Knowledge and Practices among Nurses Regarding Patients’ Care Following Cardiac Catheterization at a Tertiary Care Hospital in Karachi, Pakistan

Aims: The purpose of this study was to assess the knowledge and practices among nurses regarding patient care, following cardiac catheterization, at a tertiary care hospital in Karachi, Pakistan. Background: Cardiovascular diseases (CVDs) are the major cause of morbidity and mortality, globally. Nurses are the largest body of health care professionals who attempt to reduce the burden of cardiovascular diseases. Design: This study employed a descriptive analytical cross-sectional study design to answer the research questions. Me-thodology: The data were collected from 70 participants using two instru-ments. Knowledge was assessed through a 50-multiple-choice questions-based questionnaire, whereas, to assess the practices, an observational checklist was utilized which comprised of 20 components. Findings: The majority of the nurses, 54.3%, had adequate, 40% nurses had inadequate, and only 5.7% nurses had excellent knowledge scores. Moreover, 87.1% nurses were observed as carrying out unsatisfactory practices, whereas, only 12.9% nurses were found carrying out satisfactory practices. Conclusion: Since variation in the practices was observed in each of the department, therefore, there is a need for further research, to assess nurses’ attitudes through a qualitative approach and to develop and implement a standard post-cardiac catheterization care protocol.


Background of the Study
Cardiovascular diseases are the major cause of morbidity and mortality worldwide. Developing countries contribute a greater share to the global burden of cardiovascular disease. Nurses are the largest body of health care professionals who attempt to reduce the burden of cardiovascular diseases. Being at the patient's bedside round the clock, a nurse is in the best position to closely monitor and initiate the resuscitation process if any complication is observed. Hence, a competent nurse with sound knowledge and practical expertise is a key person for any health care organization.
A nurse's role in caring for patients post coronary intervention is identified as having a "spider-in-the-web" like character. A specialized nurse can effectively deal with cardiovascular emergencies, including rhythm recognition, early defibrillation, and emergency medication administration.
Nurses can play a key role between the attending consultants and patients. This intermediary role can be combined using two aspects, caring as "nurse" and curing as "physician" [8]. This role can be appreciable only if nurses show these competencies through building sound knowledge and achieving expertise in practical skills.
The purpose of this study was to evaluate the gaps in knowledge and practices among nurses regarding patient care following cardiac catheterization, at a tertiary care hospital in Karachi, Pakistan. This study also attempted to identify the gaps in nursing knowledge and practices, in order to improve the quality of nursing care and patient outcomes.
The study intended to answer the following questions: Q1. What is the level of knowledge among nurses regarding patient care following cardiac catheterization, at a tertiary care hospital in Karachi, Pakistan?
Q2. What are the practices among nurses regarding patient care following cardiac catheterization, at a tertiary care hospital in Karachi, Pakistan?

Methods
This study employed a cross-sectional analytical study design to answer the research question. The cross-sectional design was used because it involved the collection of data about different variables of the sample at one point of time in order to uncover relationships existing among those variables [9].
The study was conducted at a 300-bed, charity-based tertiary care teaching hospital during Feb.-May 2018. It consists of 150 beds for adults and 150 beds for the peads population. Since it is a charity hospital, therefore, patients from all over Pakistan come to this facility.
The target population of this study included registered nurses with a qualification of at least diploma in general nursing, and had a valid license issued by the Pakistan Nursing Council (PNC).

Eligibility Criteria
Nurses with the following characteristics were eligible to participate in this study: Inclusion criteria.
1) Staff nurses above 20 years of age, from both the genders.
2) Nurses who had a qualification at least three years general nursing diploma.
3) Full-time employee. 4) Registered Nurses who had at least six months of experience dealing with cardiac patients.
1) Nurses who were not registered with the Pakistan Nursing Council.
2) Registered Nurses working in the non-cardiac Intensive Care Unit of the ICU.

