An InvestigationOf The Ed uc a t i ona l PreparationOf Nurses
PriorTo working
In Land- ba sedMultiplace Hyperbaric chambers In Canada
BY
M. ELI1. ABETH DAVIS
A thesissubmi t t ed to the School ofGr a d uate St udies in partial fulfilment of the
requirementsfor the degree of Master of Nursing
Sch oolof Nur s ing Memorial uni versityof Newfound land
1992
st. Jo hn's Newfoundland
1+1
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!SDN 0- 3 15-6 259 4-4
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Abstract
AnInvest i g a t i o nOf TheEduc a t i o nalPr e p a r a t i o nOfNurses Prior To Work ing In Land-based Multiplace Hyperbaric Chamber s In Canada
The purpose of this study was to descr i be the hy p e r b a r i c nurses work ing in clinical mu l t ip lace hyperbariccha mbe r s in Canada, todeterminethe i r age , sex, marital sta t us anded uc ational preparation , andto iden t ifythetopics thattheyperce ive shoul d beinc lu ded inanintroductoryeducati onal program offered pr i orto workingin mUl t i p l ace hyperba ri c ch ambe rs.
Data for thi s descr iptive stud y were ga the r ed by meansof author-constructedquestionnairesandpers onal interv iews. The que s tio nnai r e s identifie d eig h t demographicva r iabl e s, and askedparticipant storate the importance of 37 topics for inc l us i on in ahype r ba ri c nu r s i ng course. The pers ona l intervi ew la s ted approximatelythirtyminutes and was guidedby fiveopen- ended questions. The int e rv i e w tap eswerescrutini zed, and content analysis wa s used to extract common themes Wh i c h wereorganizedinto five categories.
The sample was made up of 32 of the 33 English- speakingnurses who workedfUll-t i me, part-ti me or on an
on-call basis in the three ca na d Len Hyperbaric units which were operational dur i ng January/February, 19 90 . These nurses werefoundto sharema ny similardemographic character Is t i cs. The interview data showed that the numberof facto rscontributingto job satisfaction fa r exceeded those contributi ngto job dissatisfaction.
The most frequently cited concern mentioned spo n t a neo us l y by 12/ 32nur s es in the categoryof personal and lifestyleadaptationswa s the occurrence of si gnificantfatigueaft era hyperbaric treatment. It was noteworthyand warrants attention becausethi ssensation hasnotbeen re portedprevi ou slybyhyperbariccaregivers in th e literatureand it isknown to be associatedwith decompressionsickness.
other fi nd i ngs were obtained in relationship to edu c at i onal and professionalconcernsand focusedon the challengesof in f r e que nt di vesand communication. The discussion includes the design of an Introducto ry Hyperbaric Nur s i ng Course. At the conclus ion of th e at udy a number of recommendations related to nursing practice , educationandrese arch were made.
I i
Acknowl edgeme nts
First and fore most, I want to exp ress my de ep apprec iat i o nto thenurs e swhosoeage r ly par ti c ipated in th~sstudy, espec i ally the nurs ing supe rvisors of the three hyPerbaric un itsthat I visited :Beth Coo k , Toronto General HospitalINonanLo, Vancouver Ge nera l Ilosp ital and Jenniferwaring, Vict o ri a General Hospit a l. During my contact wit h this de dic ated group of professiona ls the yrepeatedlyshowed theircommitme nttothe patien ts, a hi gh le ve l ofcomp ete nc e and an enthusi a smfor their professiona l growth. I came away fr omII gruelling sc h e du le ofint e rv i e ws feelingenergized ,havi nghadyet another experiencewhichma d e me p rc udto be anurs e.
Mydeepe st tha n ks to lIy thesi sco mmitte e, Ms.Joan Rows e ll andDr.HenryHanson, for th e i r hel pful feedba ck, ent hus i a sm anddedicat i o n to the study. I allespe cia l ly ind e bted to Dr. Patric i a Robert s , Dy thes i s committ ee chairperson, forher enc ouragement,end l esspa tie nc e and unfailingcommitment. Dr.Robertswa s abletochallenge meto go beyondmy limits whilealways ma intaining environmentconduciveto lea rning.
I wan t to gladly acknowkedqe the contr ibutio n of Trud y Coo mbs , who not only typ ed numero us drafts and
iii
revisionsbut did it witha tremendousamountof patie nce annhumo r.
Finally , my deepest gratitude to my husba n d, Chris t o phe r Joy for his support and en c ou r ag e me nt. I am es p e c t eiivinde b t ed to mydau ghter ,Adriana,for her gift of loveandjo y. Despite the fact that she came into our I ives during data analysis, she has given me the mo tivat ion ne e d ed to co mpl e t e a project of this magnitude. I wish to express my appreciation to my friendsand fa mil y, especially my father,Mr. WilliamJ. Davis , who qa v e me the courageto believe in mysel f.
iv
Tabl eof Con tents
Page Ackno ....led ge men ts •••••• ••••• •••••••.•••..•...•• IV List oftab le s •••• ••• ••• •• ••.•.••••• •• ••• ••...•••
Li st of figu re s •••••••••• ••••••••••.••••••••. •••. XI CHAPI'ER
RES EARCH PROBLEM
Int r od uction to the Pr o b l em••• •••• •••. •. ••• Pr ob lemSta te ment .••.••••••.• ••• •. •.••• Rat i on ale .••..•• ..••..•.• • • • ...• ... ..•.
Litera ture Revi e .
Mon op l a ce Hyperbar i c Chambe rs •• ••• ••• •• Hultiplace Hyp e rba ric Cha mbers •••••• ••• Nurs i ng Is s u e s inHyperb a ric Oxygen The rapy ••••• •••.• ••..•...•.•. .•• Phys ical andPs y chol og i c a l Fa ctors •• •••
Envi r o n me nt a l Hazards ••••• ••••••••••••• 14 Modi ficati on to Equipment . ... 16 Patient EducationinHyperbaric
OxygenTherapy••••.••••••••••• •••• •.•• 17 Ed u cat ionalNe ed s of Hyperba ric
Nursing Pe r s onnel ••••••• •••• •.••••••••• 16 Summary••••••• •••••• • •••••.• •.••....• •. 24 conceptual Framework••• •• •.••• • ••• • •• • • •••.. 26 Limi t at i o nsof thest udy... ... ... 32
Purpose ... . ... .... •... . ...•...•... 33
Research Questions ... .... ... ... . 33
Definitions of ceneept s 34 I I METHODOLOGY.••••• •• • ••••••••••••••••••••••• • 36 Research De s i gn 36 setting.... . .... . .. ...•. .. .. . ... . .... 36
Sample Sel ect ion .... . ... .. .. •.••..•• .. 37 EthicalConsiderations 38 Data Collection .. .. ..• •..•. .•... . ..•...• 40
pilot Stud y ... . ...•.. .. . 42
Data Analysis . ... .. . . ... ... ... 43
JII THERESULTS ... ... .. .. 45
Characteristicsof the Sample ..•. ...• •.... 45
Analysisof Educ ationalNeeds Questionnai re. 49 AnalysisofInte r vi ew Data•.. . .•.•. .•... . 55
Nurses Perceptionoftheir Educational Ne eds .•... ...•.. ..•.. .• ... . 56
Prior Educationand Experie nce Required. ... . .. ... ... ... . 57
PersonalCha racte risticsand Competencies.... .... ... ... .. 61
Additiona l Knowledgeand Skills Required ..•.••..• •.. . .. .. .... . .• 74
CourseContent •..••. ... ....•. ..• 75
Course Format .• •. •.••. . .. .. •.• .... 96
vi
Summary •... . . . ... .•.•... . . • .•.. . ...• • 100 Jo b Satis faction .•. ....• ..•..•.•••..•... 10 5 The Cha ll e ng ingPat i e n t ...•.•.. .••... 116 SU;!Ima r y ..•.•.. •.•.. ...• •... ... ... 12 4 JobDissat isfac tio n ...• •• •... .... 125 Summary ••...•... . ...•...•.... .... .. 112 Personal an dLife styleAdaptiolls •...•. .... . . III Summary .. ... ... ... ... ... . 149 Administrati ve lind Profession al Su g ge s t ions. 150 Summary .••. . ••.• ..•.••.. .. . .•. ... .. .. 166 IV DISCUSSION . . .. .. ... .•.• ....•..• .. ... 168
Demograph icsandPerso nal caa r ect ertr.tIc s
