الفهرس 
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Abstract
Thoracic surgical nursing is a practice of nursing care involved in thoracic surgeries, so nursing those patients requires special training in complex clinical management and wound care. Thoracic surgical patients pass through three operative phases; called the preoperative, intraoperative and postoperative phases; during each phase the thoracic surgery nurse plays important roles.
In order to assure quality of care, standards must be established to control practice of nursing care delivered for thoracic surgical patients, as they define what constitute safe basic nursing practice in order to achieve quality of nursing care provided for thoracic surgical patients.
Establishing basic standards for the desired quality of nursing care, as well, require the identification of the basic nursing skills, with the integration of basic nursing care knowledge in an organized manner.
The aim of this study was to identify basic competencies of thoracic surgery nursing care, as well as establishing standards of pre and postoperative nursing interventions for thoracic surgical patients. This was carried out through:
1. Identifying basic competencies for nursing care of patients undergoing thoracic surgery.
2. Setting basic standards for management of patients undergoing thoracic surgery.
3. Developing valid and reliable assessment tools for measuring basic standards for management of patient undergoing thoracic surgery.
Descriptive design was used to conduct this research to explore basic competencies of pre and postoperative nursing care for thoracic surgical patients.
The study was carried out at the cardiothoracic surgery unit, in the Main University Hospital at Alexandria, Egypt.
The subjects of this study were consisted of two groups, group I consisted of three categories of experts. This group consisted of 65 expert members in nursing, medical education and service was included in the study as follows: 20 members of Medical Surgical Nursing Department, 5 members of the Emergency and Critical Care Nursing Department, 5 members of the Nursing Administration Department, Faculty of Nursing, University of Alexandria. 30 members of cardiothoracic surgery unit of Alexandria Main University Hospital: Fourteen surgeons and sixteen medical specialists and consultants, Faculty of Medicine, University of Alexandria. 5 nurses with more than 5 years of experience working in the cardiothoracic surgery unit at the Main University Hospital.
group II: Consisted of 20 nurses who were assigned to provide direct care for patients undergoing thoracic surgeries in the cardiothoracic surgery unit at Alexandria Main University Hospital.
To fulfill the objectives of the study, four tools were developed by the researcher to collect the necessary data for this study.
Tool I: Basic Nurses’ Competencies Opinionnaire Sheet for Thoracic Surgeries Patients.
This tool was developed to elicit the opinions of experts group (jury members) who had experience in the field of the study regarding patients undergoing thoracic surgeries, basic required nurses’ competencies for care during the hospitalization and to investigate the nursing interventions to be offered in the cardiothoracic surgery unit. It covered 9 major broad competencies which were subdivided into nursing activities and skills to be answered.
Tool II: Nurses’ Performance Checklist for Thoracic Surgeries Patients.
It was used to assess the actual performance of nurses who were providing care for patients undergoing thoracic surgeries.
Tool III: Assessment sheet of Cardiothoracic Surgery Unit Structure.
It was used to assess the cardiothoracic surgeries unit actual structure; it included three main parts: the supportive services, the physical environmental preparations and services for patients’ comfort and safety and the unit preparations for patients’ administration.
Tool IV: Nurses’ Knowledge Questionnaire for Thoracic Surgeries.
It is a structured written questionnaire aimed to address the thoracic surgeries nurses’ basic knowledge. It was developed by the researcher in Arabic.
The following were the most important results encountered by the present study:
All experts agreed upon:
The importance of presence of the philosophy and objective where it should be written and available to all members, while 50% of nursing educators didn’t agree about philosophy must define the staff responsibilities as well as job descriptions.
The unit policy items are important components of the cardiothoracic surgeries unit structure, which must be available to all members of the cardiothoracic surgeries unit.
It was observed that; the following were not available in the cardiothoracic surgery unit:
Written philosophy and objectives, items of organization to all members of the cardiothoracic surgery unit, policies and reference materials and items of ’job description. Assignment record, inventory record, incident report, complaints report, requisition report and guidelines, protocols, standards and pathways for providing nursing care for cardiothoracic surgery patients in the unit. In addition, the performance appraisal system for nurses and documentation system. Medical progress notes, preoperative assessment sheet, preoperative checklist, consultation reports, Glasgow Coma Scale sheet, discharge planning sheet and census records.
Regarding cardiothoracic surgery unit design:
Parallel bars in water, and towels were not present at all sink used for hand washing by patient or staff. There was overcrowding in the patient room where the number of beds was not adequate for patients more than 8 beds / room and the space between each bed was less than 80 cm. In addition, the number of bedside tables, bedside chairs and lockers were not adequate with bad cleansing and state of repair.
All machines and equipment were available in the unit except the Magnetic Resonance Imaging (MRI), Computer Tomography Scan (CT) and a working sterilizer or autoclave was no sufficient amounts of linens and pillows as necessary items of bed components. In addition, booklets showing various nursing interventions / instructions and health education booklets for patients undergoing thoracic surgeries were unavailable for each staff member in the unit.
