Nurses ’ Performance and Knowledge Regarding Newborn Screening Program for Congenital Hypothyroidism , EL-Behaira Governorate

Background: Nurses have a major role in caring for congenital hypothyroidism (CH) neonates in the pre-analytic phase of the Newborn Screening Program (NSP) as well as at the post-analytic phase. Objectives: To assess performance of nurses working in the pre-analytic phase of the Egyptian NSP for CH at Kafr El-Dawar Health District, El-Behaira Governorate and to assess their knowledge regarding this program before and after implementation of educational sessions. Methods: Crosssectional and quasi-experimental designs were used to conduct the study in 39 health units, representing all health units in Kafr El-Dawar health district, and included 122 nurses working in these units. Observational checklist was used to assess their screening performance during collection of samples and their adherence to the program guidelines.The Knowledge was assessed before and after the application of an educational program using knowledge assessment sheet. Results: Adherent nurses' performance was observed at all heath centres (100%) regarding the following items: the use of appropriate filter paper in collecting the samples; the accuracy in writing cards information; disinfection of the heel; putting the used lancet in the safety box and sending sampling cards to lab in the same day (5 items out of 20 items). On the other hand, washing hands before every sampling was not done in 100% of observations. The lancet was used in the appropriate site in nearly two thirds of observations (74.6%).The sample cards were kept in its special rack in nearly 73.8% of observations. The screening cards were put in its envelope after drying in 81.1% of observations. Health education of mothers about CH in general and CH complications in particular were done with only 57.4% and 28.7% of cases respectively. It was not done about the symptoms of CH in 100% of the observations. There was a statistically significant improvement in nurses' Knowledge after the educational program. Recommendations: Continuous education programs should be mandatory for all nurses providing pre-analytical phase services of NSP for CH. In addition, adequate supervision, guidance and regular feedback by head nurses as well as availability of clinical protocols and guidelines are greatly needed to improve nurse's performance. To facilitate implementing the guidelines by nurses, adequate infection control materials should be available in units providing the service.


INTRODUCTION
(3) The term "newborn screening" is used to describe various types of tests that are done during the first few days of a newborn"s life. ( The goal of newborn screening is to detect CH and begin treatment before the infant reaches one month of age. Studies show that by detecting CH at birth or shortly thereafter, and by beginning thyroid replacement therapy with L-thyroxin within the first few weeks of life, hypothyroid infants can be expected to grow and develop normally with only minor problems.(2,4,5)   Newborn screening is not just a laboratory test.Newborn screening has evolved into a system that relies on smooth integration of the efforts of a number of individuals and processes.This newborn screening system is comprised of six essential components namely; education (health professionals, parents, the general public and politicians); Evaluation (outcome monitoring and quality assurance throughout the system). ( In general, quality evaluation is only applied to the pure laboratory analytical phase of newborn screening laboratory tests.Less attention is given to the pre-analytical phase (e.g.timely sampling, maximum coverage) and the post-analytical phase. (7)Nurses have a major role in caring for CH neonates in the pre-analytic phase of the Newborn Screening Program (NSP) as well as at the post analytic phase. (

Study setting:
This study was conducted at Kafr El-

Study design:
Cross-sectional and quasi-experimental approaches were used in this study.The cross-sectional design was used to assess the performance of nurses during samples collection while, the quasi-experimental design was used to assess nurses" knowledge about the NSP before and after the implementation of an educational program.

Study sample:
All All health units in Kafr El-Dawar Health District applying CH screening procedure (39 health units) were visited and evaluation of nurses" performance was done separately at each unit using the observational checklist.

Data collection:
Data was collected over a period of 4 months starting at August 2010 to November 2010 using the following tools:

1) Observational checklist:
It was designed by the researcher based on The Egyptian Ministry of Health and Population (MOHP) guidelines for NSP for CH. (3,9,10)This checklist was used to assess the nurses" screening performance and their adherence to the program guidelines during samples collection.Also, nurses were observed while conducting health education for mothers of screened newborns.This observational checklist included 20 items (Table 1).
Each nurse was observed separately at the health unit where she works.It is important to mention that the observations were done before the application of the knowledge assessment sheet (i.e.before the pre-test or implementation of the educational program).
Each activity was assigned score of 1 if done and 0 if not done.
2) Self administered questionnaire:  The results of the pilot study were included in the final results.