ofCanadi an Hy per ba r i c Nurses 169
Fac to rs Contrib ut i n g toJob Satisfac tion or Dis sati sfa c t i on .•.•... ••.. ... . •• 172 Cou r s e desi gn for Int roductory
Hyp e rbar i c Program ...••.•. . ..•.•••.. .•.• ..•. 117 Pre-SelectionProgram .. .•.••..•.•.•..•. 177 HyperbaricCourseContent .•...•..• . 18 0
Physiology andMechan ism
of Action•.•..•.•.••.• •....•.• ... . 180 C(.ond it i on s to be Tr e ate d .. ... ... 18 1 Nurs i n g Care andEquipment.. ... 181 Chambe r Ope r ationsand
Emergenc y Procedu r e s ...•... 18 5
Pa t i en t Education 187
vii
se r e nd i p i tous Admin istrative and
Professio nal suggestions .... . . .. .. ... . 189 Disc u s s i onofLimitations ...• ... . . 193 Rec omme ndat i ons for Educatio n and Pr ac t ice .• 197 Re c o mme nd a t i ons for Further Re se a r ch 199 References ... .... ... ... ... 201 Appen dices .. . ... ..• •.... ... ... ...•...•. . .. 205
A. Part 1Informa tionShee t 205
Pa rt2Educ at i o nalNe e ds
As ses smen tQue s t i onna ire .... ..•. 206 B. Inte rviewQue st i o nnaire .. ..•... .••.. 212 C. Lettersto Oire c tors ...•... 213 D. Let te r of Explanation toNur s es ....• .. . 215 E. Informe d Con s ent For m... ... . 217 F. Let te r ofPer miss iontouse
Conc eptual Fr amework.... ... . ... . .. 219
vii i
List of Tables
TA BLE PAGE
Pers ona l ch a r ac t e r istics of Canad ia n 46 Hype rbaricNurses
ProfessionalCharacteristics of 48 CanadianHyperbar i cNurses
OverallRanking of Educ a tiona l Ne ed s 52 for Canadian Hyperbar i cNur ses - Mos t Ne e de dTo pics
Ove r a ll Ranking of Ed uc at ion a l Need s 54 for CanadianHyp e r ba r ic Nur ses - Least NeededTopic s
Types of Challenging Patients 118
.ix
List of Fig ures
FIGURE PAGE
Fr amewo rk fo r Con ce ptuali zing 27 Educational Programs inHyperba ri c Nurs ing Ada p ted from Frameworkof Urbano "Jahns (1988 ).
CHAPTER1 RESEARCHPROBLEM Introduction To The Problem
The enthusiasm surrounding the clinical use of hyperbaricoxyg e n therapy (HBO) has fluctuatedoverthe last several decades but has now st abilized. The increased interest inhyp e r ba r i c swa s in re s po ns e to a broad range of cli nical research supporting its effectiveness, and the needfor emergencytreatmentby an escalating numbe r of Lnddv Ldua Lc involved in diving activitiesfor workand le i s ur e.
Hy pe r ba r i c oxygentherapy requires the expertise of a mUl tidisc ipli na ry team, which includes nursing personnel,physicians andotherstaff whoha v e a variety ofte c hnI c a l backgro unds. Thecomplexte c hno l og y andthe wide variety of co ndit i o ns treated with hyperbaric pre s s ur e means that comprehensive introductory education aswel l ason-going educationa l programsare essential for allmembers of the clinical treatment te a m.
Problem stateme nt
Certifiedpro g ramsthataddressthepu re ly nur s ing issues of hy p e r bari c oxy gen t.herapy do not pr e s e ntl y exist. Mc Ki e l,LockyerandpechLujLs (1988),acknowledge the value of conjoi nt education, but caution that mul tidisc iplinary pr og r a ms may not specificallymeetthe
needs of one di sci pl i ne. This fact, as wel l as the abs e nce of res e arch on le arni ng needs of hyperbaric nursing pe r s onn el, indica t e s that res ea rchinthi s ar e a is required. It follows as a logical step that the le arning ne ed s of nu rse s be surveyed, based on the assump tio n thatcontinui ngeducationprogramsde signedto me ettheperce ive d need sof the le a r ne r s cou l dbe more eff ective tha n pr ograms whose content was di ctat ed by ot he rs(Crayto r , Brown&Morrow, 19 78 ). The re f ore, this study will focus on determ ining the educat iona l needs tha t nurs es who are working in Ca na d ia n multiplace hy pe r ba ri c chambe rs perce ive tobe importa nt. Although the researc h wil l focu s onthe ex pe r i e ncesof Cana d i a n nurses, it is expected tha t the findings wil l be of inte r est to hyp e rb a ric nursing pe r s o n ne l in other cou ntr i e s aswell as in Canada .
~
The clin ic a l value of this study is that itwi ll prov id e detail ed anal ysis of the pre v iously unree earchededucat ionalneeds of thehyp e r baricnur se. Th isinfor mat i o n isnotcurre ntly availablein th e North Amer ica n li t eratu reandit would bebenef icial notonly to guide futu reres earchbutto as sis t in thedeve lopment of imp rov e ded uca tiona l programsto enhance thesafe ty of pat i ent care.
Literature Review
Hype r ba ric lIIedicinearose fro. the need totreat de c ompr e s s ion sickne ss. Hyperbaric oxyge ntherapy is admi n ist ere din hype rbaricchamber swh ichhave been used for 80 yearstotr e at divingcasualtie sand for25years totreat altitudedecompression casua ltie s (Hy e rs , Baker
& cowley, 1982). There are two type s of chambers
(mon o pl aceandmultiplace unit s) , whi chvaryinsize and capabilities.
Monop iace Hyperbaric Chamb ers
The monop lacechamber is usually a cle a r acrylic cyl i nderapproximat ely8fe et long andJ fe etin diameter whi c h normall y acco mmodate s one recl ining pat i ent . Alt hough it ha s not be enmention e d in the literat u re, hyperbar icnurs e shav e reportedto theinvest iga t orthat occ asiona l l y anunse t t l e d infantma ybe treated wit h his mot he r or a hyperbaric nurse in thescnc p tece unit. In thi s unit, thepati entdoesno t requ ire amasktore c e i ve oxygen asthecha mber itself is pr e ssur i z e d withoxyg~n.
since no hands-on careis pos s ibl e , patients Who are trea ted inthemon opl a c e chamberareusua ll ythos e tha t are or i enta t ed, alert and abl e to follow instruct i ons commu ni cate dth r o ugh a twowa y intercom. Ifnecessary ,
unconscious critically il l patients, such as th os e described by Kri ngs (198 7 ) , can be treated in the monoplace cha mbe r since i t can be equipped wi t h mechanica l ventilation, cardiac and hemodynamic monitoring equipment (Glo wa c ki & Chew, 1988 ; Krings, 1987; Horkoo!, 1985).
Mu l t i pl a c e HyperbaricCha mb e r s
Hultiplac ehyperbaricchambersarepressurevessels constructed of aluminumor steel that can be sealed gas-tight. Thay have the structuralint e g rity to con tai n the int erna l pressure to which theywi ll be exposed, which, for mostclinical chambers, is a pressure le s s thanor equal to6 atm.abs. (atmospheres, absol ute).
This is thepressureexperienced at a depthof 165 feet underthe sea (POUl ton, 1981) .
The chambers have specia llyconst ructeddoors th at sealwit h pressureto preven taccidental opening. The re are entrylocksorpass-throughlocks thatvaryaccording to sizeandthat ca n be pressur izedinde pe nd e ntly from the main chamb e r. The pxensure in the locks must be equalizedto the internal pressure of the mainchambe r before accessingthe lock (Ha r r ing t on &Carter, 19 6 6 ).
Th ~ service lock can acco a ecdec e smal l piece s of equi p.e nt, while the pe rso nnel lock will allow the mov ee e nt;ofpe rso nne land la rg e r equi pJle nt in and out of the.a inchllllllber lIhile itisin us e, thu s pr oviding an impo rtant safetyadv an tage. "A networkof clo s ed-circu it te l evi s i o n camera sand severalsmallwindowport sprovide visualaccess to thecha mb e r " (Norko ol , 1979 , p , 729). Communication is ensur ed through multipl e systems in cludi ng two-wa yintercom, telephone and/o r he adphone.