Data Collection Plan
The data were collected using two instruments, which were designed by the primary investigator with the help of literature. The knowledge was assessed through a questionnaire, which was based on 50 multiple-choice questions. The

Content Validity Index
After approval from the Ethical Review Committee (ERC), Karachi, and the Institutional Review Board (IRB), the study tool was reviewed by eight experts, who were approached based on their experience and qualification in the discipline of cardiology. The panel included six medical experts and two nursing experts. Out of the six medical experts, two were consultant cardiologists, of which one was a professor, having more than 10 years of experience in the field of cardiology, two were cardiology residents, having more than four years of experience in the relevant field, and two were medical officers, one of whom was an SMO, having more than eight years of experience in cardiology. Out of the two nursing experts, one was a nurse specialist in cardiology, having more than five years of experience, and one of them was a Head Nurse (CCU), who had three

Pilot Testing
Pilot testing of the tool was done on 7 participants (10% sample size) after the CVI calculation. The purpose of pilot testing was to examine the tool's utility and its weaknesses. No significant suggestions were reported during the process of pilot testing.

Data Analysis
The collected data were entered and analyzed using the statistical package for social sciences (SPSS) version 20, this was done by the primary investigator and the data input operator. Once the data collection was complete, it was checked for any inconsistencies. Descriptive and inferential statistics were used to analyze the data. Mean and standard deviation were calculated for continuous variables, whereas proportions and frequencies were calculated for categorical variables.
The nature of the relationship between the level of knowledge and practices were compared using the independent t-test and chi-square test [11]. These comparisons were done between expert and novice nurses, between nurses who have different levels of qualification, between nurses with and without having cardiac diploma, and between male and female nurses. The difference between three  [12]. P-value of less than 0.05 was considered significant. The study was adherent to the strengthening of the reporting of observational studies in epidemiology (STROBE) statement.

Ethical Considerations
The confidentiality of the study participants was maintained throughout the study. All the data files were locked in cabinets and all the soft copies were kept protected by a password, to which no one had access except the primary investigator, thesis supervisor, and the thesis committee members.

Results
This chapter presents the findings of the study. It has four sections: section one describes the demographic characteristics of the participants. Section two discusses the overall knowledge level among nurses and the level of knowledge related to knowledge subcategories. Section three explores the level of practices among nurses and the difference in practice scores between the various demographic characteristics of the participants. Lastly, Section four represents the practice associations with theoretical knowledge and its sub categories.

Section One
A total of 70 nurses, who had more than six months of experience dealing with cardiac patients, were recruited for this study.

