.   41. 42. 43. 44. 45. 46. 47.   48.   49. 50.   51. 52. 53.	Fluid and electrolytes Administers I.V. fluids as prescribed Assesses hydration status of the child using clinical signs Monitoring pulse oximetry Documents SpO2 level hourly Assesses the probe site for maintenance of skin integrity Rotates the probe site every 2 hourly Measurement of temperature Places thermometer in the roof of axilla parallel to the body Keeps the thermometer in place for at least 5 minutes before readi Documents measured temperature hourly Care of neonate under radiant warmer Applies temperature probe on the abdomen securely Puts the radiant warmer on the servo mode Documents radiant warmer’s temperature hourly Skin care and hygienic needs Changes position of the neonate 3 hourly Provides sponge bath daily to baby with warm water Uses sterile bowl and water Provides oil massage to child after sponging (if child not under phototherapy) Provides education to attendants regarding preparation of cotton napkins Changes cotton napkin when soiled Takes measures for temperature maintenance of the neonate (radiant warmer/ warm covering ) Informed consent Ensures informed consent prior to sending child for surgery Patient identification and preparation pre-operatively Places identification band on the child’s left wrist Confirms the patient’s identity using at least two identifiers before sending the child to surgery Sends the correct blood bag issued for the child Sends file and radiological reports along with the child Ensures maintenance of temperature during transport to the OT	.000 .017   .000 .402 .350   .258 ng     .270 .000   .402 .165 .000   .270 .000 .000 .000 .000 .000 .000   .000   .000 .000 .000 .000 .000 .000	.760 .762   .760 .750 .749   .754 .754 .760   .760 .758 .760   .754 .760 .760 .760 .760 .760 .760   .760   .760 .760 .760 .760 .760 .760

– Overall Cronbach’s alpha for the checklist section ‘Pre-operative care’ was 0.76

Table 3 shows the item-total correlation and Cronbach’s alpha values of the observation checklist on deletion of each item in the domain ‘Post-operative care after primary repair’. Many items show corrected item-total correlation of <0.2 (poor discrimination) but when these items were deleted one by one, the value of Cronbach’s alpha did not increase significantly, therefore it is evident that all the items had significant contribution. The highest value of alpha that could be obtained on deletion of an item was 0.777 and the lowest was 0.678. Deletion of any item did not significantly increase the overall value of alpha from 0.700. Therefore, none of the items were deleted.

Table 3: Item Statistics of Checklist for implementing ‘Nursing care protocol for care of neonates with EA/TEF’– Post- operative care after primary repair                                                     N=30

Sr. No.	POST-OPERATIVE CARE (PRIMARY REPAIR)	Corrected Item- Total Correlation	Cronbach’s Alpha if item Deleted
1. 2. 3. 4. 5. 6. 7. 8.   9. 10. 11. 12. 13. 14. 15. 16.   17. 18.   19. 20. 21.   22. 23. 24.   25. 26. 27.   28. 29. 30. 31. 32. 33.	Receiving the child from OT Obtains advance information of the child’s condition from the OT prior to receiving Pre-warms radiant warmer prior to receiving the child Obtains information on the surgical procedure done Specifies surgery performed on the identification card/chart of the child Carries out immediate post-operative orders Documents vital signs hourly Documents child’s respiratory status using a neonatal respiratory distress scale Records the nasogastric aspirates Care of surgical anastomosis following primary repair Carefully handles child without hyper-extending neck Places child’s head-rest in a way that child’s neck is neither flexed nor extended Places a soft cotton roll under the head of the child to stabilize it Restrains the hands of the child with ball bandage Secures the trans – anastomotic nasogastric tube with adhesive tape Avoids pacifier before 48 hours of post – operative period Initiates chest physiotherapy following 48 hours of surgery Practices minimal handling Therapeutic positioning of a neonate post-operatively Practices minimum handling of child with pooling of nursing activities Provides comfortable nested position to the child Post-operative oro-pharyngeal suctioning Performs oral suctioning only when needed Inserts the feeding tube only within 5-6 cm into the oral cavity Performs gentle suctioning Care of neonate with chest drain Secures the chest drain of the child below the crib Measures and records child’s chest drain output every 24 hours Documents characteristics of the chest drain exudates Assessment and management of pain Assesses pain/ sedation level of child using neonatal pain scale Documents pain/ sedation level of child using neonatal pain scale Administers analgesics as prescribed Chest physiotherapy Identifies the area to be drained on the basis of physical findings and chest x-ray Covers the child with a thin layer of clothing prior to percussion Provides CPT prior to oral suctioning Provides nebulization to the child prior to CPT Performs gentle percussion with fingers/infant mask Provides CPT with positional drainage	.624 .425 .517 .392 .000 .000 -.132 .000   .000 .212 .000 .000 .000 -0.31 .624 .000   .000 .000   .420 .082 .000   .000 .073 .000   .564 .212 .000   .178 .019 .000 .624 .000 -.031	.719 .693 .678 .678 .761 .761 .777 .761   .761 .653 .761 .761 .761 .769 .719 .761   .761 .761   .626 .669 .761   .761 .762 .761   .701 .653 .761   .654 .677 .761 .619 .761 .769

