http://doi.org/10.33698/NRF0328-Navpreet Kaur, Rupinder Kaur, Ram Samujh
Introduction: Caregivers involvement in care of children is helpful in performing the procedure well and for increasing parents’ satisfaction regarding child’s care. Objective: To develop skills of caregivers of children in performing bowel wash procedure. Methodology: An Operational study was conducted on caregivers of children with anorectal malformation, hirschsprung’s disease, neurogenic bowel and neural tube defects. Protocol on Bowel training program was developed. Demonstrations and teachings were planned for 50 caregivers on the basis of developed protocol with feeding tube method and enema can method. Booklet on bowel training program that includes steps of bowel wash procedure was given to the caregivers for ready reference. Return and re- demonstrations were taken from the caregivers to check their skill prociency in performing bowel wash procedure. 15- point checklists were used to assess the skills of caregivers, each point was of 1 score. Total 3 observations were made, at which performance of caregivers was analyzed. Results: The results revealed that caregivers who scored 13 or above 13 score out of total 15 scores, were considered as procient. Mean skill performance score of caregivers was increased upto 14.79±0.426 after 3 subsequent demonstration by using feeding tube method from 8.71 ±
1.72 in 1st observation. Similarly, in case of enema can method, mean skill performance score was increased upto 14.50±0.697 from 8.56 ± 2.17 in 1st observation. At 3rd observation, all 50 (100%) caregivers became skilled in performing bowel wash procedure. Conclusion: Skills of caregivers can be developed with the help of repeated demonstrations and teaching.
Key words: Bowel wash; Caregivers; Children; Demonstrations; Skill development
Introduction
Defects that present at birth, either abnormal in structure or function, are termed as Birth defects. As per CDC, birth d e f e c t s a r e c o m m o n , p r e s e n t i n approximately 1 in 33 newborns per year.1 According to WHO Report, birth defects resulted in 7% mortality.2 Birth defects of gastrointestinal system and central nervous system resulted in lack of bowel control in children. Conditions like anorectal malformation present from birth with a prevalence of 1 per 5000 births,3 incidence of hirschsprung’s disease is 1 in 5000 newborns4, Spina bida accounts for 1-2 children in every 1000 newborns.5 These defects demands special care of children at home and usually care given by the parents such as bowel wash etc.
The skill of caregivers in giving bowel wash and adherence to continue the bowel washes resulted in increased satisfaction level among family members and to deal with problem of fecal incontinence.6 Caregivers are responsible for providing care to the children in home setting as well as in hospitals. It is important to teach the correct method of bowel wash to the caregivers for the effectiveness of the procedure. Teaching parents, demands joint efforts and partnership among the family members and health care team. Study was undertaken to develop the skills of caregivers regarding the procedure of bowel wash. It can be given by two methods i.e. feeding tube method and enema can method, which were selected according to the requirement of children.
Objective
To develop the skills of the caregivers regarding bowel wash procedure in children with hirschsprung’s disease, neural tube defect, neurogenic bowel and after PSARP in anorectal malformation at APC, PGIMER, Chandigarh.
Material and methods
Study was conducted in Pediatric surgery units i.e. Pediatric Surgery Outpatient department (OPD), Pediatric Surgery Ward (PSW), Neonatal Surgery ICU (NSICU) of APC, PGIMER, Chandigarh. Caregivers of children (1 to 12 years of age) with hirschsprung’s disease, neural tube defect, neurogenic bowel and after PSARP in anorectal malformation from month of July-December, 2019, were taken for the study. Tool was prepared in the form of interview schedule and checklist. Tool consist of: I) Interview schedule, which comprised of: a). socio-demographic prole of caregivers and children. b). clinical prole of caregivers and children.
- II) Two checklists to evaluate the skills of caregivers regarding bowel wash procedure i.e. by feeding tube method and other by enema cane method.
Protocol in the form of booklet on Bowel training program was developed, that included steps of bowel wash procedure by two methods i.e. feeding tube method and enema can method. Tool and protocol were validated by experts in the eld of nursing, research and pediatrics surgery. Pilot study was conducted on 5 children and the study was found to be feasible. Booklet on bowel training program was made in English, Hindi and Punjabi language and given to caregivers as per t heir l anguage convenience for ready references.
