الفهرس 
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Abstract
Summary
rainage of the pleural space by means of a chest tube
drainage is the commonest intervention in thoracic
trauma, and provides definitive treatment in the majority of
cases. While a relatively simple procedure, it carries a
significant complication rate, reported as between 2% and 10%.
While many of these complications are relatively minor, some
require operative intervention and deaths still occur (American
Thoracic Society, 2014).
Incorrect nursing management of chest tubes drainage
may lead to a number of complications which can result in
increased morbidity, extended hospitalization and, in some
cases, mortality. The patency and integrity of chest drainage
systems are, therefore, crucial to the preservation of
cardiopulmonary performance and the health and well being of
patient (Millikan et al., 2014).
The nurse is responsible about many aspects of the
management of chest tube drainage. Also the nurses have
responsibility for the day to day monitoring and management.
Complications are more likely to occur if chest tube is used
without appropriate knowledge or skill (Parkin, 2013).
Nursing intervention for management of patient with
chest tube drainage is important. The nurses must have a
comprehensive understanding of all aspects of care with the
chest drain systems and areas requiring special attention would
D
be important to reduce the complications arising from chest
tube drainage (Sullivan, 2008).
Nursing intervention guidelines need to beyond simply
providing new knowledge and skills, by addressing issues of
confidence and involvement to their professional roles. There
have a continuing positive impact on participant’s interest and
commitment to their professional growth (Allen, Shebesta and
Falcone, 2013).
Nursing intervention guidelines is a planned organized
sort of evaluated activities that based upon needs assessment,
philosophy, conceptual framework, local policy and
procedures. As well as economic facilities in order to achieve a
broad objective of acquired and or refreshing knowledge skills
become increasingly competent when dealing with patient
(Allen et al., 2013).
Aim of the Study
This study aimed to evaluate the effect of nursing
guidelines for chest drainage management on nurses’
performance through:
1. Assess nurses’ performance (knowledge & practice)
regarding chest drainage management
2. Develop and implement the nursing guidelines for chest
drainage management based on nurses’ needs assessment.
3. Evaluate the effect of nursing guidelines for chest drainage
management on nurses’ performance.
Summary
138
4. Assess chest tube drainage associated complications pre and
post guidelines implementation.
Research Hypothesis
The nurses’ performance (knowledge & practice) regarding
chest drainage management will be improved post the
nursing guidelines implementation.
Patients who received nursing care post the guidelines
implementation will have less chest tube drainage associated
complications than patients who received nursing care pre
the guidelines implementation.
Operational definitions
Nursing guidelines: mean the nursing intervention
guidelines implementation training program developed by
researcher based on review of literature and nurses
performance that including the essential nursing care for
management of patients with chest tube drainage insertion
and removal (pre, during and post procedure).
Nurses’ performance: means the nurses’ knowledge and
practice regarding the nursing intervention for management of
patients with chest tube drainage
Subject and methods of this study were portrayed under four
main designs as follows:
Technical design
Operational design
Summary
139
Administration design
Statistical design
I. Technical design
The technical design for this study included the
following: research design, setting, subjects and tools for data
collection.
A) Research design
A quazi experimental design was used to conduct this
study.
B) Setting
This study was conducted in the cardiothoracic surgery
intensive care unit at - Ain Shams University.
C) Subjects:
A convenient sample included all available nurses (No. = 35),
who working in previous mentioned setting and accepted to
participate in the study from both gender with different
qualification (diploma nursing, diploma with specialty,
bachelor degree, and master degree), different age, training
courses and years of experiences were recruited to this study.
A purposive sample composed of 50 adult patients from
both gender with chest tube drainage. They were recruited
from the above mentioned setting, 25 of them (control
group) who received routine care, while other 25 (study
group) who received nursing intervention guidelines
implementation training program (study group). The patients
in both groups (control & study) included in the present
study were selected according to the following criteria:
Inclusion criteria:
• All adult patients aged ranged from 30-60 years.