Regarding the following of thoracic surgery nurses of the principles of aseptic techniques, the findings showed that more than 75% of those nurses followed all principles correctly.
The majority of patients to sign the written operation informed consent and assist the patient to remove all clothes and wear gown, put on theatre hair cap, ensure the removal of hairpins, dentures, artificial nails, nails polish, make up, and jewelries and ensure fasting at least 8 hours before surgery.
Nearly 50% of thoracic surgery nurses did not provide nursing instructions for the patient and his/her family correctly, while 45% of those nurses had teach the family the importance of no smoking in the unit and about the need for long term follow up correctly.
The majority of thoracic surgery nurses provided competent postoperative nursing care in the post anesthesia care unit correctly, while the minority of those nurses (less than 30%) did not provided competent postoperative nursing care in the post anesthesia care unit.
Regarding care of patient attached with tubes, the findings revealed that, the majority of thoracic surgery nurses followed the activities regarding care of drain correctly.
Regarding the postoperative nausea and vomiting the results indicated that more than 40% of thoracic surgery nurses performed activities to alleviate postoperative nausea and vomiting, while 40% of those nurses performed activities to alleviate postoperative thirst correctly.
As regards to prepare equipment, electrodes placement, attach electrodes to patient’s cable, attach cable to monitor, turn on monitor were done correctly by the majority (more than 70%) of thoracic surgery nurses.
As regards to all steps of the procedure, the results revealed that the majority of thoracic surgery (more than 65%) did not follow most steps of the procedure correctly.
The majority (85% and more) of thoracic surgery nurses were follow steps of the procedures correctly except wash hands, wear gloves, record I.V types and amount were done correctly by 70% of those nurses.
Regarding check physician’s order, gather equipment, obtain blood product from refrigerator, prepare equipment and check the patient’s name, blood products type and expiration date were done by less than 65% of thoracic surgery nurses.
Less than 25% of thoracic surgery nurses were done steps of CPR correctly when needed. More than 75% of thoracic surgery nurses were assisted in the insertion of CVP catheter correctly.
More than 50% of thoracic surgery nurses ensure patient personal confidentiality and privacy regarding medical information correctly.
More than 80% of thoracic surgery nurses did not record the pre and postoperative values correctly in the patient’s chart.
The largest proportion of nurses who had good knowledge was in an area related to the preoperative preparations and patients’ education elements knowledge and postoperative nursing interventions 45% and 40% respectively. While the largest proportion of nurses who had fair knowledge was in the areas related to prepare ready environment for receiving the thoracic surgery patients and prepare safe therapeutic hospital environment and safety measures are followed during patients’ transportation 80% and 75 % respectively. On the other hand, the largest proportion of nurses 75% had poor knowledge in the area related to ethics and patient’s rights are followed when providing nursing care as well as in continuous monitoring, recording and reporting for all phases of patient care.
The following were the main recommendations based on the findings of the present study, the following recommendations are suggested:
1. The developed standards of basic nursing interventions for management of patients undergoing thoracic surgery should be available in the cardiothoracic surgery unit and should be revised and updated regularly.
2. The appropriate equipment and supplies necessary for safe practice must be accessible for all nurses at cardiothoracic surgery unit at morning, evening and night shifts.
3. Job description must be available for all nursing personnel and for workers in the cardiothoracic surgery unit for better utilization of nursing capabilities.
4. The distribution of nurses on cardiothoracic surgery unit should be according to the dependency needs.
5. Provision of adequate supervision of nurses during their practice and provide teaching with motivation and feedback on performances.
6. Motivation and financial rewards to encourage the thoracic surgery nurses to do their best.
7. Increase nurses awareness about the developed standards of basic nursing interventions for management of patients undergoing thoracic surgery.
8. Evaluation of personal nursing performances should be based on the attainment of the professional standards.
9. Integration of the current knowledge of nursing and management theories and concepts into the practice environment.
10. Increase nurses awareness about the developed standards of thoracic surgery nursing interventions for management of patients undergoing thoracic surgery.
11. A basic orientation training program should be provided to newly employed nurses in cardiothoracic surgery unit who must be examined for their knowledge and skills before assuming independent responsibilities for patient care.
12. Continuing education programs, in-service education and workshops should be planned on regular basis to nurses working in the cardiothoracic surgery unit and should be made on free days so that these programs don’t interfere with nurse’s clinical work schedule and each one is able to attend these programs.
13. Research about exploring the effect of an educational program for nurses on their practice with thoracic surgical patients.
14. Research about developing a clinical pathway for care of thoracic surgical patients.
15. Research about exploring the effect of implementing the developed nursing interventions standards on the thoracic surgical patients.