MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF NURSING RESEARCH TITLE

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES

SCHOOL OF NURSING
RESEARCH TITLE: ASSESSMENT OF KNOWLEDGE REGARDING ABG ANALYSIS AND INTERPRETATION OF ABG RESULTS AMONG UNDERGRADUATE THIRD AND FOURTH YEAR NURSING STUDENTS AT MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES, ILALA MUNICIPAL, DAR ES SALAAM CITY, TANZANIA.
NAME: BENEDICTO TENSON MGALA (REG. NO. 2015-04-08692)
PROGRAME: BACHELOR OF SCIENCE IN NURSING
RESEARCH PROPOSAL
SUPERVISOR: EMMANUEL SUMARI
COORDINATOR: DR. LILLIAN T. MSELLLE

ABBREVIATIONS
ABG………………Arterial Blood Gas
PaCO2……………. Partial pressure of Carbon dioxide
SaO2………………. Saturation of Oxygen
HCO3-……………. Bicarbonate
MUHAS…………… Muhimbili University of Health and Allied Sciences
ICU………………… Intensive Care Unit
EMD………………. Emergency Medicine Department
EC…………………. Emergency Centre
TU…………………. Trauma Unit
MNH………………. Muhimbili National Hospital

DEFINITION OF KEY TERMS
ABG: Arterial blood gas (ABG) analysis is a blood test that measures the levels of many different gases in the oxygen rich blood(Pagana, Pagana, & Pagana, 2017). Some of these levels are measured directly; while others are calculated from the measurements of other gases(Thomas, 2017). It is used as a monitoring tool to test the effectiveness of ventilation in Critically ill patient(Basnett, Devi, & Chetia, 2016)
Assess: It is a statistical measurement of knowledge by structured questionnaire regarding ABG interpretation among Nursing Students (Bhanu P.B, Limi E.D, & Indira S, 2016)
Knowledge: It refers to the verbal response of Nursing students to the structured knowledge questionnaire regarding ABG interpretation(Patrisia, 2012). It includes inadequate, moderately adequate and adequate to assess the knowledge of Nursing students(Pagana et al., 2017)
Interpretation: It is the judgment made by the Nursing students on ABG results in relation to the treatment of a client admitted in critical care unit(Larkin, 2018)
Nursing Students: Refers to someone who is studying or training to be a nurse (Collins dictionary, 2018)
Critical Care Unit: Refers to a unit in the selected hospital which is designed to take care of critically ill patients(Basnett et al., 2016)
KEY WORDS
Knowledge, ABG Analysis, Nursing Students, Tanzania

TABLE OF CONTENTS
ABREVIATIONS…………………………………………………………………………………………………ii
DEFINITION OFKEYTERMS………………………………………………………………………………..ii
1.0 INTRODUCTION……………………………………………………………………………………..1
1.1 BACKGROUND……………………………………………………………………………………………….1
1.2 PROBLEM STATEMENT………………………………………………………………3
1.3 RESEARCH OBJECTIVES……………………………………………………………4
1.3.1 Broad objectives………………………………………………………………………4
1.3.2 Specific objectives…………………………………………………………………….4
1.4 RESEARCH QUESTIONS………………………………………………………………5
1.5 RESEARCH HYPOTHESIS…………………………………………………………….5
1.6 CONCEPTUAL FRAMEWORK…………………………………………………………6
2.0 LITERATURE REVIEW………………………………………………………………8
3.0 METHODOLOGY. ……………………………………………………………………………………………………………. 11
3.1 Study design. …………………………………………………………………………………………………………………… 11
3.2 Study site. ……………………………………………………………………………………………………………………….. 11
3.3 Study setting. ………………………………………………………………………………………………………………….. 11
3.4.0 Study population. …………………………………………………………………………………………………………. 11
3.4.1 Inclusion criteria. ……………………………………………………………………………………………………… 12
3.4.2 Exclusion criteria. …………………………………………………………………………………………………….. 12
3.5 Sample size. …………………………………………………………………………………………………………………….. 12
3.6 Sampling procedure. ……………………………………………………………………………………………………….. 13
3.7 Data collection tool. …………………………………………………………………………………………………………. 13
3.8 Data collection method. …………………………………………………………………………………………………… 13
3.9 Data management. ………………………………………………………………………………………………………….. 14
3.10 Data analysis. ………………………………………………………………………………………………………………… 14
3.11 Ethical consideration. ……………………………………………………………………………………………………. 14
3.12 Validity& Reliability of the information. ………………………………………………………………………… 15
3.13 Dissemination ……………………………………………………………………………………………………………….. 15