• from both gender
• Different educational levels
• Patients with hypertension under control which most
common predisposing factor for cardiac diseases.
• Free from other chronic diseases, complicated or
debilitated diseases
• Able to comprehened the instructions
• Agree to participate in the study
The exclusion Criteria:
• Patients with mental or psychatric disorder.
• Patients who were exposed previously to educational
program or guidelines about the nursing intervention for
management of chest tube drainage
Tool of data collection
Three tools were used for data collection
I. Self-administered questionnaire sheet: (pre, post
and follow up tests) (Appendix I)
It was used to assess the nurses’ level of knowledge
regarding nursing intervention for management of patients with
chest tube drainage, pre, post and follow up of the nursing
guidelines implementation training program. It was developed by
the researcher in English language based on review of relevant
recent literature (Sim, 2006 and Arnold and Harvey, 2003), and
translated into Arabic language then back translation was done.
This tool was filled three times the first time pre the
guidelines implementation training program; the second
time was immediately post the program implementation and
the third time post 3 months later (follow up) of the its
implementation.
The total scoring system for the questionnaire sheet was as
follow: one grade was given for the correct answer and zero
for the incorrect answer, total grade of knowledge was (83)
grades.
The scoring level of nurses’ knowledge was used as follow:
o ≥70% satisfactory level of knowledge.
o <70% unsatisfactory level of knowledge.
II. Nurses’ practice observational checklist: (pre, post
and follow up tests) (appendix II):
It was developed by researcher to assess the nurses’ level
of practice regarding the nursing intervention for management
of patients with chest tube drainage, pre, post and follow up of
the nursing intervention guidelines implementation training
program. This tool adapted from Shaker (2011), Dobra et al.
(2001), and Jacob et al. (2007) and modified by the researcher.
This tool was filled three times the first time pre the
guidelines implementation training program; the second time
was immediately post the program implementation and the
third time post 3 months later (follow up) of its implementation.
Scoring system: as the following
The scoring system for the nurses’ practice observational
checklist was as follow; one grade for each step that done
correctly, and zero for step that don incorrectly or not done, the
grades were summed up and converted into percent total
grades, and then the scores were converted into qualitative
variables through categorization. The total grade of nurses’
practice was (228 grades).
The scoring level of nurses’ practice was used as follow:
• ≥70% satisfactory level of practice
• <70% unsatisfactory level of practice
III. Patients’ chest tube drainage associated complications
assessment sheet (III)
Part one: It was concerned with demographic
characteristics of patients under study such as age, gender,
level of education, number of chest tube drainage that
connected for patient, site of chest tube drainage insertion
and size of chest tube …etc.
Part two: It was used to assess the complications in both
groups (study and control).
Scoring system: as the following
The scoring system for the patient’ assessment sheet was
as follow; one grade for each problem and complication that
present, and zero for not present and take mean for each
problem.
Tools’ validity and reliability (Appendix 4):
o Tools validity was tested through a jury of of (9) experts and
tools reliability was tested by Alpha cronbach test.
Ethical consideration:
The ethical research considerations in this study
included the following:
The approval for data collection from the nurses was
obtained and the researcher clarified the aims, objectives and
expected outcomes from the study. They were secured that all
the gathered information be confidential and used for the
research purpose only.
Pilot Study
A pilot study was carried out on 10% of the study sample
under study to evaluate the applicability, clarity and efficiency
of the tools. The necessary modification would be done
according to the result of the pilot study.
The field Work:
Data collections took about nine months, started from
March 2015 to the end of Novamber 2015. The training
program was implemented for nurses in cardiothoracic surgery,
intensive care unite in term of sessions with integration the
theory into practice regarding the nursing intervention for
management of patients with chest tube drainage.
The data were collected throughout three phases as
following; first phase of assessment for nurses performance
(knowledge and practice) and patients complications associated
with chest tube drainage in the control group pre conducting the
training program, this phase took two months, the second phase
of assessment for nurses performance and patients
complications in the study group immadiatly post conducting
the training program, this phase took two months, and the third
phases of assessment for nurses performance post 3 months
form the secondary assessment. It took one month. In addition,
the training program implemntation phase took a period of one
month.
