Effect of Implementing Educational Strategies on Nurses' Performance Regarding Cardiac Catheterization for Children with Congenital Heart Disease

Background: Congenital heart disease in children is the most common major congenital anomaly that is required to be treated by cardiac catheterization which stands out as a reasonable tool to diagnose and treat children of various heart diseases. The aim of the study was to evaluate the effect of implementing educational strategies on nurses' performance regarding cardiac catheterization for children with congenital heart disease. Research design : Quasi-experimental research design was used . S ubjects and setting: Convenience sampling of nurses (50nurses) from Cardiac Intensive Care Unit and Cardiac catheterization Unit at Tanta Educational International Hospital. Two tools were used to collect data: Tool I : Structured interview for nurses regarding their knowledge of congenital heart diseases and cardiac catheterization. Tool II : An Observational checklist for nurses’ practices. Results demonstrated that Three quarters of nurses had poor knowledge and majority of them had unsatisfactory level of practice before implementation of the educational strategies, while immediately and after one month total scores of nurses` knowledge and practice were improved with a statistical significant differences .The study concluded that: The finding of the present study revealed there was significant improvement of nurses' knowledge and practices after implementing of educational strategies. The study recommended that Continues in-service training programs for all nurses should be conducted in order to improve, update and refresh their knowledge and practices regarding cardiac catheterization for children with congenital heart disease.


Introduction
Congenital Heart Disease in pediatric children is life threatening disorders that affect the child health and family, about 1 in 120 newborns born each year in the United States has a congenital heart diseases.Congenital heart defects are structural problems with the heart that are present at birth.They result when a problem occurs during heart development soon after conception; it has to occur during the first 8 to 12 weeks of gestation (Salma.2018).Congenital heart disease is caused by prenatal environmental hazards as well as hereditary reasons, most of the time, the real cause of heart abnormality is unknown.More than 32,000 newborn each year with some forms of heart defect (Powell-Wiley., et al.

2021). Incidence of Congenital heart disease among
Egyptian children was found to be 5:6/1000 live births (staff, 2023).These children are often diagnosed in the first year of life and childhood (Garg., etal.2013).The birth prevalence of congenital heart disease varies among studies worldwide and is mostly reported between 8 and 12 per 1000.With a prevalence of 9 per 1000, approximately 1.35 million newborns are born with Congenital Heart Disease every year globally" (Powell-Wiley., et al. 2021) The etiology of congenital heart disease in children is not fully understood in more than 90% of cases.However, certain factors are associated with a higher prevalence of these defects, including prenatal influences such as maternal rubella infection during pregnancy, maternal alcoholism, advanced maternal age (over 40 years), and maternal insulindependent diabetes.The increasing prevalence of congenital heart defects is likely attributed to advancements in diagnostic capabilities and improvements in overall survival rates.Scoring system for nurse's practice as follow: -Done correctly and completely were scored as (1).
-Done incorrect or not done at all were scored as (0).The total score level of practice was calculated and classified as follow: -Satisfactory practice ≥ 80 % -Unsatisfactory practice < 80% Method: The study was conducted through the following steps 1-Official permission was obtained from Faculty of Nursing, Tanta University and directed to the administrators responsible for cardiac Intensive Care Unit and Cardiac Catheterization Unit of Tanta Educational International Hospital to obtain their approval and cooperation to conduct this study 2-Ethical Scientific Researcher Committee gave its ethical approval with ethical code (54-4-2022).a) Nurses were notified of the study's purpose before providing their informed consent for inclusion in the research study.Privacy and confidentiality for the nurses was assured.b) There was no harm or injury to the nurses as a result of the study.c) Nurses had the right to leave the study at any time.d) The aim of study was explained to the studied nurses before conducting the study.3-Tools development: Two tools were utilized in the study:-Tool I, II were designed after reviewing of relative literature to assess nurses` knowledge and practice.4-Content validity: -Prior to initiating the research, both tools were tested for content and construct validity by five experts in nursing field to verify that the data was accurate and pertinent.Content validity index were 98%.Recommendation from expertise was done 5-Reliability: -The reliability of the tools (I and II) was evaluated using Cronbach's alpha, which was 0.891.6-A pilot study involving 10% of nurses from previously setting was conducted in order to assess the viability and intelligibility of the tools.The essential change was made.7 -Application of the current study done taking the subsequent steps: I. Assessment phase:-The researcher reviewed recent related literature regarding cardiac catheterization for children with congenital heart disease strategies and expertise in order to implement it to assess the children who meets the inclusive and exclusive criteria of this study and to assess nurses' knowledge regarding cardiac catheterization and congenital heart diseases which include the following :-1-Preparation of the content: The researcher developed an educational Arabic booklet based on nurses' needs and data from the assessment phase, using recent relevant literatures available locally and internationally (books and magazines -The fifth session, Focused on nurses practice regarding fluid balance(intake and output), administration of intravenous fluids procedure or blood if needed and medications as ordered -The sixth session: Focused on practices of skin care, wound dressing procedure, oxygen therapy procedure if needed, monitoring intake and output and prepared the child for discharge through nutritional needed, exercise and follow up plan