Multiplace uni ts ca n acc ommoda te two or more patients seated , and up toseveral med ica l and nursing pers onn el, equi pment and anint uba ted pati ent . Becaus e the s ecba nber- s ar e pre s s uriZedwith ai r the pat ient (s ) re c e i ve 100\ oxygenviamask , hea d hood or endotra c he a l tube. To pre ve nt oxygen to xic ityduri nglon ghyperbaric tr ea tme nts,the patient breathes cha mbe rair for regular sho rt"a i rbreaks "and usually during de c ompr e ssi on . The nursingpe r s onnel,onthe other hand,bre athe chambe rai r mostof the time,exc e ptup o n deco mpres s i onwhentheyma y be provided with100 \ oxygen. Thistherap e ut icuse of a pressurized, oxygldnated envi ronment within a limited space presents a number of is su e s ....hi ch must be consideredas they relate to patients, pers onnel and
equipment.
A review of the medical literature provi ded an imp ressiv e list of re search projects, using bothhuman and ani mal sUbj e cts, and it appearsthat many significant de v e lopmen ts in this fieldhavetakenplacein the last de c ade. One of the consequences of thisre s earch has been the ident ific a t i on of conditions for which HBO the rapyis accep t ed as theadj unctor primarytreatment. Ros s (1986) identified the following 12 diagnostic ca t e go riesas benefit ing from HBO therapy:
r:adia t io n necrosi s, car bo n monoxidepoisoning, re fr actoryost eomy elit i s , burns,
comprom i s ed skin grafts. deco mp re ss i o n sicknes s, ga s embol ism, cr ush injur ies , cya ni d e po i son i ng, softt is su e infections, selectedprobl em wounds and sele c t e d refra ctoryllIycos es .
The last diagnosis istheonl y one that....as notaddressed extensive ly in the literatur e .
The nursing literature during the saIDe period is lirtited, with no attention given ta research and only minimalattention focused on nursingstaffor educational preparation . Thisissurprising si nc e the smal l numb er ofpaperswrittenonpers onnel,emphasize the importanc e ofproper education and se lect i onofsta ff , as ....ell as the need to be aware of the imp orta n c e of certain environmental va r i a ble s. Bond (1966)comme ntsth a t,ev e n underrout i n e operatingcondi t i ons, ...orkingina pres sure chamber is hazardous, physicallydemandinqand pr oduces physiologicCiland psychologicalst r e ss.
Th e following rev lew of the literatur e wi ll be divid e d intotwosections. First ,nu rsi ng iss ue s related ta hyperbaric oxyg e n therapy ...ill be presented sothat educati ona l topics may be identified . The n related lite r atur e an surveying educatio nal needs will be examined.
8 A' Nurs i na Is s u e s in Hyperba ri c OxygenT ~
Issuesimporta ntto HOOnurs i ng ide nt i f ied fromthe li terat ure can be classified into four general catego ries:
1. the phys ical andpsychol o g i ca l fact ors hyp e r bar i c st aff mayencounter .
th e envLz-o nnerrt.al hez arde , inparti cula r ,therisk of fir e .
3. thealte ratio nsto equipmen tth a t are required fo r usein a pressurized envi ronmen t.and
4. patient educat ion.
Physical andPsychol o gical Fa c tor s
Th e re area number of physical fact o rstha t put nurs ing and me di calper sonnel at risk asth eycare for a pati ent in ahyperb aric ch amber . The y encou n terthe same phys i ologi cal effectsexp e rienc edby divers (Gl owacki &
Chew, 1":J8B) andare the refore at r is k, particularly
during the dee per expos u r es requ ired to treat diving acciden t s . Workman (1 966) wr ote, "t he eff e cts of pre s sur e on a man may be divid ed int o two mai n categori es : 1)those that are di.rect andee c nant cat,and 2) tnoe o tha t come beca useof changes in the partial
pressure of respiredga s e s " {p, 110}.
The first category of conditionsresult ingfromthe direct effects of pressure canoccur duringdescentor ascent in the hyperbaric proce ss. Glowacki and Chew (19 8 1.') warned that barotrauma, the damage that results from changesinthe volume of ai r-contain ingcavitiesin the body, occ u rs when pressure outsid ethe body space differsfromth atwithi ni t. Thecons e que nc e s of the s e pressure changesare usuallyconfi nedto damage and pain inthe ears or sinuses, and to a le s s e r exte nt,painin the teet h. However. serious damage canbe causedtothe lungs if breathhol d i ng occurs dur ing depressurization (Wor klnan, 1966). Meijne (1970 ) ca u tione d that the pro cessof ascentcanbe lif e-thr ea t en i ng if expanding air is not ventedcontinuously. Bond(196 6 ) noted that evenwit hout having problems duringdescent , personnel work i ng in air compressed to 7 atmospher es absolute pressure (ATA) willinevitablyencounterincreasedeffort in thewo r k of breat hing, and staff must,t.nere rore, be in goodpul mon a r y health.
The second ca te gory suggested by Work.man (1966) focused on conditions that would be attributable to pressure Lndfr-e ctIy, as a res ult of ch a nge s to partial
10 pre ssure of ga s e sin the pressuri zed environment. The most impo rta nt of these problem s. experienced during hyperbaricpres suri zation, arenitrogen narcosi s ,oxygen toxi c ity and decompress ion sic kne s s.
Nitrogen narcosi s Lc due to the weak anesthetic effect of ni t r ogen upon the central nervous sys t em occurri ngat levelspro ba b lybeginningat about2ATA (33 feet under wate r) with its' typical symptoms becoming obvious between 50and 100 feet (Workman ,1966) . The se ns atio n is similar to alcohol int o x i catio n, as the di s s ol ved ni trogengas affects the brain. Invi e w of thiseffect,La n p hi er (1966)not edthat for dee p expos ur e s to app roxi mate l y 16 5 feet (6 ATA) , detail s of the pr oc e dur e or exami n a ti on of the patient must be communic a t e dco n tinua l l yto personneloutsidethe ch a mbe r toconf i rm the findings/ diagnosisandto checkthenentiaI sta t us of thechamber per sonne l.I t isalso required , in this situa tion , that the inside tenders adhe r e to the or de r sand decis i ons ofthe surfacepersonnel. Workman (1966 ) recomme n ded that beginning at a depth of 3 ATA.
personne l perf orm ing pr ocedures that require cle ar th ink i ng and manual dex t e rity, suc h as ope r ati ve pro c edure s, sho uld be mainta i ned helium-oxygen
11 mixture.
O)lygen toxicityoccurs whenoxygenat. ahighpartial pressure is inhaled for long periods of time. It can affect the brain, causing seizures, and can affect the lungs, causing cumulative and ultimately irreversible damage. Seizures can be prevented and lung damage can be ameliorated by providing air breaks, reducing the percentage of oxygen in the ai r or by limiting total exposure time and/orchamber pressure.
Decompression s Lcknese or the "bends" is caused by formation of gas bubbles in the tissues and blood during the ascent phase of under ....ater diving, flying or hyperbaric treatment where inert gases, usually nitrogen, are inhaled under pressure. Thorn (1992) writes that this phenomenon occurs .... . when the speed of decompression exceeds the ability of the saturated tissues to vent the gases by simple diffusion" (p. 25). Hyperbaric oxygen therapy is the primary treatment for this disorder ,whi ch has a wide range of clinical manifestations beginning with mild symptoms ot: joint pain moving to severe symptoms of cerebral, spinal or cardiac trauma possibly resulting in death. Although it is almost exclusively associated with underwater diving it is a concern for
12 hyperbaricpersonneland the reasonstaff areco mmi tte d to spe c if i c treatments protocolsfo r certaindepths of pressure.
In con s i de r i n g the effects of elevated partial pressure s of nitrogen, pr egna n c yis a crucial factor.