Ethical approval for the study was obtained from the Institute Ethics Committee of PGIMER, Chandigarh before conducting the study with allotted Reference number NK/5172/MSc/10 dated 02.04.2019. Informed written consent from caregivers and assent from children were taken. Data was collected from July- December 2019. After enrolment, caregivers were interviewed as per interviewed schedule. Demonstration and teaching method were used to teach the caregivers. Skills of caregivers were assessed with the help of checklist. As per the procedure, 14 caregivers with feeding tube method and 36 caregivers with enema can method performed bowel wash. At 1st observation who met inclusion criteria, were provided with demonstration of bowel wash. After 1st demonstration, return demonstrations were taken from the caregivers and when caregivers made mistake then return- demonstrations were taken from them to make them skilled. Total 3 observations were made at which skills were assessed with the help of checklist. For data analysis, frequencies and mean±SD were calculated by using SPSS Processor.
Results
Socio-demographic prole of caregivers (Table 1) shown that, total 50 caregivers participated in study. Out of 50 mothers, 24 (48%) mothers were having age group of 21-30 years with mean ± SD 31.62 ± 5.74 years. As per educational status, 21 (42%) mothers had senior secondary level education. Majority of mothers i.e. 43 (86%) were housewives out of 50 mothers.
Table 1: Socio-demographic profile of caregivers of children
(N = 50)
| Variables | Mother f (%) | Father f (%) |
| Age (in years)
<20 |
1 (2.00) |
– |
| 21- 30 | 24 (48.0) | 14 (28.0) |
| 31- 40 | 23 (46.0) | 28 (56.0) |
| 41-50 | 2 (4.00) | 7 (14.0) |
| >51 | – | 1 (2.00) |
| Educational status
Illiterate |
8 (16.0) |
5 (10.0) |
| Matriculation | 8 (16.0) | 7 (14.0) |
| Senior secondary | 21 (42.0) | 28 (56.0) |
| Graduation and above | 13 (26.0) | 10 (20.0) |
| Occupation
Housewife/ Non-working |
43 (86.0) |
6 (12.0) |
| Craft and related Trade workers | 0 (0.00) | 2 (4.00) |
| Private job | 7 (14.0) | 24 (48.0) |
| Elementary occupation | 0 (0.00) | 18 (36.0) |
Mean ± SD age of mother in years (Range) 31.62 ± 5.74 (19-52) Mean ± SD age of father in years (Range) 34.96 ± 5.90 (27-54)
Half of the fathers (56%) were in the age group of 31-40 years. Educational status of 56% fathers was senior secondary level and method (Table 2b) become skilled in performing bowel wash. Almost all of the caregivers were able to perform most of the nearly half (48%) of fathers were in private steps correctly in 3rd observation by using job.
Skills of caregivers were assessed with the help of checklist scoring. At 3rd observation, all the 14 (100%) caregivers with the help of feeding tube method (Table 2(a) and 36 (100%) caregivers with the help enema can feeding tube method. Table 2(a) revealed that few steps like informing and preparing child regarding bowel wash was performed correctly by 92.9% caregivers. Step of preparation of swabs were accurately performed by 85.7% caregivers.
Table 2(a): Assessment of skills of caregivers in performing bowel wash procedure in children with the help of feeding tube method
(N = 14)
| Sr.
No. |
Steps of Procedure |
Correctly performed steps | ||
| 1st observation f (%) | 2nd observation f (%) | 3rd observation f (%) | ||
| 1. | Arrangement of articles | 4 (28.6) | 7 (50.00) | 14 (100.0) |
| 2. | Inform and preparation child regarding procedure to get cooperation from child | 2 (14.3) | 7 (50.00) | 13 (92.90) |
| 3. | Spread plastic sheet and towel | 8 (57.10) | 11 (78.60) | 14 (100.0) |
| 4. | Position the child in side lying position | 10 (71.40) | 14 (100.0) | 14 (100.0) |
| 5. | Hand washing with soap and water | 8 (57.10) | 12 (85.70) | 14 (100.0) |
| 6. | Preparation of swabs for cleaning | 3 (21.40) | 7 (50.00) | 12 (85.70) |
| 7. | Preparation of solution by adding one table spoon of salt into 1 litre of warm tap water | 12 (85.70) | 13 (92.90) | 14 (100.0) |
| 8. | Clean anus with wet swabs | 7 (50.00) | 8 (57.10) | 14 (100.0) |
| 9. | Take water solution into the syringe as prescribed by physician | 7 (50.00) | 12 (85.70) | 14 (100.0) |
| 10. | Remove air from feeding and check patency of tube before insertion | 7 (50.00) | 10 (71.40) | 14 (100.0) |
| 11. | Apply lubricating jelly on tip of tube | 10 (71.40) | 12 (85.70) | 14 (100.0) |
| 12. | Insertion of tube appropriately as per age | 7 (50.00) | 11 (78.60) | 14 (100.0) |
| 13. | Clean and dry the child after passing stool | 13 (92.9) | 13 (92.9) | 14 (100.0) |
| 14. | After care of articles (wash syringe and feeding tube, discard other things appropriately) | 10 (71.4) | 11 (78.6) | 14 (100.0) |
| 15. | Handwashing with soap and water | 14 (100.0) | 14 (100.0) | 14 (100.0) |
Almost all of the caregivers were able to perform most of the steps accurately in 3rd observation. By enema can method (Table 2b), few steps such as preparing and informing child about procedure was performed correctly by 75% caregivers. And other steps of spreading plastic sheet and preparation of swabs was performed correctly by 94.4% caregivers.