The field work of the current study included the
following stages; I. Pre implementation of the training program
(intial assessment), II. Nursing intervention guidelines
implementation training program, III. Implementation of the
training program (intervention) and IV. Evaluation the
effectiveness of training program.
Stage (I): Pre implementation of the training program
(Initial assessment)
For nurses:
The first phase of assessment of their performance
(knowledge & practice) regarding nursing intervention for
management of patients with chest tube drainage by using the
two previoslly mentioned tools (I & II) as following; the
nurses’ practice observational checklist was used prior to
administration of the questionnaire sheet to ensure the maximal
realistic observations of nurses’ practice and minimize the
possibility of bias. The nurses’ practice observational checklist
was filled by the researcher by observing the nurses while
caring of patients with chest tube drainage at Cardiothorasic
Surgery Intensive Care Unit.
Filling the observational checklist in the morning and
afternoon shifts during actual work and documenting the
nursing intervention for management of patients with chest tube
drainage. It was carried out through a scheduled and specific
days arranged for visiting the selected setting (Saturday,
Sunday and Monday) for each week. The researcher observed
nurses during morning and afternoon shifts for three days
weekly were chosen to collect data.
The questionnaire sheet was conducted in the clinical
area where the nurses were providing the care for patients with
chest tube drainage. The researcher interviewed the nurses and
explained the purpose of the study. The nurses were assured
that information collected would be treated confidentially, and
it would be used only for the purpose of the research. Only
code numbers were used and no names appeared.
The questionnaire sheet was filled by the nurse after
completing observation for all nurses. It was filled 3 times (prepost-
and follow up). It was administered to each nurse
individually using the personal interview method. The
interview was carried out in the separate space at the unit
during break time the questions were directed in simple Arabic
language and the answers were recorded immediately.
The sheet was filled by nurses’ staff in the presence of the
researcher to ensure maximum homogeneity response. It was filled
3 times per the nursing intervention guidelines implementation
training program; immediately post its implementation and post 3
months later (follow up) of its implementation. Its filling took
about 30- 45 minute. The data were collected through interview
sessions over a period of four weeks.
• For patients in the control group
Data about the complications associated with chest tube
drainage among the patients in the control group was collected
using the previously mentioned tool (III), as following:
The assessment sheet was conducted individually for
patients eligible for the study (control group) (fulfilled the
inclusion and exclusion criteria) in order to explain the purpose
of the study. Filling the assessment sheet took one hour ⁄ day ⁄ 3
days ⁄ week, the numbers of patients were 2 patients per day, 6
patients per week, and 25 patients per month, but some
modifications were needed according to the patients’ condition,
the number of patients in each day and their free time.
Stage (II): Nursing intervention guidelines implementation
training program (Appendix VI)
Preparatory phase:
It was included reviewing of literature related to the
nursing intervention guidelines implementation training
program design and the theoretical knowledge of the various
aspects of the training program using books, articles,
magazines, and internet to develop data collection tools and the
training program for nurses.
The preparatory phase took about one month. Requesting
the permission for data collection from the faculty of nursing/
Ain Shams University to the director of Ain Shams University
Hospital at which the study was conducted.
Planning phase:
Development of the nursing intervention guidelines
training program was based on the results of nurses’ knowledge
and practice (pre-test result) and reviewing the most recent
related literature and revising by expertise. The nurses learning
needs were identified and classified into knowledge and
practice. Detected needs, requirements and performance
deficiencies were translated to aim and objectives of teaching
guidelines. Objective was categorized to general and specific
objectives. The general objectives of the nursing intervention
guidelines training program was to upgrade nurses knowledge,
and practice related to the nursing intervention for management
of patients with chest tube drainage and prevent any sign and
symptoms of any complications for such group of patients.