Jennings, in his 1987 article on women in hazardous onvi ronme nts, di scussed the very importantpr o blem of pregnanc yvnen ....orking in ahy p erbar icchamber. While furtherveseercn needs to be pursued, Jenningssuggested that expos ureto pressuresgreater th an normal pose a considerable ris k to the developing fe t u s. Several nu r sing paperspointedtothe need fo r restrictionson diving duri n g pregnancy becauseof the possibility of birthdef ect s, especiallyin thefirs ttrimester (Cor r y
&Montoya ,198 9 ;Greenberg,xeeetne , Reichow&MacLean, 1979). H.Ma nson (personal communication. April ,1992) sai d, "The placen ta appears to be a like lysite for bubble growthduringdecompression . Sinceth e fetus will also be exposed to increased partial pres sures of nitrogen, bubbles could formonthe fetal side of the placenta and the n c e access the fetal circulatio n . De ve l o p i ngl imb buds, etc.areli kel y vulnerableto suc h emboli. Hence thereisa fear ofcausingdamagetothe
13 retiua", In light of the sensitivity of fetal development to medication, alcohol and cigarettesmoke, adhering to precautionsseemsto be a wise suggestion.
In the literature apart from pregnancy, women were not found to be at greater risk of experiencing more untoward effect sthan men. Meljne (1970) did report that one argument used against women working under pressure was thatwomen tend to have more adipose tissuein the upper arms and buttocks and that because adipose tissue absorbsgreater quantities of nitrogen i t could increase their risk for decompression problems. In reality, additional problems have not occurred and a similar argument could be made for men who tend to have more adipose tissue around the abdominal area. Bond in an 1966 pUblication stated that, "With nursing personnel,an added and poorly evaluated factor of sexis introduced"
(p.146), because a large percentage of nurses are female. However, evidence suggests that concerns reported by Meijne and those of Bond are not justified in brief hyperbaric exposures.
As opposed to the physiological effects, the psychological impact of working in a hyperbariccha mbe r is related to the way mental activity and functioningare
"
altered in a pressurizedenvironme nt. Emotio nalstra in may also be associated wit h the intense dema nd s and respons ibilities created by the env i ronment and th e confinedquarters of th e cham ber. Bond (1966) sta t es that claustropho b ic tend e nci e s and overt reactions to confined spaces are significan tfa ctors to be cons i de r ed in selecti ng pe r s on ne l to work in this area. "An individualnor ma l l y una f fect edby closedenviro nme nt smay reactseverely to t.he situation ina hyp erba ri c chambe r wherethe sense of completeincarcera tionis very real"
(Bond, 19 66 , p , 14 4) . Even if, after one or two expoeures , the nov i ce nurse is she wn to be abletowo r k insuchan environment,the restillremain stheincrea s ed tens i on ofwo r king ina limitedspace. Both phys i c al and psychological close noss of pa t i entand st a f f can be a prob lem,since it is hei g htene das the y enc o unt ersimilar risks ina confined space.
2 Env i r o nme nta l Hazards
Of theha z a rd s ofworJdn gin amultipl a c e hyperbaric chamber , fire is by far the main safe ty con c ern. Ros s (1986)noted tha t in an oxyge n-chargedenvi r onment there isagreater risk for sparks tocause fireor exp losion.
15 Poulton(19Sl) stressedtha tthe rate atwh i c h subs ta nces bu r n is considerably increased with higher oxygen pr e s s u r e . The po t e nt i a lsou r c e s offire in a chamber are numerous, LncLud Lnqsparks fr o m electrical equipment or even stat ic electricity. Petroleu m products, suc h as lu b r ica n ts, grease, hair spray , na i l po l i sh , bo d y lo t i o ns, as well as petro leum-based cosmetics and dressing preparations. can cause spontaneousexplosionin the presence of high partialpressures of oxygen (Bolton, 19 81 ; Gaul &Hart,19 7 5: Glowacki&Chew, 1988; Poulton, 1981; Ross, 1986). In an oxygen charged chamber, tires are fata l because of the confined space, limited acceau to exits,and the increased toxic effects of combustion gasesund e r pressure. Asa resu lt,safety precautions, such as monitoring and removing excess oxygen in the chamberand reducingoxyg en inproportio nto the depth , are taken to decrease the fire hazard. Safety considerations, cautioned poulton (1961), must be of primaryimportance andfire regUlationsmust be strictly enforced. Providing th e se pr ecautionsare adhe red to the pote ntialriskof fire in a multiplacechambers is far less tha n the risk inmon op l a c e chambers whichunl ike mu ltiplaceunits, are pressurizedwi t h10 0 % oxygen.
16 3 MOdifications to Equipment
Another area of concern to nursing and medical personnel carrying out HBO therapy is the safe and accurate moni taring of patient status in the chamber.
especiallythe critically ill patient . A mercury spill in a mul tiplace chamber. either from a standard thermometer or aphyqmonancmet.er , exposes patients and staff to tox icmercury vapour, which maybe especially dangerous at high pressures. Mercury can also damage the metal of the chamber itself. Poulton (1981) suggested measuring arterial blood pressure using an aneroid manometer is preferred over the sphygmomanometer because it works without mercury. Another problem of using a standard sphygmomanometer in the chamber is that as pressure changes, the amount of time required to inflate and deflate the cuff also changes.
Ross (1986)recommended that in order to accommodate pressure alterations, medical devices with air filled balloons, such as endotracheal tubes and catheters, need to have their air pressure constantly monitored or neve the air replaced with water. Glass intravenous bottles/bagsshould be replaced b}o" plastic or great care must be taken with placement of their vent-tubes.
17
Ampules and syr i nge s also ne ed tobe properly vented.
similarly , measurement of arterial blood gases pr e s ents a cha llenge, si nce upo n decompr ession, blood samples los ethe ir oxygensaturation. In thete sttube, arte ria l bloodappears to boil as the gas content is decr e a s e d. Poul to n(1981 )noted tha t the bloodsample is still adequat efor measuring otherblood gases bu t not oxygen content. Ho we ve r, inthissituationmeasureme nt of oxygen content is not necessary si n c e "h y p e r b a r i c oxygen therapy ensures adequatetissue oxygenationfor vir tually all patients-including those with severe respiratory failure" (p,84).
4. PatientEduc a t i o n inHyperbarlc Oxy genTherapy A lastarea of concernidentifie din the literature is patient education. This has not been addressed di r e c tly inpublishedpapers but is included in nursing articles under thetopics of pa t i e nt preparatio nor risk factors . Ross (1986) re c ommende d close attention to fire prevention byrepe a ted l y reinforcing tothepatienttha t trheze beno smOki ng, lighters,cigarettes orele c t r onic equipment. Fire- ret a rda ntClothing and approvedfootwear aswell as non-petrole umbased lotionsare requiredtobe
18 worn in the chamber. Glowackiand Chew (1988) support these recommondations, in particular the meticulous attention to preventionof fire. Ross alsosuggests tha t the nurseshould teach the patient abo ut voice changes during treatme nt, use of oxygen masks and methods for relieving ear pressure.
Norkool (1979, 1985) emphasizes the importance of explaIningthedetails of the tr e a t me nt procedure to the patient and the family. Anxiety, especially fear of claustrophobia , may be significantly alleviated by explanation andreassurance from nursing staff. Norkool st ressedtheimportanceof educationand support for the disorientated or semicomatosed patient and Krings, in he r 1987 article on treating the critica lly burned patient with H80, also emphasizedthe need of patient educa tion:
"Oneof the most overwhelming challenges in this world of critical care nursing is explaining pressure change sensations on eardrums to a semi-comatosed, intubated patientwhois unable to seethr o ug h edematous eyesll (p, aD-H) •
B. Educational Needs of Hyperbaric Nursing Personne l The factors to be included when designing educational program for hyperbaric nurses can best be
19 identifiedbyconsidering thecha llenges th a t theyface, such as the pressure-related al te ra tions to the env i ronment and equipment, the physiolog ical and psyc ho logicalad a pta tionsfor both thepatientand nurse. educa t ionand awa r e nessabout hyper-bar -Lce , and final l y, theuniquenessofthe en viron mentaswel las the ha za rd s. When considering the s e challenges , it isnatural to look atthe educationalpreparationfor nursing staf f in this speci al t y. In 1966Wo r kma n comme ntedtha t therewereno form a l courses available at tha t time but he sa w educ a t i on ases sential. Glowacki andChew(1988) later comme nte d that the beginni n g de v e l opment of clinica l tr a ining cou rses intheUni ted state shad ope nedthe door tothedevelopment of ano t he r specialtyin the nur s i ng and me d i c al profes sion. The ysuggest edthat ed ucationa l prog ra ms ne e dto conti nue to deve lopin the hyp erbari c fiel d.However, inNort hAmericano coursesspe ci fi cally desig ned fornu rs i ng pers onn e l hav e yet been devel oped and no detailed educ atio na l needs as s e s s me nt of hyperbaric nurses ha s been carried out.