Table 2(b): Assessment of skills of caregivers in performing bowel wash procedure in children with the help of enema can method
(N = 36)
| Sr.
No. |
Steps of Procedure |
Correctly performed steps | ||
| 1st observation f (%) | 2nd observation f (%) | 3rd observation f (%) | ||
| 1. | Arrangement of articles | 15 (41.7) | 25 (69.4) | 36 (100.0) |
| 2. | Prepare and inform child for procedure to get cooperation from child | 5 (13.90) | 15 (41.7) | 27 (75.00) |
| 3. | Spread plastic sheet and towel | 11 (30.60) | 29 (80.6) | 34 (94.40) |
| 4. | Position the child in side lying position | 27 (75.00) | 32 (88.9) | 36 (100.0) |
| 5. | Hand washing with soap and water | 24 (66.70) | 33 (91.7) | 36 (100.0) |
| 6. | Preparation of swabs for cleaning | 12 (33.30) | 21 (58.3) | 34 (94.40) |
| 7. | Preparation of solution by adding one table spoon of salt into 1 litre of warm tap water | 22 (61.10) | 31 (86.1) | 36 (100.0) |
| 8. | Clean anus with wet swabs | 16 (44.40) | 27 (75.0) | 33 (91.70) |
| 9. | Fill the can with solution as prescribed | 21 (58.30) | 32 (88.9) | 36 (100.0) |
| 10. | Remove air from the tubing before insertion | 21 (58.30) | 25 (69.4) | 36 (100.0) |
| 11. | Put enema can at appropriate height | 22 (61.10) | 28 (77.8) | 36 (100.0) |
| 12. | Lubricate the nozzle tip with lubricating jelly | 25 (69.40) | 28 (77.8) | 35 (97.20) |
| 13. | Gently insert the nozzle tip into the rectum through anal opening | 29 (80.60) | 35 (97.2) | 36 (100.0) |
| 14. | After care of articles
(Cleaning of enema can with soap and water & discard waste material appropriately) |
23 (63.90) | 30 (83.3) | 35 (97.20) |
| 15. | Handwashing with soap and water | 35 (97.20) | 36 (100) | 36 (100.0) |
At 1st observation, none of the caregivers procient and skilled in performing procedure become procient, it was increased to 21.4% (Table 3), by using enema can method. at 2nd observation and all the 14 (100%) The mean score was increased from 8.71 at 1st caregivers become procient and skilled at observation to 14.79 at 3rd observation by the 3rd observation by feeding tube method using feeding tube method. The mean score (Table 3). At 1st observation, none of the was increased from 8.56 at 1st observation to caregivers become procient and at 2nd observation it was increased to 25% and at 3rd observation all 36 (100%) caregivers become 14.50 at 3rd observation by using enema can method (Table 3).
Table 3 : Effect of intervention on performance score of caregivers of post-operative children in doing bowel wash procedure by using feeding tube method
(Maximum score = 15)
| Feeding tube method (N=14) | observation 1 f (%) | observation 2 f (%) | observation 3 f (%) |
| Excellent (80-100%) 13-15 score
Very good (61-80%) 10-12 score Good (41-60%) 7-9 score Average (20-40%) 4-6 score Below average (<20%) <3 score |
– 5 (35.7)
8 (57.1) 1 (7.1) – |
3 (21.4)
11 (78.6) – – – |
14 (100.0)
– – – – |
| Mean ± SD (Feeding tube method) | 8.71 ± 1.72 | 11.57 ± 1.15 | 14.79 ± 0.42 |
| Enema can method (N= 36)
Excellent (80-100%) 13-15 score Very good (61-80%) 10-12 score Good (41-60%) 7-9 score Average (20-40%) 4-6 score Below average (<20%) <3 score |
– 14 (38.9) 13 (36.1) 9 (25.0) – |
9 (25.0) 26 (72.2) 1 (2.80) – – |
36 (100.0) – – – – |
| Mean ± SD (Enema can method) | 8.56 ± 2.17 | 11.86 ± 1.50 | 14.50 ± 0.69 |
Repeated measure ANOVA and Bonferroni tests were used to calculate the multiple comparison among means of various observations (Table 4). It revealed that at each observation, skills of caregivers improved signicantly as compared to previous observation.