– Overall Cronbach’s alpha for the checklist section ‘Post-operative care after primary repair’ was 0.70 Table 4 describes the item-total correlation and Cronbach’s alpha values of the checklist on deletion of each item in the domain ^Post- operative care after esophagostomy& gastrostomy’. Many items show corrected item-total correlation of <0.2 (poor discrimination) but when these items were deleted one by one, the value of Cronbach’s alpha did not increase significantly, therefore it is evident that all the items had significant contribution. The highest value of alpha that could be obtained on deletion of an item was 0.840 and the lowest was 0.696 which was undesirable. Deletion of any item would not bring a significant improvement in the overall alpha value of 0.820. Therefore, none of the items were deleted.

Table 4: Item Statisticsof Checklist for implementing ‘Nursing care protocol for care of neonates with EA/TEF’– Post operative care after esophagostomy & gastrostomy

N=30

Sr. No.	Nursing care for ESOPHAGOSTOMY & GASTROSTOMY	Corrected Item- Total Correlation	Cronbach’s Alpha if item Deleted
1.	Obtains advance information of the child’s condition from the OT prior to receiving	.000	.693
2.	Pre-warms radiant warmer prior to receiving the child	.958	.696
3.	Obtains information on the surgical procedure done	.000	.693
4.	Carries out immediate post-operative orders	.000	.693
5.	Specifies surgery performed on the identification card/chart of the	child .444	.840
6.	Records the gastrostomy aspirates	.000	.693
7.	Covers esophagostomy following removal of surgical dressing with petroleum jelly gauze	.000	.693
8.	Changes the gauze covering over esophagostomy every 2 hours	.444	.840
9.	Clears secretions from esophagostomy through suctioning	.000	.693
10.	Performs gentle suctioning of esophagostomy	.000	.693
11.	Performs gentle oral suctioning	.000	.693
12.	Limits each attempt of oral suctioning to 5-7 seconds	.444	.840
13.	Initiates chest physiotherapy after 48 hrs of surgery	.000	.693
14.	Teaches parents regarding care of esophagostomy and gastrostom	y     .000	.693
15.	Washes hands before administering feeds	.000	.693
16.	Administers feed in a clean feeing container	.000	.693
17.	Administers feed over one hour	.000	.693
18.	Flushes the gastrostomy tube with 1 ml of warm sterile water after administration of feed	.000	.693
19.	Provides education to parents regarding administration of gastrostomy feeds	.000	.696
20.	Provides sham feeding with pacifier/ spoon feed when prescribed	.000	.693
21.	Educates the parents regarding the administration of sham feeds to the child	.958	.696

– Cronbach’s alpha for the checklist section ‘Post-operative care after esophagostomy & gastrostomy’ was 0.82

Table 5 shows the item-total correlation and Cronbach’s alpha values of the checklist on deletion of each item in the domain ^Care for intubated neonates with EA/TEF’.Many items show corrected item-total correlation of <0.2 (poor discrimination) but when these items were deleted one by one, the value of Cronbach’s alpha did not increase significantly, therefore it is evident that all the items had significant contribution. The highest value of alpha that could be obtained on deletion of an item was 0.698 and the lowest was 0.677. Deletion of any item would not bring a significant improvement in the overall alpha value of 0.690. Therefore, none of the items were deleted.

Table 5: Item statistics of Checklist for implementing ‘Nursing care protocol for care of neonates with EA/TEF’- Care of intubated neonates with EA/TEF                                                      N=23

Sr. No.	CARE FOR INTUBATED NEONATES	Corrected Item- Total Correlation	Cronbach’s Alpha if item Deleted
1.	Uses appropriate size suction/feeding tube for ET suctioning	.000	.677
2.	Inserts suction catheter only 1 cm more than the total length	.425	.612
	of the ET tube
3.	Sets suction pressure between 80-100 mm of Hg	.691	.690
4.	Specifies the depth of ET tube insertion for each neonate on the	.631	.698
	bedside of the child
5.	Avoids instillation of saline in the ET tube	.000	.677
6.	Practices aseptic procedure for endotracheal suctioning	.000	.677
7.	Provides oral care with normal saline every shift	.022	.682
8.	Takes adequate measures for oxygenation throughout procedure	.000	.677
9.	Documents ventilator parameters hourly	.000	.677