Stage (III): Implementation of the training program
(Intervention):
The nursing intervention guidelines implementation
training program for nurses caring of patients with chest tube
drainage at cardiothoraxic surgery intensive care unit. It was
developed by the researcher based on the current related
literature developing. The content of the nursing guidelines
implementation training program based on nurses’ identified
needs as illustrated in the booklet (Appendix VI).
The nursing intervention guidelines implementation
training program included 5 sessions (2 sessions for theoretical
part and 3 sessions for practical part) in addition to one session
conducted at the begining of the program for orientation and
pre test application while another session conducted at the end
of the program for revision and post test applications.
Each session started by the summary about what was
given in the previous session and the objectives of the new
topics were mentioned, taking into consideration using simple
language to suite the level of the nurses. Motivation and
reinforcement techniques as praise and recognition during
conducting the training program sessions were used to enhance
learning. The booklet was distributed to all nurses included in
the program from the first day of its implementation. Each
session included the new topics with general and specific
objectives, involving the attractive media and methods.
The group of studied nurses was about 12 nurses for each
shift according to their schedule of working. It was difficult to
gather all the nurses at one time, so nurses were divided into
two groups in each shift about 6 nurses, and conducting session
twice in each shift and the training program was implemented
for each group separately according to the suitable time for
them, this is to decrease intensity of work stress and their time
of ICU allows.
Timing of training pogram sessions or teaching lectures
conducted as following; for the nurses in morning shift, the
sessions started from 10.00 am to 11.00 am or from 12.00 am to
1.00 pm, for the nurses in after noon shift the sessions started
from 3.00 pm to 4.00 pm or from 4.00 pm to 5.00 pm, while the
nurses in night shift the sessions started from 7.00 am to 8.00
am or from 9.00 am to 10.00 am.
To ensure exposure of all nurses to the same learning
experience, each group received the same nursing intervention
guidelines content and using the same teaching strategies;
discussion, teaching and correction on the spot, real objects,
handout, posters and data show. Learning CD was also used to
clarify some items during the training.
Stage (VI): Evaluation the effectiveness of training
program:
Second phase of assessment was collected post
conducting the nursing intervention guidelines implementation
training program for assessment of nurses’ performance
(knowldage & practice) and patients’ complications in the
study group as following:
For nurses: The nursing intervention guidelines
implementation training program was evaluated by researcher
for comparing the change in nurses’ knowledge and practice
pre, immediately post the training program implementation and
post 3months later (as follow up) of its implementation using
the same data collection tools (I&II).
For patients: patients’ complications associated with
chest tube drainage was evaluated by researcher for comparing
the change in patients’ complications in both study and control
groups by using the same data collection tool (III).
Limitation of the study
Many obstacles faced the researcher in the previous’ clinical
settings including:
- The turnover of patients was high, so the nurses couldn’t
have time to answer the questionnaire sheet and its filling
exceeded the estimated time.
- Shortage in staff nurses, so the hospital policy didn’t allow
nurses to be free completely to engage in program
implementation.- It was difficult to collect all nurses together, at the same
time, to attend the program session; this problem was
overcomed by implementing the program twice per shift.
- Short term leaves, such as day off, causal leaves, short sick
leaves were overcomed by repeating the missed sessions to
these nurses separately.
The most important findings obtained from the study can
be summarized as following:
Regarding demographic characteristics, the result reveals
that all of study sample (nurses) 100% were females.
Regarding the nurses’ age, the study result revealed that
54.3% of the study sample were less than 25 years, while
22.9% of them were between 25-30 years, 22.9% of them
were more than thirty years.
Regarding nurses’ educational level, the study finding
shows that (51.4%) of the studied sample had secondary
school diplom and (31.4%) of them had technical nursing
education, while 14.3% of them had Bachelor degree in
Nursing Science.
Regarding the nurses’ years of experience, less than half of
the studied nurses 45.7% had experience less than 5 years,
while 34.3% of them had 5-10 years and 20.0% had more
than 10 years and the mean years of their experience was 7.3
± 3.6 years.