1.0 INTRODUCTION
1.1 BACKGROUND
All over the world, Nurses in ICU, Emergency departments, and trauma units, use considerable time in drawing, documenting, reporting and interpreting blood gases (Xafis, Sa, & Em, 2014). Arterial Blood gas is a blood test that measures the levels of many different gases in the oxygen rich blood (Pagana et al., 2017). Some of these levels are measured directly; while others are calculated from the measurements of other gases (Thomas, 2017).
The key parameters of ABG analysis are, PH, PaCO2, HCO3-, PaO2, and SaO2 (Pagana et al., 2017). The key steps in analysis include; Analysis of PH, Analysis of PaCO2, Analysis of HCO3-, Matching the PaCO2 or HCO3- with PH, assess for compensation, and finally Analyze the PaO2 and SaO2 (Larkin, 2018).
Arterial blood gas analysis is a common investigation in emergency departments, intensive care units and trauma units for assessing respiratory compromise, status peri- or post- cardiopulmonary arrest, and medical conditions that cause metabolic abnormalities such as sepsis, Diabetic ketoacidosis, renal failure, toxic substance ingestion, drug overdose, trauma, or burns monitoring patients with acute respiratory failure (Basnett et al., 2016). It also has some applications in general practice, such as assessing the need for domiciliary oxygen therapy in patients with chronic obstructive pulmonary disease(Mohammed & Abdelatief, 2016; Pagana et al., 2017).
Since Nurses and student nurses in critical care units, emergency department and trauma units are more involved in ABG interpretation as well as caring patients on ventilation, correct interpretation of ABG can prevent complications, avoid errors and help in the progress of Patients condition (Thomas, 2017). Knowledge about interpretation of ABGs is consequently essential for nurses and physicians who are working not only in these units but also in general wards, to be able to analyze each component of the ABGs in order to avoid overlooking a change that could result in an inaccurate interpretation and lead to inappropriate treatment(Mohammed & Abdelatief, 2016; Xafis et al., 2014)
For these reasons, a thorough Understanding of the pathophysiology surrounding ABG’s and the clinical implications, therefore requires Nurses to be proficient in their interpretation of ABG’s (Glenn, 2014). However, current evidence in different countries all over world, supports the contrary that nurses and physicians working in Emergency department (EMD), Intensive Care Unit (ICU) and Trauma settings have unsatisfactory ABG theoretical knowledge and interpretations skills with potential adverse effects on patient care from misdiagnosis, mistreatment, and improper care (Smeltzer, 2014; Xafis et al., 2014).
In the study done in Iran by (Jaddoua, Mohammed, & Abbas, 2013) showed that, Nurses have unsatisfactory knowledge regarding ABG analysis and Interpretation. The author revealed problems in Iran curriculum that led to poor knowledge among nurses on ABG analysis (Jaddoua et al., 2013).
In Africa the study done in Nigeria by (Emejulu, Nkwerem, & Ekweogwu, 2014), shows poor knowledge among Nurses staffs in Nigeria. This was supported by study done in south Africa by (Xafis et al., 2014) that physicians and Nurses working within and without the Emergency Care setting have unsatisfactory ABG theoretical knowledge and interpretation skills, with potential adverse effects on patient care from misdiagnosis and mistreatment (Xafis et al., 2014).
In East Africa, no article was found from different search strategy that study knowledge of nursing students regarding ABG analysis and Interpretation. However, from experience in Tanzania, nurses in many hospitals in our clinical areas face the same challenge of unsatisfactory knowledge in analysis and Interpretation of ABG. This has profound significant effects on patients leading to poor care, misdiagnosis, and mistreatment (Mohammed & Abdelatief, 2016).
The aim of this study is to assess knowledge of Nursing students at MUHAS to determine their ability and proficiency to analyze and interpret ABG’s results. Findings from this study will help Nursing lecturers and clinical instructors to plan better ways and strategies to teach students on accurate and proper ways of analyzing and interpreting ABG results

1.2 PROBLEM STATEMENT
Nurses are required to be able to analyze each component of the ABGs to avoid overlooking a change that could result in an inaccurate interpretation and lead to inappropriate treatment (Larkin, 2018) However, Acid base balance and ABG analysis are complex concepts requiring a great deal of study in order to improve the knowledge for all nurses regarding ABG analysis and interpretation of results(Bhanu P.B et al., 2016; Mohammed ; Abdelatief, 2016)
Despite the fact that, there is increased need for Nurses to be competent in analysis and interpretation of ABG results but studies show that still Nurses have poor knowledge regarding ABG analysis and interpretation (Thomas, 2017). A study done by (Bhanu P.B et al., 2016) show that among 400, results showed that majority of nurses (52.5%) in wards have poor knowledge on ABG analysis and interpretation. Unsatisfactory knowledge among Nurse staffs (Patrisia, 2012) raises concerns and doubts on the knowledge acquired during their training and studying in Nursing schools.
Furthermore, the problem of ABG analysis and interpretation is present to nursing students indicating doubt in their knowledge base (Teles M, Preeti, B MMilka, 2013).Therefore, there is a need to assess the knowledge of Nursing Students regarding ABG analysis and Interpretation
More studies are required to assess nurses including nursing student’s knowledge regarding ABG analysis and interpretation. From different search strategies, no study found that has been done in Tanzania, necessitating the need for more studies. The purpose of this study is to examine Third year and Fourth Year nursing students’ knowledge regarding ABG analysis and Interpretation at Muhimbili University of Health and Allied Sciences.