Section Two
One of the major outcomes of the study was to assess the level of knowledge among nurses, regarding patient care following cardiac catheterization. The knowledge tool comprised of 50 questions. Each question was given a score of one and the total score was 50. The mean knowledge score was 27.2 + 6. The minimum knowledge score was 16, whereas the maximum knowledge score was 46. Knowledge was categorized into three levels: inadequate, adequate, and excellent knowledge levels. A total of 38 nurses (54.3%) showed adequate knowledge scores, 28 nurses (40%) had inadequate knowledge scores, while only four nurses (5.7%) reached up to the excellent knowledge level (see Table 3).   The mean knowledge related to cardiac physiology was 4.8 + 2.4. The minimum knowledge score was zero, whereas the maximum was 10. A total of 31 nurses (44.3%) showed inadequate knowledge scores, 28 nurses (40%) obtained adequate knowledge scores, and 11 nurses (15.7%) got excellent knowledge scores related to cardiac physiology. The mean knowledge related to cardiac pathology was 7 + 1.4. The minimum knowledge score was four, whereas the maximum was 10. A total of 39 nurses (55.7%) attained adequate knowledge scores, two nurses (2.9%) got inadequate knowledge scores, whereas 29 nurses (41.4%) got excellent knowledge scores related to cardiac pathology.
Similarly, in terms of knowledge related to common electrocardiogram interpretation, the mean knowledge was 1.5 + 0.9. The minimum knowledge score was zero, whereas the maximum was three. A total of 34 nurses (48.6%) scored adequate knowledge and 28 nurses (40%) showed inadequate knowledge, whereas only eight nurses (11.4%) had excellent knowledge related to the interpretation of common electrocardiogram strips.
In analysis of knowledge related to the procedure, the mean knowledge was 6.8 + 1.3. The minimum knowledge score was four, whereas the maximum was 10. A total of 47 nurses (67.1%) attained adequate knowledge scores, three nurses (4.3%) acquired inadequate knowledge scores, whereas 20 nurses (28.6%) got excellent knowledge scores related to procedural awareness.
In the knowledge related to procedural complications, the mean knowledge was 3.4 + 1.8. The minimum knowledge score was zero, whereas the maximum was nine. A total of 52 nurses (74.3%) acquired inadequate knowledge scores, 16 nurses (22.9%) got adequate knowledge scores, whereas only two nurses (2.9%) had excellent knowledge scores.
The mean knowledge related to cardiac pharmacology was 5 + 1.8. The minimum knowledge score was one, whereas the maximum was nine. A total of 37 nurses (52.9%) got adequate knowledge scores regarding cardiac pharmacology, 26 nurses (37.1%) obtained inadequate knowledge scores, whereas seven nurses (10%) achieved excellent knowledge scores related to cardiac pharmacology (see Table 4).
Difference in knowledge scores between age categories was analyzed using one-way ANOVA. To have a better understanding, the age brackets were divided into five groups, which included: 20 -24, 25 -29, 30 -34, 35 -39, and >39. In all, there were 24 participants in the first age group, with a mean knowledge Open Journal of Nursing score of 26.2 + 6.6, there were 32 in the second age group, with a mean knowledge score of 27.1 + 6.3; in the third age group with a mean knowledge score of 29.6 + 5.3; and five and three in the fourth and fifth age groups, with a mean knowledge score of 28.2 + 10.4 and 29.3 + 7.5, respectively. There was no statistically significant difference in the knowledge scores between these age groups, as the p-value was 0.78 (see Table 5). To identify the difference between the knowledge scores of male and female nurses, the t-test of two independent samples was utilized. The mean knowledge score of male nurses was 27.8 + 6.3, whereas for female nurses it was 26.2 + 6.9. Therefore, no statistically significant difference was found between the knowledge scores of male and female nurses, as the p-value was 0.31 (see Table 6).  One of the study outcomes was to compare the knowledge scores of nurses with specialization, i.e. diploma in cardiology. For this comparison, the t-test of independent samples was used. The mean knowledge score of nurses having specialization was 28.5 + 6.5, whereas it was 25.8 + 6.4 for nurses without specialization. The current finding was statistically insignificant. Therefore, it was concluded that there was no difference between the knowledge scores of nurses with and without specialization (see Table 7).
The difference in the scores of the knowledge subcategories between nurses with and without specialization was compared using the t-test for independent samples. The mean knowledge score in cardiac physiology among nurses having specialization was 5.2 + 2.4, whereas the same among nurses without specialization was 4.4 + 2.4. There was no statistically significant difference between the knowledge scores of both groups, as p-value was 0.19.
Similarly, the mean knowledge score in cardiac pathology among nurses having specialization was 7.2 + 1.5, whereas those without specialization had a mean score of 6.9 + 1.4. There was no significant difference between the knowledge scores of both the groups, as the p-value was 0.52.
On the contrary, the mean score of procedural knowledge among nurses having specialization was 7.1 + 1.3, whereas this was 6.4 + 1.3 among nurses without specialization. There was a significant difference in the scores of procedural knowledge between nurses with and without specialization, as the p-value was 0.02.
On the other hand, the mean knowledge score of procedural complications among nurses having specialization was 3.6 + 1.7, whereas the mean knowledge score in procedural complications among nurses without specialization was 3.2 + 1.8. There was no significant difference in the scores of procedural complications between nurses with and without specialization, as the p-value was 0.39.  28.5 ± 6.5 25.8 ± 6.4 0.08 P-value was calculated using independent t-test, with level of significance at P < 0.05.
In the same way, the mean knowledge score in cardiac pharmacology among nurses having specialization was 5.3 + 1.7, whereas the same in the cardiac pharmacology of nurses not having specialization was 4.7 + 1.8. Hence, no significant difference was found between the knowledge scores of both the groups, as the p-value was 0.19 (see Table 8). there was no statistically significant difference in the knowledge scores of nurses having varying qualifications, as the p-value was 0.14 (see Table 9).
The knowledge scores of procedural complication and cardiac pharmacology were found to be significantly different among nurses with varying qualifications, as the p-values were 0.015 and 0.012, respectively. Whereas, the rest of the knowledge subcategories were found insignificant when compared with different qualifications (see Table 10).     were 0.03, 0.00, and 0.00, respectively (see Table 12).