In amoregeneral co ntext , Matt hews l.d Sch umache r (1979)statedth a t noone rea l lychallenge d thene c e ssit y of continu ing educa t i on innur singand the belief in the
20 importanceofongoingeduc a t i on co ntinuestoheaccepted today. However . the s e aut ho r s also noted that the co nt rove rs y persi sts as to howthese cours e s sho u l d be develope d , i.e. should the conten t be dete rJllined by knowledgeablespecialists ,or be ident ifiedbyconducting a needs assessment su rvey of the opin ions of nurses worki ng in hyperbar ic un its ? Fa rle y and Fay (1988) conc l ude d from theirresearchthat a comprehensive need s as sessment is a vit a l part of continuing education program planningand theprimarysourceofdatatobeg i n the planning pr oc e s s, because it facilitates the development of proq r a lls that eeet; ex i sting needs and utilize slimited he alth care resou rce s ef fi c i ently •
ChesneyandBeck (1985) clas s ifie d needsassessmen t su rve ys in nur s ing continu i ng educatio n into three differ en t ty pe s :
1. nee d ee e e e e a e nc e whic h focus on the feat u r e s of cont i nuingeduc a t ion programs tha t make the m mo r e attractive to nurs e s. These surveys, suc h as the work of Mat the ws and Schumac her (1979), did not re que s t informati on oncontent are a s buton le ngth of progra ms,nu1llber of major topicsto bepresented
21 aswell asothe r items.
2. needs assessment that aim fo r gene ralesseesae neof preferred educa t iona l topic s for a large gr o upof Che sn ey and Bec k (1985), we r e one of a small numbe r of re searchers to choose this approach. Theycol lect e d data on educ a t i onal needs for nu rsesin12counties of the Coastal Bandar ee of Texas . Farley an d Fay (198 8) als o ident if ied th e educat ionalneedsof2,9 49 nurses inth e state of NewHa mps h i re.
3. needs assessment of nurs e s dealing wit h a particul a r to p i c, for exa mpl e cancer, part i cu l a r setting, for exe e pte , nursing home s. Thesa lient poi ntsof the ar t i cles that haveus ed thisthird appro...ch seem the most appro pria t e for this studyand they will berev iewedhere.
Crayto r , et a1. (1978 ) comp leted thre e studies that aimed at de t e rJllining nurs e s' lear n i ng ne eds in relationsh ip to cancer, whi ch wa s the most fr e q ue nt ly occurr ing topic in the lite ra ture on le a rni ng ne e d s assessment . Their findings ind i c ated "that increasi ng knowledgeandsk i lls decreased feeli ng sof he lplessnes s and that learningtak e s pla c e whenlearners are anxious ,
22 because of inabili ty to meet perceived demands•.0"
(Craytor , et aI., 1978, p , 219). Fernsler(1987), ina series of articles on program de v el op me nt in cancer nursi ng, le nt support to this finding by stating tha t
"ad u l t s are nmenable to le a r ni ng when they perceive a need to learn and are gi ven the opportunity to participate in the planning ..." (p. 59). Seta, Ong, Chi ng, Liu and 'lau (1988) similarly stated th a t "t h e adul tlearner is a demandingstudentand theeducationa l process may be superfluousifit is not tailoredtohi s orhe r needs" (p. 24).
The wide variety of topics selected by the nur s e s and the unpredictable natureof their choices supports the necessity to assess the learner'sneeds and inv olv e them in planning educationa l prog rams . For example, Pittman, Stevens, FUlpand House (1988) evaluated the continuing education ne e ds of PUblic health nurses in Nort hCarolina. Their findingsshowedthetop five needs to be: 1) le ga l aspects/riskma na ge me nt, 2) obtaining continuedcomplianceby patents, 3) counsellingskills, 4) sexual abuse of children, and 5) leade rshipskills.
All of these areas are of importanceto pUbl i c he al th nurses and the high ranking of these top i c s provided
23 valuable information.
Bye (1988) surveyedth e needs of nurses in nursing homes and found that the five most requested topics included; 1) drug therapy, 2) how to motivatestllffto perfonn well, J) techniques to handle behavioural problems of residents, 4) how to handle a performance problem with staff, and 5) how to manage a crisis situation. This author also stated that there was a significant difference in the topics selected by younger nurses compared to oldernu r s es, and between nurseslotith different educational backgrounds. Conedera and Schoessler(1985)did not examine the effectotage but like the previous authors proposed that the responses of experienced nurses differ~d from neophyte nurses.
Mazonson, WU&Scaltrito (19B1), in a well organized study of nurses educational needs in reLa t n.o ns b Ip to patients diagnosed with cancer, found the five most requested topics included: 1) nursing interventions in helping patients and families cope with cancer, 2) psycho-social needs of cancer patients and their families, 3) nursinginterventions in complications/side effects resulting from chemotherapy, 4) stress reduction for nurses, and 5) current uses of chemotherapy in
24
In a survey of a paediatric nu rsinggroup, Bowman, wo l k enh e l m, Beck, O'Donne ll and Schneide r (1985) fo un d that the five educational topicsperceivedto be the most ne e de d were: 1) emergency int e rv ent i on . 2) emergency nursing. 3) dealing withchild renand families, 4) pathophysiologyof common diseases,and 5) interpretation oflabvalues.
The uniqueness of eachlis t of prlorized education topics for the settingsdiscussedreflects the variation of eachnu r s i ng specialtyand reinforcesthesugges tion that a thorough comprehensive needs assessment is required for each specific nursing setting.
IDll!!mHY
A review of the lit e r a ture re ve a l ed that a comprehensiveassessmentof educatio nalneeds specific to eachnurs i ng settingis important. It can alsobe seen that, although desirable , the r e are no courses th at target only nursing personnel for nurses working in hi gh l y complexhyp erba ri c units.Most ofthe present day courses offeredat facilities outsideof Can a da are aimed at the medical profession . While in ind i v i dual cases
25 htperbaric nurses may have been asked to indicate what they perceive to be important content for an introductory hyperbaric course, no indication of this is present in the literature,and yet this information is an essential prerequisite to designingcourses specifically for HBO nursing personnel. There are no articles that report the knowledge required of the dally experiences of nurses working in hyperbaricunits, although this is an area of nursing that differs considerably from general nursing practice. This is an important area requiring further stUdy.
26 concep tual Framework
This study uses the work of Ferns le r (19 B7 )and Seta et a1. (1988) who state tha t adul ts are amenable to learning whe n they perceive a need tole arn andare given the opportunitytopa r t i c i p ate in the plann ing ; an dalso anadaptation of Urbano&Jahns'model of participation in continuing education. This framework has been expanded to specifically address nursingissues related to working in hyperbaricun i t s (See Figu re1, page 26).
The fr a me wor k highlights intrinsic factors and extrinsic factors that must be considered by th os e planni nga continuing edu c at i on programbecause the yare crucial in determining whether or no t an individual participatesandsucceeds in th e program. The intrins ic factors inclUde: 1) basic huma n needs, 2) attitUdes, values, beliefs,expectat ionsand pe r c e p t i o n s , an d 3) motivationalorientations.and are representedinth e model by theconcentric circles.
27
DEMOGRAPHICS
1---
ON-THE-JOB TRAINING)---t-~----I~~~~i~~~
ST RUCTUR E
f - - - -CONTINUINGEDUCATION COURSES
LIFESITUATION
FIGURE1: Framework.for conceptualiz ing educational progr ams in HyperbaricNursingadapted fro m the frameworkof Ur bano
&Jahn s (1988).
28 Basic huma n ne e ds were organ i zed int o a ge nera l theorybyMa slow (1970) . wholoo k ed at human need s ina progressi ve hierar c h y. The needs began wit h phy sic al survivalmoving throug hsafe ty , love, esteem and fi na llY se lf-actua lization (a sense of ha v ing ach ieved one 's full estpoten t i a l ). He be l ieve dthat the r e needed to be so mesatisfactionofea ch ne ed before the per s on could move on to concentrat eonth enext hi gherlev el , and that an unmet need wa smo ti va t ion for the person topu r s ue activities tha t wouldsatisfy thisnee d .