Table 4 : Multiple comparison among means of various observations of bowel wash performed by caregivers of children with the help of feeding tube method and enema can method.
| Observation (I) | Observation (J) | Mean Difference (I-J) | Std. Error | p-value |
| Feeding tube method | ||||
| (N=14) | ||||
| Observation 1 | Observation 2
Observation 3 |
-2.857
-6.071 |
0.329
0.412 |
0.05 |
| Observation 2 | Observation 3 | -3.214 | 0.261 | 0.05 |
| Enema can method | ||||
| (N= 36) | ||||
| Observation 1 | Observation 2
Observation 3 |
-3.306
-5.944 |
0.251
0.376 |
0.05 |
| Observation 2 | Observation 3 | -2.639 | 0.276 | 0.05 |
(p-value signicant at 0.05 level)
Discussion
Congenital malformation includes various defects, that demands special care from the caregivers for the children. Caregivers play an important role in providing and continuing care to the children. Learning correct procedure of bowel wash and adhering to it is important to deal with the problem of incontinence in children.5
Methodology of study was based on demonstration method to improve skills of caregivers. As per the principal of education, “I hear and I forget, I see and I r e m e m b e r , I d o a n d I k n o w i t ” , demonstration method was selected. So, when one performs the things by one self, that will leads to permanent and concrete learning, which was similarly done for the development of skills of caregivers in the students become more smoother and better.9 Assessment of performance skills was done by using checklist in the present study on the basis of return demonstration and re- demonstration. Present study concluded that with repeated demonstrations and re-demonstration, all the (100%) caregivers were able to become procient and skilled in doing bowel wash procedure. Study recommended that to improve the skills of caregivers, demonstration method is the effective method. Similar studies can be conducted on caregivers to involve them in the care of children.
References
- Congenital Malformation – an overview | ScienceDirect Topics [Internet]. [cited 2020 Jul 30]. study.7 Process of learning become more Available from: concrete with the help of demonstration method.8
Results of the current study proved that with repeated demonstrations and teachings, skills of caregivers were improved in doing bowel wash and all the 50 (100%) caregivers become procient. By adopting good teaching learning method, we can enhance the capability and prociency of caregivers in performing task. Similar study was conducted by Bosse et all on the benets of repetitive skill training in acquiring procedural skills of nasogastric tube insertion. Study was conducted on 50 medical students. After demonstration, clinical skills and procedural performance were evaluated by expert rated video-tapes. Study concluded, that with repeated training, performance of
https://www.sciencedirect.com/topics/ medicine-and-dentistry/congenital- malformation
- Congenital anomalies [Internet]. [cited 2020 Mar 19]. Available from: https://www.who.int/news-room/fact- sheets/detail/congenital-anomalies
- Anorectal Malformation in Children – Health Encyclopedia – University of Rochester Medical Center [Internet]. [cited 2020 Mar 18]. Available from: https://www.urmc.rochester.edu/ency clopedia/content.aspx?contenttypeid= 90&contentid=P01980
- Reference GH. Hirschsprung disease [Internet]. Genetics Home Reference. [cited 2020 Mar 21]. Available from: https://ghr.nlm.nih.gov/condition/hirs chsprung-disease
- Bischoff A, Levitt MA, Peña A. Bowel management for the treatment of pediatric fecal incontinence. Pediatr Surg Int. 2009 Dec;25(12):102742.
- Colorectal Program | Pediatric General Surgery | Stanford Medicine [Internet]. [cited 2020 Apr 21]. Available from: http://pediatricsurgery.stanford.edu/C onditions/BowelManagement.html
- Vaillancourt “I Hear and I Forget, I See and I Remember, I Do and I Understand.” Can J Hosp Pharm. 2009;62(4):272-3.
- What Are the Benets of Demonstration As a Teaching Method? | Reference.com [Internet]. [cited 2020 Apr 18]. Available from: https://www.reference.com/world- view/benets-demonstration- teaching-method-1c6dc5936f279bac
- Bosse HM, Mohr J, Buss B, Krautter M, Weyrich P, Herzog W, et al. The benet of repetitive skills training and frequency of expert feedback in the early acquisition of procedural BMC Med Educ. 2015 Dec;15(1):22. doi : 10.1186/S12909-015-02865