Statistical analysis:
The SPSS statistical computer application, version 26, was used to arrange, tabulate, and statistically analyze the data that had been gathered.The range, mean, and standard deviation were computed for the quantitative data.To compare qualitative data, the Chisquare test (χ2) was employed.The paired samples t-test was utilized to compare the means of two variables within a group.The analysis of variance (ANOVA).R, the correlation coefficient between Pearson and Spearman, was used to assess the correlation between the variables.-Correlation between variables was evaluated using Pearson's correlation coefficient (r).Significance was adopted at p<0.05 for interpretation of results of tests of significance.
-In order to evaluate the findings of the significance tests (*), a significance level of P<0.05 was used.The findings of tests of significance were also interpreted using a highly significant at P<0.01 (**).(White E. 2019).Results: The nurses who can spot issues early are best positioned to take decisive action and enhance pediatric outcomes.Therefore, lowering the mortality and morbidity rates for children undergoing cardiac catheterization may be possible for nurses with experience in patient care during Cardiac catheterization (Qiu, 2024).High quality nursing care for children in cardiac intensive care units demands professional nursing knowledge and practical skills, due to its specificity and complexity (Vozzella & Hehman, 2023).Therefore, the current study was conducted to assess the effect of implementing educational strategies on nurses' performance regarding cardiac catheterization for children with congenital heart disease.Regarding educational level of the studied nurses, the present finding revealed that half of them graduated from technical institute of nursing while the least of them had post graduate diploma.The educational level of nurses is a critical factor that directly affects the quality of care provided to children, especially those with congenital heart disease undergoing cardiac catheterization, as these children are frequently in critical condition and require advanced, specialized care Concerning the acquisition of knowledge about congenital heart disease and cardiac catheterization, the result of the current study revealed that there was an improvement in the total level of nurse's knowledge immediately and one month after the implementation of intervention compared to nurses level before the implementation of intervention.The result of current study revealed that more than half of studied nurses had low level of knowledge score before implementation of educational strategies.From the researcher point of view, it may be due to lack of orientation programs before their work, absence of their inspiration in refreshing their knowledge, work overload in cardiac catheterization unit.the lack of inservice educational program cardiac catheterization, no accurate sources for acquiring knowledge , the lack of training courses and lack of availability of manual booklets about caring of child after cardiac catheterization.

Ali et al. (2023)
were in the same line with the current study, they reported that more than half of studied nurses had poor knowledge scores about Cardiac Catheterization before the implementation of educational guidelines.On the opposite immediately after educational strategies implementation, nurses` knowledge improved and most of them obtained high Scores.It might be due to the effectiveness of implementing the content of educational strategies which was developed based on nurses` needs, its clarity and simplicity, and using of audiovisual aids, in enhancing their knowledge through availability the booklet about how to deal with child undergoing cardiac catheterization.Aburaghif and Hassan (2016) who were in accordance with the current finding, they illustrated that there were highly significant differences between the two periods (pre and post-tests) of study sample in all domains of (nurses' information about cardiac catheterization and its complication.Also, El-Sol and Badawy (2017) were in accordance with the current study.They showed that total knowledge of nurses significantly increased after the application of teaching module.Furthermore, one month after the implementation of teaching strategies and follow up, there was slightly decline in nurses` knowledge and near to two third had moderate level scores in all items of knowledge.From the researcher view, this might be due to forgetting and decreasing of knowledge with the time factor.Monis (2017) who were in a harmony with the current results who confirmed that information can be easily forgotten if they are not refreshed periodically Similarly, Ali and Ali (2019) was in accordance with current study, they showed that nurses' level of knowledge was higher after the implementing of the designed teaching protocol post implementing the designed teaching protocol than pre implementation.The current study revealed that most of the studied nurses had satisfactory level of practice regarding care of children undergoing cardiac catheterization immediately after implementation of educational strategies.From the researcher point of view, this might be due to the efficiency of strategies implementation in enhancing nurses` practice through demonstration of nursing skills about how to care for the child undergoing cardiac catheterization.Sania, S., & J. (2022) were in same line with the current finding .They revealed that there was a significant difference between nurses' level of practice after implementation of educational training.While after one month of strategies implementation, there was a slight decline in nurses ` practice.From the researcher point of view,.This might be due to forgetting about the time factor and the need of nurses for repeating educational strategies periodically to maintain their satisfactory level of practice.Shini S.& W. (2019) who congruent with the present finding.They found that after three months post-test of nursing care protocol, the scores of nurses' total practices were slightly reduced and most of nurses had satisfactory levels Also Elewa and Elkattan (2017) who showed that nursing skills must improve through training and continuing education, this provides quality and effective health care to children.Concerning correlation between the total nurses` knowledge, practice scores and their socio-demographic characteristics.It was cleared that there was a positive correlation between studied nurses` age, educational level and their knowledge and practice.From the Researcher point of view, this finding may be since administrators of the unit were selecting them for the unit of cardiac catheterization due to their abilities to understand the tasks more efficiently.