Another compone nt of the int r ins i c or personal variabl es is the person's atti t udes, values or bel ie fs which can eit her hin der or faci l i tat e ed uc atio na l invo lvement dependi ngon person 'sexpe c'..:atio ns . If the end resultofthe educa tiona l programis expected to be relevant and need fUlfilling for thestuden t the n thi s has apo s i t i v e effect uponthe atude nt. esbel i e f system and subsequent ly upon pa r t i c ipa t i on (Urbano &Ja h ns , 1988)•
The final per s o n a l variablelabel led "motivat i o nal orie nta tions" are gr o uped by Urba no lit Jahns into six categories: exter n a l ex pecta tio ns, pro f e s s i o nal advanceme nt , social re l ations h i ps , soc ial wel fa re,
29 escape -stimulation and cognitive inte r est (More t a ! n &
Sma r t, as cited by Urba n o , 1988). These 50c1 a 1- psycho logica l characteristics whi ch were onl y briefly me n t ionedbytheaut ho rsare the primary motiva t orsfor professio nalpar tici p ationin continui ngeducation.
These int r ins ic facto r s ar e impacted upon by extrinsicor societa lforceswhich aredivided into three categories: 1) demogra phic charac teris tics, 2) life si tua tion var iables, and 3) educationa l opportuni ty structureCharacter istics. Urbano &Jahnscla s s i f y as demographicCharacteristics, factors such as age, sex, educationlevel andmaritalstat us be c au s e these fact o rs ha v ebeen assoc iatedwith moti v a t i o n and participationin educational programs. The y influe nce, among other things , the att i tudes and expectations of the pa rtic ipant s, as well as their financial status, time av ail a bil ity and heal t h , and conseque nt ly effect the qua lity of success or fail ure of the ed uc a t i onal ex p e r ience.
The Life Sit uat ion variabl e s of the fr a mework inc lude the sociologica l influencesof adu ltgrowth and de v elopme nt , andtheeffect of the significa ntpeoplein the learner'sfamily,personal,and/ o rprofe s &io n al life.
' 0
The lear ner\lIaybeinfl u e nced by theirown at t itud e s and cet Iere as we ll as those of others. For example, a pers on ' s att itude to....ard the ir job, the suppo r t of colleagues and fami ly members toward cont inu i ng educati on, their care er goals, and their stage of perso nalor professional development can all effect the quality of the educational experience. These life si tuationvariablesneed to beconsideredwhen selecting targ e t gr oup s for recruitment, pUbl icity and pla n ning continuingeducationprograms.
Educational opportu nity structu re represen ts th e varying availab ility of programs whlch will affect participation. Ava ila bi lity of programsconsiders such factors as location, timing, cos t, and course con t en t tha tmust be addressedbythoseplan ning the con tinui ng educa tionprogram. Urbano and Jahns mode l has been ex pandedto inclu de on- the-job training and con t i n u i ng educationcourses (see Figure1).
At present, on-the-job tra i n i ng in hyperba ric units is the main av e nue by whic h nurses in canada are introduced to this specialty and th r o u gh which their kn owl e dg e is kept current. In most facilit ies, thi s on- the-joborientationis supplementedby rea dingrelevant
31 materialG, and a few units also provide study gu i des and/or films. Practical eupez-vLsLo n inthech amb e r is providedbythe senior nurseor physici an as ti me and wo rk lo ad permit.
Because no courses specifically designed for hyperbaricnurs ingexistaned uc a t iona lneeds assessment should be carr i e d out as an important initial ste p in designing program for hyperbar i c nursing. consequently. this study will de te r mine Canad ian hyperbaricnurses perception ofthe educationalneeds to be addres s ed in a hyperba ric course . I t is not the intention to test the conc eptualfr ameworkmodif i e d from Urbano (, Jahns'work but considera t ionwi l l be givento analyzingcomponentstha t are relevant to thi sres earch . The fo ll owi ng as sum ptions have been made in this inve stigation:
1. Hyp e rb a r ic nu r s e s intervie wed will be able to recall accurate lythe education and training they were given prior to working in a hyperbari c cham be r.
2. They will be abIe to rec all the ir most sig ni fic a nt early work expe r i e nce s in an hyperbaricchamberaccurately.
32 a, They will be ableto identifyinformationthat the y did not have tha t would be useful to them.
4. This in f o rma t i on wil l be ueerur to those re s po ns i bl e forde s i g n i ng educa tiona l courses for hyperbaric nurses.
Limitationsof the Study 1. only the three Canadian English -
spe aki ng clinic al hy pe r bar i c uni t s were sampled.
2. With the excep tion of the pil ot st ud y , the questionnairesused inthe studywere not previous l y te s t ed .
J. Informationob tained byasking nursesto recall the i r introductory hyperb aric educational experience may not provide an accuratepi ctur e ofthatexperie nce . Despite theselimitations, it is expectedthat th e nurses will recall the most significantde t a il s. This study is expected to pr o du c e useful information, and provide a starting point for furthe r research and for developing contin ui ngeducatio na lprog ramsfor hype rba r i c
3J
Purpo s e
The illlmediatepurposeof th i s study isto~escribe the hyperba ric nurses working in cli nic a l JIlui tiplace hyp erbaric chambe rs inCa na d a, to determIne theIr age, sex, ma r i t a l sta tus and educ a tiona l pre paration ,andto ident ify thetop i c stha t they pe rceiv e shouldbe inc l uded in an introductory educat i ona l progra moff ered pr iorto wor k i ngin mUlt i pl a c ehyp e rbariccha mbers. The ultimate purpose istosupply basic informa t ionfor thos e pla nni ng an intr od u ctory hype r bariceducat i on course spec i fi c al ly for nursesand alsoto pr ov i de a fo undat i onfor fur t her researchinto hyperbaricnu rsingpract ice .
1. What
Re s e a r c h Questions
the demogr aphic and professio na l cha racte rIstIcs of nurs e s who are work ing in hyperbaricchambers providingclinicaltreatment in Can ad a?
2. What ed uc at ional preparationwa s providedecnur s e s be f o re the y began to work in a mUltfp lace hyperbari c cha mber?
34 3. What additiona l informa t i onwouldthe s enurs ehave
found useful for their hy pe r b aricwo r le?
Def l n it icnof concepts
Hyperbaric oxygen therapy (8BO) is th e admin istrat ion of 100% oxygenbyinha la tioninachamb er at greater than atmos pheric pr es s ure. I t func tions on two principles : 1.thatin apr es s uriz edhype r o x ygenated environment the amount of ox yo;;en is increased in th e plasma, tissues and ce ll s and 2. that gas bubbles decrease in size andare re abs or b ed as pr e s s ure inth e chambe rinc reases .
Hyperbaric chambers are vessel.sthat can be sealed gas- tig ht andmaintainincreased in ternalpressure. They can be eit heramonopl a c ecneneer, whi ch is a un i t on ly large enoughfor one pe r s on, or a tnultlp laceunitwhich is large enough to accommodate two or morepeop le .
Hyperbaricnurse is a registered nursewho hasbe e n specifically educated to care for pa tients in a mul t i place hyperbaric chamber.
l'n introductory proqra.ra. is a forma l continu ing education program, includin g cla s sroom lind clinic al experiences, designed for nurs es begi nn i ng to work in
35
hyperbaricun i t.
contin u inqedu cat ionprogr. .arecou rse sof fered to reqister ednur s e s after theirbas ic nursingprograll for the purpo s e or int rod u cing newkno wl edge or upda t i ng existingknowl edg e.
Learninq needsarethose educa t i onalne edsper ceive d by th e learnerto be impor t a nt as opposed to as cribe d ne eds which areed uc at i ona lneeds identifiedby seneone other thanth ele arner (Vo lke r,1987).
36 CHAPTER II
METHODOLOGY ResearchDesign
In viewof the limited inf o rmat i o n in the 11terature on hyperbaric nursing ,i t wasdecidedto do a descriptive st udy. Thi s stUdy was conductedto det ermine certain pers onal and profess i onal characteristics of Engl!sh- speaking nur s e sworkin g inclin i c a l multiplace hyperbar-Lc ch ambe rs in cana d a, as we l l ee their perception s regarding th e content of an introductory educational program in hyperbaricox y ge n therapy .