– Cronbach’s alpha for the checklist section ‘Post-operative care after esophagostomy & gastrostomy’ was 0.82

Lowest Value                                   Highest Value

Table 6 shows the item-total correlation and Cronbach’s alpha values of the checklist on deletion of  each item in  the   domain ^Discharge advice given to parents/ guardian’. Many items show corrected item- t o t a l c o r r e l a t i o n o f < 0 . 2 ( p o o r discrimination) but when these items were deleted one by one, the value of Cronbach’s alpha did not increase significantly, therefore it is evident that all the items had significant contribution. The highest value of alpha that could be obtained on deletion of an item was 0.904 and the lowest was 0.260. Deletion of any item did not have a significant improvement in the overall Cronbach alpha value of 0.900. Therefore, none of the items were deleted.

Table 6: Items statistics of Checklist for implementing ‘Nursing care protocol for care of neonates with EA/TEF’ – Discharge advice given to parents/guardian                                                       N=11

Sr. No.	DISCHARGE ADVICE GIVEN TO ATTENDANTS	Corrected Item- Total Correlation	Cronbach’s Alpha if item Deleted
1.	Provides education regarding positioning (head – end raised) of child	.000	.904
2.	Provides education regarding administration of antacids as prescribed	.000	.904
3.	Provides education regarding danger signs in the child	.828	.260
4.	Provides education regarding immunization of the child	.828	.260
5.	Provides education regarding follow up of the child	.000
				.904

– Cronbach’s alpha for the checklist section ‘Discharge advice to parents/guardians’ was 0.90

Lowest Value                                   Highest Value

Table 7 describes the overall Cronbach’s alpha value of each section of the observation checklist prepared from the protocol. For the section of ^pre-operative care’, the sample size for analysis was 30 (i.e. 30 pre-operative neonates were observed). The Cronbach’s alpha coefficient for this section was 0.76.In the section of ^post- operative care after primary repair’, the sample size for analysis was 30 (i.e. 30 neonates who underwent primary repair were observed) The Cronbach’s alpha coefficient for this section was 0.70. In the section of ^post-operative care after esophagostomy and gastrostomy’, the sample size for analysis was 5 (i.e. 5 neonates who underwent esophagostomy and gastrostomy were observed). The Cronbach’s alpha coefficient for this section was 0.82.In the section of ‘Nursing care for intubated neonates with EA/TEF’, the sample size for analysis was 23 (i.e. 23 neonates who needed mechanical ventilation were observed) The Cronbach’s alpha coefficient for this section was 0.69.In the final section o f ^ d i s c h a r g e a d v i c e g i v e n t o parents/guardians’, the sample size was 11 (i.e. 11 neonates who were discharged from NSICU were observed)The Cronbach’s alpha coefficient for this section was 0.90.

Table 7: Internal consistency reliability of Observation checklist for protocol implementation

 

Section of Protocol	Cronbach’s Alpha
Pre operative care for neonates with EA/TEF	0.76
Post operative care for neonates who underwent primary repair	0.70
Post-operative care for neonates who underwent esophagostomy + gastrostomy	0.82
Nursing care for intubated neonates with EA/TEF	0.69
Discharge advice given to parents/guardians	0.90

 

 Acceptability of ^Nursing care protocol for care of neonates with EA/TEF’: Following assessment of reliability, the final draft of the ^Nursing care protocol for neonates with EA/TEF’ was made available for use in NSICU. The nurses who were trained and observed for implementation of protocol guidelines were asked to fill a feedback proforma to assess their views on the protocol.Table 8 describes the level of acceptance among the staff nurses who were trained on the protocol and had utilized it for the care of neonates with EA/TEF.  Out  of  the  30 nurses participating in the study, 90% of the participants believed that the protocol was extremely beneficial to them. 93.3% of the participating nurses said that the protocol had extremely/highly improved their nursing skills while 6.7% said that it had moderately done so. 96.7% nurses also stated the protocol to be extremely/ highly easy to use whereas 3.3% said that it was moderately easy to use. 100% of the participating nurses highly/ extremely recommended that the protocol needs to be implemented in NSICU in practice.