Bakar et al. (2020)
were agreed with the current study who confirmed that older nurses have less access to continuing professional development activities when compared to their knowledge.Also, Abolwafa, H., & Mohamed (2019) who agreement with the current findings, as they stated that the highest knowledge and practice scores were found among nurses having bachelor degree in nursing science which provide them with more information.Regarding correlation between total knowledge and total practices scores of studied nurses, the results of the current study revealed that there was statistically significant positive correlation between total knowledge scores and total practice scores before, immediately and one month after the implementation of educational nursing strategies about cardiac catheterization, This could be due to using of theoretical component which help in regulating nurses` practice as the nurse acquire new knowledge, developed skills that they were able to apply them perfectly during their practice.Therefore nurses` knowledge level was linked with their competency level of practice.Mohamed et al. (2023) who illustrated that there was a significant improvement in nurses' healthy behaviors post intervention protocol.
Furthermore, Ghareeb & Abouelezz (2022) illustrated that nurses' practice regarding the care of patients before cardiac catheterization significantly improved after coaching program.Finally, it is revealed from the present study that there was an improvement of nursing staff knowledge and practice after educational strategies implementation in relation care of children with congenital heart disease undergoing cardiac catheterization.This may be due to the fact that successive educational sessions using different educational strategies and continuous evaluation improve nurse`s knowledge as these strategies were planned and implemented according to their pre assessed needs.Furthermore, simplification of well-presented information by suitable educational aids increases their interest and desire to acquire a lot of knowledge.

Conclusion
Based on the findings of the present study, it can be concluded that, there Was a statistically significant improvement in nurses' total knowledge and practices scores immediately, and one month after the implementing of educational strategies regarding cardiac catheterization for children with congenital heart disease.Also, there was a positive correlation between nurses' knowledge and practice before, immediately, and one month after the implementation of educational strategies.

Recommendations:
1. Continues in service training strategies should be conducted periodically and regularly for all nurses working in Cardiac Catheterization Units about implementation of educational strategies regarding cardiac catheterization for children with congenital heart disease.2. Cardiac Catheterization Units must have a documented policy describing the standard nursing care that should each child receives in the unit.3. Developing a system at Cardiac Catheterization Unit for evaluating nurses' performance regarding updated strategies in care of children undergoing cardiac catheterization.
who were align with current study, these findings revealed that most of the nurses in the study graduated from a technical institute of nursing, and onequarter of them had never attended training courses related to cardiac catheterization.Regarding the attendance training program related to care of children undergoing cardiac catheterization, The results of the current study revealed that slightly more than two thirds of the studied nurses didn't attend the training program cardiac catheterization care for children with congenital heart disease From the researcher point of view, it might be due to the shortage of nurses in cardiac catheterization unit and work overload that prevent them from attendance of training program.These findings correspondent to Mohamed, Fathy & Mahmoud, (2023) who found that most of the studied nurses didn't attend previous training courses related to cardiac catheterization.Ali, Fadl, Adel, Mahmoud & Abdelaziz, (2023) were disagreed with these findings, as he stated that three quarters of them attend previous training program pediatric patient safety post cardiac catheterization .

2019, Vozzella, et al. 2023):-
heart disease.It included the following: Part(1) Nurses` practices pre-cardiac catheterization: it included the following; Monitoring vital signs, and physical examination, checking child from head to toe in a systematic manner, in addition to measurement of weight, height, body mass index, fluid balance (intake and output) oxygen saturation, administration of intravenous fluids and medications as ordered Part (

Table ( 1
): Illustrates that 70% of the studied nurses were in the age group 30≤40 years with mean age 33.74± 4.71 years and 50% of the studied nurses graduated from health technical institute.Also 62% of the studied nurses were from urban areas and 52% of them were married.

Table ( 3): Total level scores of the studied nurses` practices regarding physiological measurements for children with congenital heart disease.
*: Statically significantly difference at (P value <0.05)