Set ting
Thesett i ng for thisstudywas the three hype:rbaric multipla ceunits in Canadawho elllploy nurses, that are located in 1. TorontoGeneral Hospita l, 2. Va n c ouv e r General Hospitalan d 3.Victoria General Hospital . Taped interv iews were conducted in pri vacy , withon l y the SUbj ec t and the investigator present, either inthe hyperbari c un i t or at a lo cationsel e ctedby theSUbjec t.
37 SampleSelec ti on
Ate l ep h one surv eyofthe runemult1pl a ceunits in Canad a revea l e d tha t English -s peaki ng nu rses we r e emp loyed inthree of the facilities : 1) Toront oGene r a l Hospital .Toronto,Ontario,2)VictoriaGene ralHo s pital. Halifax, Novasc oti a,and J)Vancouver Gene ralHospital, Vancouver,Bri tishCol umbia.
Aft er app r oval to conduct the study had been obtai ned fromthe app rop ri a t e admini strativeandresea r ch pers onnel of these lnst!tution s (se e Appendix C), the initial expl an ation of th e studytothenurs eswas made bytheaenf.crhy per b arienurs eorsup e rviso r,anda.e ma wa s sent toth e nursing staff prior tothere sea r che r vis iting the unit . Upo n arr iv i ng at the unit the researche r's firstphone contact '11t h the pa rticipants focused on explaini ng the purpose ot th e rese arch pr o ject, therol eof theresearcher,expectationsofthe nursingpa rti cipants and therequire ment s for info t1lled co n se nt (s eeCo nsent ForminApp endixE). Anappo i ntment was also sc hedul edtoran interv iew andarra ngeme nt swe re mad e for each parti cipant to receive a pac k a ge of inf onati o n aboutthe resea r ch prior to the intervi ew.
Thi s packa geincl uded acons ent rera, inf onation
3'
about the study and the re s e a r ch quest ionnaires. The sUbjects were askedto completePar t I, TheInformation Sheet and Part 2, Educationa l Needs Assessment Questionnai reand bring them to the Ineeevtev . Th irty~
two of the 33 English-speakingnurses who work full-time, pa r t- t i me or on an on-callbasis in thesethr e e unitsin January/February. 199 0 agreedtopa r t i c ipa t e.One nurse wasno t asked becauseof hospitalizationduetoilln e s s.
None of thepar t i c i pan t s were coerced intopa r t i c i pa t i ng. The high participationrate was probably relatedto the good rappor tbetween the partici pa nts and the nursing leaders of the units(Who madethe ini t i al contact), and also the hi gh level of motivation in thi s particular nursing specialty.
Ethical Considera tions
The proposal for this research received approval from the Human InvestigationCommit teeofthe FaCUltyof Medicine, MemorialUniversity and theResearchCommIt tees of all hospitals involvedin the study. The policiesfor protectionof humanSUbjects ....ere follo....ed andmeasures wereta ke n to ensu rethat informed conse ntwas understood beginning with a discussion with the participa nts
"
concerning the nature of the st u d y (see Appendix 0), their ri g h ts regardin gparticipation .thescop eoftheir involvement , and as s u rances of the ano nymi ty and the confidentialityof the Lr informatio n.
SUbjects were presumed to have giventhe ir con s e nt to havethe questionna i r e data use d after the ybr oug ht the completed documen t s tothe inte r vie wandco nse nt to use interv iew data was obtained by comple t ion of a wri tten cons en t form(s ee Appe nd ixE)prio rto th etape d interview. A numeric a l code was use d so that questionna iresdidnot inc l ud eth e SUbj ects' name s and thus ensuredanony nity . Data was lock e d ina secur e placeby the re search er until it was entered into the computer at which time theorigina l que st i onnair e was destroyed . Individual s' res pon ses were not discussed with theemp lo ye r andthe ywe regrouped for ana l ys isso that individuals ca nno t be identified from the i r responses.
As ta r as could be determined, there were norisks to the health or saf ety of partici pants in this invest igat ion . The researcher uti liz e d the fo llowing safeguards to minimi z e ri sk:
40 1. To allay anxiety, the researcher attempted to provide a comfortable, relaxed setting using a non- jUdgemental approach.
2. Appointments were scheduled at a time and place most convenient for participants. with flexibility for sUbjects who workedinthe evening or at night. 3. Appointments were rescheduled upon request of
sUbjects even at short notice.
4. ThesUbj ect was reassured that she may refuse to answer any question.
SUbjects may not directly beneHt from involvement in the study, but long-range benefits could be derived from using resultsto design better educational programs focused onthe needs of hyperbaric nurses. MostSUb j e c t s were pleased to have the opportunity to talk about their concerns and their achievements in this clinical specialty.
Data Collection
Data collection took place from January 22,1990 to February 10, 1990. The investigator visited the hyperbaric units in Halifax, Nova scotia; Toronto, ontario and Vancouver, British Columbia and spent one
41
week at each institution. Datawere gat heredby means of aque s t i onn a i r e consisti ngof two instrumentsdeveloped bythewriter (see AppendixA),and a personal interview
(see Appendix B).
The firs t part of Instrument number 1, the Information Shee t (see Appendix A) 1 ieted eight demographicvariab leswhichhave been included in similar tools focusing on nurses working in other cf Lmcaj, settings (Bye, 19 8 8 ; Conedera & Schoessler, 1985, crayter, et al., 1978: Mazonson, et a L. , 19 8 1; pittman, et a1., 1988). Four of these variables (age, marital status, #of childrenand advancecourses takenprior to working in hyperbaric un i t s ) were included for descriptive pu r pos e s while it was hoped that the remaining itemscouldbe examined for a correlationwith the nu r s e ' s perceived educational needs (Bye, 1988;
Conedera&schoessler, 1985). The second part of thhl instrument, the Educational Ne e ds Assessment Question naire (see Appendix A), provided a list of 37 topics related to hype r ba r i c nursing. The topics were obtai ned from the literature on hype z-barLcs , the re s e a r ch e r ' s clinicalexperience in this area and the outlineofthe Hyperbaric MedicineCourse offered by st.
42 Luke's Hospital in Wisconsin. The participants asked to rate how essential these topicswould be in an introductory course for beginninghyperbaricnuxees using categories labelled as 'hav ing a great need' , 'having sc.aeneed',or 'havingno need',andto indicateif they 'd i d ' or 'did not' have th i s information in their introductory pr.oqram. A final column allowed room for co mme n t s . The second Ins t r ume nt titled Int e rv i e w Questionnaire(see Appendi" B) was a series of open-ended questions used as an interview guide to address educationalconcerns of the participa nts .In using these questions the int e rv i ewe r was careful not to lead the questioning in any way.
Pilot study
The questionnaires were pre-testedto determine if they ....erere a da bl e and SUfficiently easy to understand, andto allowthecontentto be assessed for completeness.
In the pilot s'tudy , a sample of experienced hyperbaric nurses working in the Hyperbaric Medicine Department of st.Luke'sHospital, MilwauJ:ee, Wisconsin, wereasked to ceview the questionnaires and give suggestions for revision. vnly minor grammaticalchanges were needed as
4J a result of this test. All thesenurses indicated that th e que sti on n a i r e s were readableand unde~standable.
Data Analysis
A general description of th e nurses working in hyperbaric units was obtained from examining the frequenciesof each demographicvariable. Topics in the Educational Needs AssessmentQuest ionna irewe r e ranked in order of decreasi ngperceivededucationalne e d , basedon the overall meanra nk values assigned to eachtopicby all responde nts. Where numbers in the various demographic ca t e g o r i e s al l o we d, the rank ord ering of learning needs was eua nfned to determine if any rel ationships ..xisted with the demographic variables (s ex, education, ho u r s worked per week in hyperbari c unit, and length of time working in hyperbaric unit).
using the process outlined by Wilson (1985 ),content analysiswas carriedout on the qualitativedata obtained from the tapedint e rv i e ws withparticipants. After the tapes were transcribed, the interviewerreadand reread them searching for common themes to descr ibe nur se s' experiences in hype r b a r i c chambers. During the interviewspredeterminedopen-endedquestions were used
44 to guide the participants (App e ndix B) and themes emerged fromthe in t e rvie w data. These themes were organiz ed int o fi ve thematic categories which described the nur ses education al needs, and their experiences of working in hyperbaric chambers. An ex p er i e nc e d nurse educator read a sa mp l e of the tr a nscri bed interview s to ch e c k on the valid !tyof the ca t e gor i es chosenbythe researcher.
