الفهرس 
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Abstract
Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link evidence to practice and optimise clinical outcomes whilst maximising clinical efficiency (Rotter et al., 2010). Nurses are instrumental in ensuring the successful use of clinical pathways and can best contribute by gaining a thorough understanding of why and how pathways are used (Smeltzer et al., 2009).
The present study aimed to evaluate the effect of application of clinical nursing pathway on children with intussusceptions.
Subjects and Methods:
Study design:
A Quasi experimental design was used.
Setting:
The study was carried out in the Pediatric Surgery Unit affiliated to Ain Shams University Children Hospital, and Children Hospital at Abou El-Reesh (Japanese hospital for children) Cairo University.
Sample:
The subjects included in the study sample comprised all children admitted to the Pediatric Surgery Unit for treatment of intussusceptions in the period from the first week of January 2013, to the first week of May 2015. The group exposed to the routine hospital care was considered as control group and that exposed to clinical pathway was considered as study group (60 subjects each).
In addition 50 nurses working in the previously mentioned two settings were included in the study.
Tools:
The following tools were utilized for data collection: Six tools were formulated to collect data pertinent to the study. These tools are:
2- Characteristics of the child’s sheet (Appendix 1): This included age, gender, diagnosis, weight and day of admission.
4- Medical data sheet (Appendix 2): This included present diagnosis and treatment.
5- Children’s assessment sheet (Appendix 3): which included:
Data related to condition of gastrointestinal system, diagnostic tests and physical assessment for the children.
4-Complication monitor sheet (Appendix 4): which included: monitoring the complication were designed to cover related complications such as infection, bleeding, swelling and pallor.
5- A Predesigned questionnaire sheet (Appendix 4):
The researcher developed it after reviewing the relevant literature. It consisted of two parts:
Part (1): characteristics of multidisciplinary care team, as regards their age (in years), sex, position, level of education, years of experience, attendance of previous training programs.
Part (2): Level of knowledge of multidisciplinary care team regarding clinical pathway to assess the awareness of multidisciplinary care team of the current study about clinical pathway (definition, elements/components, benefits, steps in creating and development of clinical pathway, definition, causes and type of variance and role of nurse).
6- The clinical pathway map (Appendix 6): The clinical pathway map was modified by the researcher to suit the nature of the study. The clinical pathway map , it included activities of clinical pathway (assessment, nutrition, monitoring intake and output, central venous catheter care, hygiene, activity, investigations, medication, consultation and patient/ family education and Discharge planning) some activities of clinical pathway are routine intervention/care inside the unit until discharge from the unit.
Field work:
The actual field work started from the first week of January 2013, to the first week of May 2015. Official permissions were obtained from the directors of the study settings from each pediatric surgery unit. The researcher was available three days/week for three months in previously mentioned settings before implementation of clinical pathway and again following its implementation. The researcher established meeting with multidisciplinary care team to explain the nature and the aim of the study and ask for co-operation; and then reviewed the medical records for each neonate.
Simple and clear explanation of the study and its expected outcomes was offered. The researcher explained the aim of the research to study subjects (physicians, nurses, and families of the neonates) to gain their cooperation and decrease their anxiety. Then, a verbal agreement to participate in the study was taken.
The researcher collect data regarding the control group of neonates from the first week of January 2013 to the first week of May 2015 while the children receiving the routine hospital care and during this period each studied nurses was individually interviewed for their knowledge assessment regarding clinical pathway using the previously mentioned tools. The clinical pathway map was filled in by the studied nurses providing care to children having intussusception.
Implementation of clinical pathway was carried out over 6weeks from the first week of April to the first week of May. One session weekly, where each session was given for 1 hour related to definition, benefits, elements/components, activities of the clinical pathway, steps in creating, developing and implementing of clinical pathway, definition of variance, types of variance, reasons of variance and role of multidisciplinary care team).
In order to carry out these sessions, nurses were divided into small groups; the number of each group varied (with an average of 3-4 persons in each session according to staff number in each unit) and the basic content was the same for all groups. Session started at 11.00 am. for morning shift and 3.00 pm. for afternoon shift, which were the suitable time for the nurses.
Post implementation of the clinical pathway, the researcher collect data regarding the study group of children from the second week of May 2014 to the first week of August 2014 and in this period the neonates managed by the clinical pathway map and children’ outcomes were evaluated (hospital length of stay, inpatient complications, weight gains, laboratory investigations for the neonates on admission, at hospitalization and at discharge).
The results of the study showed that:
• All of the studied nurses (100%) showed good knowledge about clinical pathway post implementation of clinical pathway and all of the studied nurses (100%) had good knowledge regarding activities of clinical pathway post program.
• A higher mean in nurses’ knowledge regarding activities of clinical pathway was found among age group 20 -< 25 ( ±SD = 45.88±12.19) compared to the other age groups, and this difference was found to be statistically significant, where f = 5.704, at P = 0.002.
• A higher mean in nurses’ knowledge regarding activities of clinical pathway was found among bachelor degree holders ( ±SD = 57.57±5.73) compared to the other groups, and this difference was found to be highly statistically significant, where f = 78.408, at P <0.001.
• A higher mean in nurses’ knowledge regarding activities of clinical pathway towards care of children having intussusception was detected among nurses working at Cairo University Children Hospital at Monira (Abou El-Reesh) ( ±SD = 49.10±10.25), and this difference was found to be highly statistically significant, where t = 8.107, at P-value <0.001.
• As regards the effect of the clinical pathway on children having intussusceptions according to their length of hospital stay, the mean hospital length of stay of the study group was 2.98±1.24 days as compared to 4.53±2.03 days of the control group subjects with a highly statistically significant difference between both groups (t = 5.80 at p = 0.000).
• There were statistically significant differences as regards to the effect of clinical pathway on the studied children according to occurrence of complications pre/post implementation of the clinical pathway.
Conclusion
The study concluded that the nurses’ knowledge regarding the clinical pathway post implementation of the clinical pathway was good and the nurses’ knowledge about activities of clinical pathway for children having intussusception post implementation of the clinical pathway was good. In addition, the effect of clinical pathway on children’s outcomes was positive, where there was a positive effect of clinical pathway on care provided by nurses to children having intussusception manifested in a decrease in the length of hospital stay and a decrease in the number of complications.
Recommendations
In the light of findings of this study the researcher recommended that:
- Emphasizing the importance of multidisciplinary care team role and the responsibility of application of the clinical pathway in caring of neonates having intussusception.
- Increasing the nurses’ awareness and that of the health care team about clinical pathway and its application in caring of children having intussusception.
- Hospitals should establish policy concerning clinical pathway and this policy should be available in each of their units.
- The usage of clinical pathway for children having intussusception for reducing hospital length of stay and decreasing complications.
- Further studies have to be carried out in order to assess the effectiveness of clinical pathway application in caring for children having intussusception and children’ outcomes using larger sample size and in different health care settings for generalization of results.