Data analysis:
The collected data were revised, coded and

Ethical considerations:
The anonymity of participants and confidentiality of their responses was assured.
Their consent to participate in the study was taken.The nurses were informed that their performances would be observed, but they did not know the items to be evaluated or the time of observation.

RESULTS:
Table 1    Mother drug intake Mother"s age Iodine deficiency Unknown cause       understand what parents need to be told so that they become able to make informed decisions about their newborns. (14)This finding supports the hypothesis of the importance of the educational program related to health problems on nurses' performance, (15) and reflects the impact of training courses that enhance nurses' technical knowledge and skills. ( The observation of nurses' performance during collection of samples revealed defect in adherence to guidelines of MOHP policy regarding hand washing before every sample collection, changing gloves before every sample, mothers' health education about symptoms and treatment of CH.In observational studies of the adherence of healthcare workers to recommended hand hygiene procedures, it was revealed that hand hygiene adherence was poor, with mean baseline rates of 5%-81% (overall average 40%). (17,18)The present study raises questions about possible barriers to hand washing before each sample collection.This issue could be investigated using qualitative methods such as focus groups or nurses" indepth interviews.
The American academy of pediatrics recommended that the filter paper spots should not be handled, placed on wet surfaces, or contaminated by coffee, milk, or any other substances.
( Finally, establishing a discipline to be followed in all health units so that CH sample collection should be done in a room where a water source is available would facilitate nurses' hand washing practice. screening (proper timing and specimen collection, transport and laboratory testing); early follow-up (abnormal test notification, tracking and confirmatory testing)monitoring and long term follow-up);

, 8 )
Pre-analytical processes include reviewing and monitoring any activity occurring prior to testing the specimen.The present study aimed to assess Abou El-Enein & Nasar 100 performance of nurses working in the preanalytical phase of the Egyptian NSP for CH at Kafr El-Dawar Health District, El-Behaira Governorate.Also, the study aimed to assess knowledge of nurses regarding this program before and after implementation of educational sessions.

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was designed by the researcher according to the policy of the Egyptian MOHP for NSP for CH for the year 2002.It included 8 headings with 25 questions (true or false) to asses nurses" knowledge about definition and causes of CH, treatment type and duration, errors during collecting samples, sending samples to lab in the same day and hand washing before sample collection.In each unit, randomly selection of one nurse was done to be observed while collecting the sample for one newborn so the number of observation is similar to the number of nurses 122.Scoring system of nurses' knowledge was Abou ElAn educational program was developed by the researcher that aimed to improve nurses' knowledge about CH and their performance of neonatal screening.The intervention was applied in three sessions for nurses as follows:  The first session took one hour and included pre-test assessment of participant nurses.The second session included the educational component of the program and it took two hours.Various teaching methods were used including lectures, group discussion and demonstrations on power point viewer.The educational material included information related to steps of CH samples collection, the common practice errors and health education of mothers about CH and its treatment.assessment of the nurses who attended the previous two sessions and it took one hour.It was done one month after program implementation.All indexed nurses were gathered on 3 occasions at the administration office of Kafr El-Dawar health office with the attendance of the supervision team in the health district (4 doctors and 8 head nurses).The presence of monthly formal appointment to all nurses collecting CH samples at Kafr El-Dawar Directorate of Health Affairs facilitated the success of the educational program sessions.There was complete commitment from both; supervision team at Kafr El-Dawar health office and indexed nurses who attended the three sessions (122 nurses).Evaluation of the educational program success was based on the improvement of nurses' knowledge scores.Each answer was assigned score of 2 if correct and 0 if incorrect.
computed.Data was then transferred to Statistical Package for Social Sciences (SPSS).Data was analyzed using PC with SPSS version 13.0 and Epi-info program version 6. Statistical analysis included frequency, percentages, cross tabulation, mean, standard deviation, chi square and one way analysis of variance (ANOVA).The 0.05 level was used as the cut off value for statistical significance.
Collected sample should be sent to central lab on the same day.
at p<0.01 mothers and infants need to be aware of the laws and policies regarding newborn screening, become familiar with the conditions screened, their inheritance pattern, and their early symptoms.The study also emphasized that they should