45
CHAPI'ER III RESULTS
The results are presented in three sections: 1. Description of the demographic characteristics of the nurses; 2. Analysis of Educational Needs Assessment Questionnaire and 3. Analysis of the data obtained from interview tapes.
Characteristics of the Sample
Table 1 shows the personal characteristics of the 32/33 Canadian English-speaking hyperbaric nurses as obtained from the Information Sheet (Appendix A). The majorityof the SUbjects are in the age range of 30-39 years while the second largest age group is 40-49 years. Overall these two age groups comprise 81% of the sample. Twenty-nineof the thirty-twoparticipants were female. Slightlymore t.nen a half of the nurses were married or living with a significant other. Twenty-three (71.9%) of the group had no children.
. 6
Table1
PersonalCharacteristi csQf CanadianHyperbaricNurses
VARIABLE CATEGORY FREQUENCY PERCENTAGE
Ago 20 -29years
,
15.630·39years 17 53.\
40- 49year, 9 28.1
50+years 1 3.1
So. Female 29 90.6
Mol. 3 9.'
MaritalStalus Single
"
43.'Palnld 17 53.\
Separallld/DlYorcedf'Mdowed 1 3.1
Number01Nurses No Chidren 23 71.9
wfthChidfen 123ChId~r8ll
"*"on . .1 12.512.53.1
47 The nurses' prof e s sion a l characte r i st i c s disp layed inTa ble 2. Theedu c a t i o na l level for 29of the nu rses was Registered Nur se (R.N.) whil e only 3 participantsheld abachelo r sdegreeinelt ha.:nursingor a related field, such as science. Mostof the nurses worked inthehype r ba r i c unitason-cal lpers onne l. onl y a sl\lal ! number (N-6) wor k e dfu l l -timeand onlyon e pa r t - time. Therewas atle as t onefull-timenurs e in each of theth ree hyperbaric unitssu rveyed.
The length of timeworkingin hyperba r i cun itsthat was most freque nt lyrecor de d on the ques tionnaire by 28.1' of the respond ents wa s 2-5 yea rs. ac vever , the majority of nur ses (62.5%) had beenworking in thi s are a for lon ge r tha n 2years , andas wa s lea rne ddur ingthe inte rv i e ws,thesenior nurse of each hyperbari c un i t ha d beenworkingin thear ea ofhype r ba ricsfor 15-20years hav ingbeen theseni or nu rse sinc e ea c h unitwas opened.
Almost all of the nurse shad workedat oneti meor anotherinInten sive Ca reor Corona ry Care uni ts and28 of them had taken an advan c ed course in ICU or CCU.
Three responde ntshad been inv o lvedin a cou rseon Wound
48 Table2
Profess io nal Characteristics Of Canadian Hy perbaric Nurses eN - 32)
Variable Categories Frequency Percentage
N
..
Education R.N. 2. 00.8
B.N./B.Se. a 9.'
M.N,/Ph .D. 0
EmploymentStatus InUnit Full-TIme 8 18.8
Part·Tlme 1 3.1
On-canBasis 25 78.1
LenglhofTime Workingin O·6mooths a 9.4
HYP9rbaric s >>6 months-'1year-2yearsyear
•
5 12.515.6>2 years·Syears s 28.1
>5years-10years a ..4
>10years 8 25.0
AdvancedCOursesTaken ICU/ CCU 28 87.5
Prior toWorkingin Hyp erba ric Wound Care a 9.4
Units' RespIratoryTherapy 0
N~47 HyperbaricOxygen Therapy 5 15.6
Other 11 34.4
Several nurs e s havetak e n morethanone cou rse.
49
Care while none of the subjects had ta ke n a course in RespiratoryTherapy. Fivepar t i c i pant s indicated inthe ques t i o nna ire thatthey hadcompl e t ed a Hyperbari cOxygen The rapy course prior to worki ng in this area. since thereare no hyperbaric coursesavailablein Canada, this was followedup during the interviewsand it was learned th a t the sUbjects were refer ring to the on-the-job orie ntat i on thatthey hadre ceive d whilebeing introduced tothe hy pe r b a ri cunit or a hyperbaric co urs e taken in the United states after commencing work in the unit. Eleven nurses indicated tha t theyhave completed other courses, some of thos e mentioned were programs in Aeromedica l Nur s ing , physical Assessment, Neurosurgical Nursing, Nursing Ma nagementor CertifiedScuba DiVing.
Analysisof EducationalNeedsQuestionna ire IntheEd uca tio nal Needs AssessmentQuestionnaire , completed by hype r b a ric nurs e s (see Appendix A), the subjectswere asked to indicatewhichof 31 educational topicslis t e d were ofmost impo r t a nce in anintroductory hyperba r i c program.
The top i c s of perceived educational ne ed were then ra nk ordered accordi ng to me an rati ng (Bowman et a1.,
50 1985: Bye, 1988 ; Mazonson at aI., 1981; pittmanet a1., 1988)• Table J shows th e tenmost needed topics as perceived by this nursing group. "Han dl i ng patient emergencies in the chamber" was rankedby all of the nurses as the most importanttopicto be addressedinan introductory course tohype r bari c s. Threetopics witha mean of 2.97 were tied as the secondmost important topic:"Te a c h i ng patientsabout HBO complications andthe importance of compliance"; "Nursing interventions for oxygen toxicity" and "Prepa ra tion of patient for hyperbaricoxygen therapy". Threetopicswithamean of 2.94were selected as the fifthmost important group of topics,they included"Nu r s i ng care for the patient with carbon monoxide poisoning"; "Contra indica tions, complications and potent i a l hazards of th i s work for nursing personnel " and "Handling pr e s s u r e generated emergenciesII• In t.his group, "Co ntr a i nd i c ati o ns , complications and potentialha z a r d s of working in the chamberfor the nurse"was the first andonlyitemin the ten 'Most Needed Topics' Which relatedto the nurse's he a l t h as opposed to patient concerns. Finally, the topics of "Pa t i en t assessment", "Nu r s i ng intervent ions for anxiety disorders" and "Fire safety and cont rol"
51 ranked7-10 respectively andcomp letedthe listofthe 10 mos t needed top ics, all witha med ian val ue of2. 91.
52 Table 3
Overall Ranking Qf Educational Needs For Canadian Hyperbarj c Nurses - Most Needed Tgpics eN- 32)
MOST NEEDED TOPIC MEAN % OF32
NURSES WHO RECE IVED TOPIC IN INTRODUCTION
TO HBO Han dling patie ntemergenciesinthe 3.00 71.9 chambe r, e.g. cardiac ar rest. (30)
Teaching patientsabout ROO 2.97 78.1
compl ications, and theimportance of compliance totr e a t men t re g i men. (11)
Nursing interventio ns for oxygen 2.97 84.4 toxicity. (13)
preparationof patie nt for hyperbaric 2.97 81.3 oxygentherapy. (15)
Nur s ing carefor thepati ent 2.94 71.9
diagnosedwith carbo nmonoxide po i so n i ng/ s mo ke inhalation. (3)
Contraindicat ions, complicat ionsand 2.94 81.3 pote nt i al hazardsof workingin the
chamberfo r the nurse. (26)
Handlingpressure generated 2.94 71. 9
emergencies, suc has pneumothorax, gas encct Iem. (29)
Psychological and physica l assessment 2.91 78.1 of patient prior to andduring
hy perba ric oxygen therapy. (1 4)
Nursing interv en tion s for anxiety 2.9 1 71.9 relatedto confinementin HBO
chamber. (17)
Fire safety andcontrol. (24) 2.91 84.4
~Numbe rsin brackets refe rto the orderof questions in the Educa tionalNeeds Assessment Questio nn aire(Appendix A).
53 Table 4 lists the fiveleastneededtopic sin order of decreasingneedas perceivedbyall the re spondents in this st ud y. "Decompressiondivingtables"and "Nur s i ng Care for the patientdiagn osedwi th ccuebinjuries" wer e at the top of leastpopular choiceswithameanof2.38, while the topi cof "NursingCare of patients di agn osed with burns" ranked th i r d (medi an 2.19 ). Interestingly. "Stress redu cti on for nur ses" with a medianva l ue of2.06 wanchosenbythenurses sur v ey e dto be the least important topic of all 37 items in the questionnaire, eve n rating lower tha t "Evolut ion of hyperbaric oxyge ntherapy" which wasrankedsec ondlast.