Table 8: Acceptability of ‘Nursing care protocol for care of neonates with EA/TEF’ among nurses

Characterstics	Extremely	Highly	Moderately	Slightly	Not at all
Beneficial	27 (90%)	3 (10%)	–	–	–
Improved nursing skills	10 (33.3%)	18 (60%)	2 (6.7%)	–	–
Easy to use	14 (46.7%)	15 (50%)	1 (3.3%)	–	–
Need for implementation of protocol in practice	27 (90%)	3 (10%)	–	–	–

 Discussion

Esophageal a t r esia/ t r acheo- esophageal fistula presents a grave challenge to the pediatric surgery nurses.11 It accounts for around 6% of all congenital anomalies and its incidence in India is estimated at 18,000 per year. In the year 2013 alone, around 270 babies with EA/TEF were admitted in the Neonatal surgical ICU of PGIMER, Chandigarh. It is believed that only 10% of neonates with this anomaly reach a tertiary care centre.12 The overall survival rate of neonates with EA/TEF is reported to be around 36%.13 Specialized neonatal nursing care is a challenge in a developing country like India. The challenge is even greater in the absence of well defined protocols and policies.During the period of study i.e. within 2 months, a total of 167 children with various congenital anomalies were admitted in NSICU. Out of these children, 36 neonates (21.5% of total admissions) were diagnosed with congenital EA/TEF. In NSICU, PGIMER Chandigarh, there are no documented guidelines with respect to nursing care of admitted neonates with esophageal atresia/ tracheo-esophageal fistula. Therefore, the researcher developed a nursing care protocol for care of neonates with EA/TEF. A checklist is also essential to assess the implementation of the protocol guidelines. Hence, a checklist was also developed for implementation of the protocol. Similarly, in the study conducted by El Sayed et al in Cairo utilized an observation checklist to assess the nursing practice in Neonatal ICU for the purpose of developing basic standards of care for nurses working in the Neonatal intensive care unit.14 The validity of the protocol and the checklist was assessed with three subsequent Delphi rounds with experts in the field of nursing and pediatric surgery. Mannix TG in 2011 employed the Delphi technique to develop standards for Neonatal Intensive care nursing education for the Australian College of Neonatal Nurses (ACNN). The Delphi panel had comprised of 13 experts who were consulted over a period of seven months.15 In the present study, the Delphi panel comprised of 10 members who were consulted over a period of two months. Consensus between the members regarding the content of the protocol was achieved in the third round. Pravikoff et al, following a study on registered nurses in the United States reported that only 46% of the respondents were familiar with the term evidence-based practice. Older nurses lacked computer, literature search and research training and there were generational differences in the approach to technology and research utilization.16 In the present study, it was found that in the NSICU, 46.7% of the total nursing staff had job experience of less than three years. 36.7% of the nursing staff comprised of diploma holders and above all, none of the nursing staff in their career span had ever attended any continuing education program for the care of pediatric surgical patients. This emphasized the need of a training program on the utilization of the nursing care protocol for the nurses of NSICU Internal consistency reliability of the observation checklist for implementation of the ^Nursing care protocol for care of neonates with EA/TEF’ was assessed by observation of nursing practice on neonates with EA/TEF. Though there were a number of items in the checklist that showed an item- t o t a l c o r r e l a t i o n o f < 0 . 2 ( p o o r discrimination),deletion of these items did not increase the overall Cronbach’s alpha value of the checklist. The experts also considered these items important. Therefore, no item was deleted from the checklist and the final checklist comprised of 5 domains (pre-operative care, post- operative care after primary repair, post- operative care after esophagostomy and gastrostomy, care of intubated neonates and discharge advice given to parents/ guardians) with 121 items.This checklist had an overall Cronbach’s alpha between 0.69 and 0.90 which was acceptable. A Cronbach’s alpha value of >0.70 is considered reliable for use. Similarly, Akuma and Jordan had conducted a survey regarding knowledge and practice regarding procedural pain management using a checklist. Their internal consistency of their checklist was found to be high (overall Cronbach’s alpha 0.976).17 The present study also obtained feedback regarding the protocol from the nurses working in NSICU. Most of the nurses reported that the protocol was beneficial to them and was easy to use. All nurses recommended that the prepared nursing protocol should be implemented in practice to provide high quality and evidence based care to neonates with EA/TEF. Since this protocol was found to be valid, feasible and acceptable, it can be used in nursing practice for providing care to the neonates with EA/TEF. This protocol can also be used to provide induction training to new nursing staff who join pediatric surgery department and who are unfamiliar in caring for such neonates. The observation checklist developed for the implementation of the protocol was found to be reliable for use. Therefore, it can be used by nursing supervisors to bring about effective implementation of the protocol. The checklist will also be helpful to staff nurses for correct implementation of the protocol guidelines. It can also be recommended that another study can be conducted to assess the effect of implementation of the protocol in terms of patient care and outcome, knowledge gain among nurses and extent of change in nursing practice resulting from the protocol. Also, protocols can be further developed for nursing care of neonates with other anomalies to provide are liable body of literature for nurses to guide themselves while providing care.

References

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