Section Three
The second major outcome of the study was to assess the practices of nurses regarding patient care following cardiac catheterization. In the analysis of three time practice observations, the mean practice score was 10.3 + 2.2. The minimum practice score was 6.3, whereas the maximum score was 15.6. This shows that the majority of the nurses (87.1%) were carrying out unsatisfactory practices, whereas only nine (12.9%) nurses were carrying out satisfactory practices (see Table 13). Difference in the practice scores of participants with regard to their demographic characteristic was determined using the chi-square test and one way ANOVA. No significant difference was found in the mean of all age groups, as the p-value was 0.25 (see Table 14). The results were found to be significant when the practice scores were compared on the basis of qualification, as the p-value was 0.05. So, there was a significant difference between practice scores of nurses, who had BScN, Post RN BScN, or Diploma in general nursing. Surprisingly, the findings were found to be insignificant when the practices of participants were compared with their specialization status and their experiences, as the p-value was 1.0 and 0.93, respectively. On the contrary, the results were found to be significant when the practice scores of participants working in CCU and different departments were compared, using chi-square, as the p-value was 0.00 (see Table 15).
The difference in three time practices was analyzed using the repeated measures ANOVA. The value of Mauchly's test of sphericity was 0.90, which indicated that there was no violation of sphericity. The mean of all the three observations (n = 70) were 10.1, 10.3, and 10.2, respectively. The findings of three time practices revealed no mean difference in all three observations, as the p-value was 0.403 (see Table 16).    No difference was found between the three time practice observations within each of the departments, as the p-value was >0.05 (see Table 17).
The frequency of obtaining the vital signs was analyzed, using descriptive sta-  Table 18).
Descriptive statistics were utilized to determine the catheter site assessments.  Table 19).     Table 20).

Section Four
The association between practice and overall knowledge scores was analyzed, using the chi-square test. When practice scores were evaluated with overall knowledge, the findings showed that nurses who scored as excellent and adequate in knowledge were better at carrying out satisfactory practices, whereas those nurses, who received scores showing inadequate in knowledge, were found carrying out unsatisfactory practices. Hence, with these findings, it can be concluded that there is an association between good knowledge and satisfactory practices, as the p-value was 0.00 (see Table 21).
With regard to association between practices and knowledge of cardiac physiology and cardiac pharmacology, the findings indicate that nurses who scored inadequate in knowledge were carrying out unsatisfactory practices. Whereas, those nurses, who scored as adequate and excellent in knowledge were found better at carrying out satisfactory practices, as the p-values were 0.001 and 0.006, respectively. The association turned out to be positive when analyzed for practices and knowledge about procedural complications as the p-value was 0.00 (see Table 22).
Some important findings were also found during analysis. The different responses of the nurses and their practices were compared. Initially, nurses who were aware of the signs of thrombus formation were compared, whether they knew where to palpate the pulses or not. The findings suggested that, out of the 20 nurses who were aware of the signs of thrombus formation, nine nurses did not know where to palpate the pulses as compared to those 11 participants who knew that. On the other hand, nurses who were not aware of the signs of thrombus formation were 50 in number, out of which 40 did not know where to palpate the pulses, whereas 10 participants knew. The findings remained significant, as the p-value was 0.00. It can be concluded that there is a difference in the knowledge of nurses who were aware of the signs of thrombus formation and they knew where to palpate the pulses, as compared to those who were unaware of the signs of thrombus formation and they did not know about the site of pulse palpation (see Table 23).
In this analysis, a comparison was carried out to see how frequently nurses  Table 24).
Practices of participants who were aware and unaware of the reasons for obtaining serum creatinine levels after cardiac catheterization were also compared, to see whether they monitored urine output, despite knowing the risk of developing Dye Induced Nephropathy (DIN), or not. The findings showed that out of the 31 participants who were aware of the reasons for obtaining serum creatinine levels after cardiac catheterization, only 12 participants monitored the urine output, whereas 19 participants did not check. In the same way, out of the 39 participants who were not aware of the reasons for obtaining serum creatinine levels after cardiac catheterization, 34 participants did not check the urine output, whereas 5 participants monitored the output. The finding was statistically significant, as the p-value was 0.01 (see Table 25).