Concerning attending training course, 100% of the studied
nurses didn’t attend any training course related to
management of patients with chest tube drainage.
In relation to the nurses satisfactory knowledge total score
regarding anatomy and physiology of respiratory system,
overview about chest tube drainage and nursing intervention
for management of patients with chest tube drainage pre,
post and follow up phases of the training program 25.7%,
91.4% and 82.9% of the studied nurses respectively had a
total satisfactory level of knowledge regarding anatomy and
physiology of respiratory system, overview about chest tube
drainage and knowledge about the nursing intervention for
management of patients with chest tube drainage at pre, post
and follow up phases with highly statistically significant
differences between pre/post and pre/follow up phase of the
nursing guidelines implementation training program at (X2=
31. 1 and 23.0 at P>0.01).
In relation to total satisfactory level of nurses’ practice
regarding nursing intervention for management of patients with
chest tube drainage (Care & Removal) pre, post and follow up
phases of the training program, 22.9%, 82.9% and 51.4% of the
nurses had satisfactory level of practice regarding nursing
intervention for management of patients with chest tube
drainage (total care for chest tube & total care for removal) at
pre, post and follow up phases respectively with a highly
statistically significant difference between pre/post and
post/follow up phases of the nursing guidelines implementation
Summary
153
training program at (X2= 25.3 and 7.8 at P< 0.01**), while,
there were statistically significant differences between
pre/follow up phase of the nursing guidelines implementation
training program at (X2= 16.6 at p< 0.05*).
In relation to total satisfactory level of nurses’ knowledge
regarding nursing intervention for management of patients
with chest tube drainage and their practice, there were a highly
statistically significant relation between total level of nurses’
knowledge regarding nursing intervention for management of
patients with chest tube drainage and their practice at pre and
follow phases (X2=7.3 and 7.7 at p> 0.01**). Meanwhile,
there were statistically significant relation between their
knowledge and their practice at post guidelines
implementation training program (X2=5.7 at p > 0.05*).
Regarding demographic characteristics among patients
participated in the study. The highest percentage age groups
ranged 30 - 40% and most of them of them were males. As
regards for qualification, technical education were considered
the highest group 56.00% and for number of chest tube, more
than half were 84.0% connected with two chest tube.
• In relation to patients’ complications associated with chest
tube drainage the table shows that, there were 64.0% of the
patients in the control group had complications associated
with chest tube drainage versus 12.0% of the patients in the
study group with a highly statistically significant differences
between both groups at (X2= 14.4 at P< 0.01**).
Summary
154
Conclusion
Based on the study finding, the nursing intervention
guidelines implementation has statistically significant postive
effect on the nurses’ performance (knowledge and practice) and
consequently reducing chest tube drainage associated
complications among the patients in study group.
Recommendations
Based on the study results, the following recommendations
could be inferred from the current study including the
following:
1) The importance of conducting the nursing intervention
guidelines training program for managment of patients with
chest tube drainage on a wider field including all hospitals
to raise the efficiency of nursing care provided and improve
the patients’ outcome for such group of patients.
2) Standardized nursing procedures should be available for
nurses in cardio-thorasic surgery intensive care unit to
guide them towrd the nursing intervention for managment
of patients with chest tube drainage
3) The availability of the booklet including the nursing
intervention guidelines for managment of patients with
chest tube drainage cardiothoracic intensive nurses for
dealing with patients with chest tube drainage for nurses in
cardio thorasic surgery intensive care unit. To improve the
Summary
155
quality of patients care and consequently deacrese the
complications for such group of patients.
4) Supervisors and nurses staff of in cardio thorasic surgery
intensive care unit should attend continuous inservice
refreshing training program about nursing intervention for
managment of patients with chest tube drainage to enhance
the quality of care for such group of patients.
5) Further study is recommented to evaluate the impact of the
nursing intervention guidelines training program for
managment of patients with chest tube drainage on the
quality of life for such group of patients.