Discussion
In this study, the overall mean knowledge score was found to be 27.2 + 6 (out of 50). This finding is consistent with [13], in which they reported that the mean knowledge scores of staff nurses regarding the pre and post-procedural nursing care of PTCA was found to be 23.58 + 2.52 (out of 30). Furthermore, the majority of the study participants (54.3%) had adequate knowledge, 40% had inadequate knowledge, whereas only 5.7% had excellent knowledge. The reason for inadequate knowledge of 40% nurses could be ascribed to the fact that nurses are not offered training sessions as, in general, institutions pay little attention to the training of nurses [14]. The mean knowledge related to cardiac physiology was 4.8 + 2.4 (out of 10). Most of the nurses (31 out of 50) showed inadequate knowledge related to cardiac physiology. On the contrary, the study [15], reported that the knowledge level of nurses regarding cardiac physiology was found to be high in 54.7% of the total nurses. With regard to knowledge about cardiac pathology, the mean knowledge was 7 + 1.4 (out of 10). The findings showed that the majority of the nurses (55.7%) had adequate knowledge and 2.9% had inadequate knowledge, whereas 41.4% of nurses had an excellent knowledge score related to cardiac pathology. This finding is consistent with the study [16], in which they reported that the knowledge level among Turkish nursing students was high regarding cardiac diseases.
In a similar way, knowledge related to interpreting common electrocardiogram strips showed that the mean knowledge was 1.5 + 0.9 (out of 3). A total of 34 nurses (48%) had adequate knowledge in identifying the abnormal ECG rhythms, 28 had inadequate knowledge, whereas, only eight nurses had excellent knowledge. On the contrary, the study [17], reported that 43 participants (out of 69) were comfortable in identifying the abnormal ECG rhythms. However, in this study, it is indicated that nurses had limited knowledge regarding ischemia monitoring on the ECG and had a room for improvement in this regard. The findings of current study may be attributed to the fact that nurses are not provided on-job training and professional development in many organizations.
However, studies indicate that the provision of ECG session by the unit management can improve the nurses' confidence and knowledge to identify the abnormal ECG rhythms [18].
In the analysis of knowledge related to procedure, the mean knowledge was 6.8 + 1.3 (out of 10). Findings showed that a total of 47 nurses (67.1%) had adequate knowledge scores, three (4.3%) had inadequate knowledge, whereas 20 (28.6%) had an excellent level of knowledge related to procedural awareness.
These findings are consistent with the study [13] in which, they reported that 62% of the nurses (31 out of 50) had good knowledge and 36% (18 out of 50) had very good knowledge scores regarding pre and post-procedure care of PTCA.
Findings related to procedural complications showed that the mean know-  [19], in which he reported that the majority of the respondents had a high percentage of knowledge regarding complications. Opposite to that, study [20], reported no relationship between nursing knowledge and occurrence of complications.
The mean knowledge related to cardiac pharmacology was 5 + 1.8 (out of nine). A total of 37 nurses got adequate knowledge scores regarding cardiac pharmacology and 26 had inadequate knowledge, whereas only seven nurses had excellent knowledge scores. These findings are consistent with the study [21], in which they reported that 57.5% nurses (23 out of 40) had a good level of knowledge and 10% (4 out of 40) had excellent knowledge, whereas 30% nurses (12 out of 10) had average knowledge scores. The low level of knowledge may imply that since the majority of the nurses (57.1%) in this study were diploma holders they did not learn pharmacology in their institutes; however, they learned it from their practical experience during their jobs. In general, when these nurses were hired, their competency-based orientations were not conducted in many organizations.
In the analysis of three time practice observations, the mean practice score was 10.3 + 2.2. The minimum practice score was 6.3, whereas the maximum score was 15.6. Results showed that a total of 61 nurses (87.1%) were carrying out unsatisfactory practices, whereas only nine nurses (12.9%) were carrying out satisfactory practices. On the contrary, the study [22] reported that the mean practice score among nurses after the administration of a nursing care protocol was found to be high. Since the nurses in this study were found carrying out practices without any standard protocol, this could have led to unsatisfactory practices.
The difference in three time practices indicated that there was no mean difference in all the three observations, as the p-value was 0.403. This finding added to the researcher's confidence that since there was no difference in the means of the three different observations of practices, the Hawthorne effect had been minimized (Gaskell, 2012). Moreover, literature suggests that frequent and long term observations can minimize the Hawthorne effect. In this study, the researcher employed a six step protocol for Hawthorne effect mitigation [23].
For determining the access site assessments, the findings were presented by taking the average of all three observations. A total of 54 nurses (77.1%) assessed the access site upon receiving the patients in their respective units. Out of 77.1% nurses, assessments of 47.1% (n = 33) were consistent in the three times observation, whereas the assessments of 30% (n = 21) were inconsistent in the three observations, while a total of 16 nurses (22.9%) did not assess the catheter access site even a single time. These findings imply that due to the non-availability of a standard protocol, nurses were practicing based on their feasibility; therefore, it is suggested that a post-cardiac catheterization care protocol should be devel-Open Journal of Nursing oped and followed by all the departments.
The frequency of assessing the catheter access site following catheterization showed that 45.7% nurses did not check the catheter access site, even a single time, during their entire shift. However, 40% nurses assessed the catheter access site only once in their entire shift, 11.4% nurses assessed the access site every three hours, whereas only 2.9% nurses assessed the access site every two hours in their entire shift.
The association between practices and the overall knowledge scores showed that nurses who scored as excellent and adequate in the knowledge scores, were carrying out somewhat satisfactory practices, whereas, those nurses, who scored inadequate on the knowledge score, were found carrying out unsatisfactory practices. Hence, with these findings, it can be concluded that there is an association between good knowledge and satisfactory practices, and inadequate knowledge and unsatisfactory practices, as the p-value was 0.00. This being the case, the conceptual model proposed by Clarke and Donaldson (2007) could bring about a difference. The model says that safe patient outcomes depend on four major components: The nurses' knowledge, experience, practice, and attitude. In this study, it is evident that adequate knowledge was directly associated with satisfactory practices.
However, the findings of those who had adequate knowledge but did not show satisfactory practices can be related to their attitudes, therefore, the reason of their attitudes towards the practices need to be assessed in further studies. Moreover, in this study, years of experience did not show a significant difference in both knowledge and practices, which the researcher considers is a result of recruiting only 70 participants; this may have been significant if more participants had been recruited.
Some important findings were also found during analysis. Different responses of nurses, on the questionnaire, were compared and contrasted. For Instance, nurses who were aware of the signs of thrombus formation, i.e. absence of distal pulses, did not know where to palpate the pulses. Likewise, nurses who were aware of the sign of thrombus formation did not check the distal pulses, even a single time, during their entire shifts. In a similar way, nurses who were aware of the rationale for obtaining serum creatinine levels after cardiac catheterization, i.e. Dye Induce Nephropathy (DIN), did not monitor the urine output. Therefore, it is concluded that, there is a difference in participants' responses and their real practices because, despite the fact that they had the knowledge, they were not found translating it into clinical practice, due to which best practices were not apparent. Hence, there is a need for further study to evaluate the nurses' attitudes, to identify the reasons as to why, despite having knowledge, they did not apply it their practices, so that the practice standards could be enhanced.

Strengths of the Study
The strengths of the current study are as follows: 2) This study had gender equality, which evidently has benefits for patient care.
3) The study tool was designed and validated according to the Pakistani context, by conducting a pilot test.
4) The CVI for the study tools was 0.98. The content clarity and inter-rater reliability was also ensured by eight expert reviews, of whom six were medical and two were nursing experts.
5) The practices were observed thrice, in three different time periods, through three different data collectors. Each participant was observed for 21 hours, cumulatively. This study employed 1470 hours of observation, for 70 participants.
6) Post hoc power analysis was done which was found to be 99.9%.
7) The study has attempted to minimize the Hawthorne effect through frequent and long duration of observations.

Limitations of the Study
This study has a few limitations, which are as follows: 1) Considering the scope of the master's thesis, only one tertiary care hospital was selected as a study setting.
2) Due to frequent and long durations of observations, only 70 participants could be recruited as a sample.
3) The attitude of nurses towards the practices could not be examined due to limited time.

Conclusion
Based on these findings, it can be concluded that there is a need to conduct periodic competency-based orientations, increased continuous development sessions, seminars, and simulation-based training for nurses, to provide better patient care. Furthermore, frequent spot rounds, audits, and quality education in nursing institutions by hiring qualified faculty should also be considered by the institute. Moreover, due to variations in the practices in each of the department, the need for further research is indicated, to assess nurses' attitudes through the qualitative approach, and to develop and implement a standard post-cardiac catheterization care protocol.