1.3 RESEARCH OBJECTIVES
1.3.1 Broad objective
To examine knowledge regarding ABG analysis and interpretation of ABG results among nursing students at MUHAS from January to February, 2018.
1.3.2 Specific objectives
i) To assess knowledge of nursing students on parameters which are analyzed and interpreted on ABG results.
ii) To assess knowledge of nursing students on identifying acidosis and alkalosis using ABG results
iii) To assess knowledge of nursing students on determination of whether respiratory or metabolic factors are causing an imbalance.
iv) To find out the association between the level of knowledge regarding ABG analysis and Interpretation of ABG results among Nursing students with their selected socio-demographic variables.

1.4 SPECIFIC RESEARCH QUESTIONS
i) What is the knowledge of Nursing students on parameters which are analyzed and interpreted on ABG results?
ii) What is the knowledge of Nursing students on identifying acidosis and alkalosis using ABG results?
iii) What is the knowledge of Nursing students in determining whether respiratory or metabolic factors are causing an imbalance?
iv) What is the association between the level of knowledge regarding ABG analysis and Interpretation of ABG results among Nursing students with their selected socio-demographic variables?

1.5 RESEARCH HYPOTHESIS
RESEARCH HYPOTHESIS
Nursing students in fourth year of study will have more knowledge regarding ABG analysis and Interpretation than those in third year of study.
VARIABLES
INDEPENDENT VARIABLE DEPENDENT VARIABLE
Year of study Knowledge

1.6 CONCEPTUAL FRAMEWORK
Conceptual framework is the way ideas are organized to achieve a research project’s purpose (Beck, 2010). Research frameworks are connected to purpose/Aim of the research study(Adom, Hussein, & Joe, 2018). In addition, it identifies the variables required in the investigation and show how the variables in the study are connected to each other (Polit & Beck, 2012).
Conceptual framework lies within a much broader framework called Theoretical framework (Adom et al., 2018). It serves as the “map” that guide the researcher towards realizing the objectives or intent of the study(Adom et al., 2018; Beck, 2010) .
In this study of assessment of knowledge regarding ABG analysis and Interpretation, there are many Independent variables which influence one dependent variables. Independent variables are, Year of study (III, IV year), Curriculum formulation, Time available for attending Clinical areas (i.e. Number of days per week), Students attendance in class sessions and clinical areas, Lecturers commitment in teaching and supervising students in clinical areas, Socio-demographic characteristics (age, sex, marital status) and Interactions of nursing students and clinical staffs. Dependent variable in the study is knowledge regarding ABG analysis and Interpretation.
All these independent variables, influence the knowledge of students regarding ABG analysis and Interpretation. However, there are some independent variables which are connected to each other. For example, Curriculum formulation may dictate time available for attending Clinical areas (Mohammed & Abdelatief, 2016).
These variables are connected to each other with knowledge at the center as shown in the following schematic diagram.

Diagram: Conceptual framework for assessment of students’ knowledge on ABG analysis ; Interpretation

KEY: RECTANGLES…. INDEPENDENT VARIABLES
CIRCLE……………DEPENDENT VARIABLE
2.0 LITERATURE REVIEW
Pagana reported that, measuring arterial blood gases can be a useful adjunct to the assessment of patients with either acute or chronic diseases (Pagana et al., 2017). The results of the study show necessity of Nurses to know if the patient is acidaemic or alkalaemic and whether the cause is likely to have a respiratory or metabolic component(Larkin, 2018; Pagana et al., 2017). The PaCO2 reflects alveolar ventilation and the PaO2 reflects the oxygenation of arterial blood(Glenn, 2014). When combined with a patient’s clinical features, blood gas analysis can facilitate diagnosis and management(Basnett et al., 2016)
Current evidence supports that physicians working within and without the Emergency Care setting have unsatisfactory ABG theoretical knowledge and interpretation skills, with potential adverse effects on patient care from misdiagnosis and mistreatment (Xafis et al., 2014)
Bhanu et al, conducted a cross sectional study to assess the level of knowledge regarding ABG analysis and interpretation of ABG results among staff nurse in NMCH, Nellore(Bhanu P.B et al., 2016). Results of the study Shows that with regard to ABG analysis and interpretation results among 30 staff nurses, only 4 (13.3%) had ‘A’ grade, 7(23.3%) had B+ grade, 12 (40%) had B grade, 5 (16.7%) had C grade and 2 (6.7%) had D grade knowledge (Bhanu P.B et al., 2016). The study concluded that, majority of staff nurses had D grade knowledge indicating poor knowledge regarding ABG analysis and interpretation among Nurses(Bhanu P.B et al., 2016)
Similarly, (Patrisia, 2012) conducted a study on the nursing personnel working in the critical care units. Results of the study shows that, even though, nurses take an active part in collecting ABG samples, their knowledge in interpreting ABG reports is inadequate and in all the learning need areas, the expressed learning need as “Necessary” and “Desirable” were 100% (Patrisia, 2012). The study shows that the teaching protocol was found to be effective in promoting the knowledge level of nursing personnel on “nurses’ responsibility in ABG analysis(Patrisia, 2012). The study concluded that, Arterial blood gas (ABG) analysis can be accurately done only when the collection, interpretation is done correctly. In order to have the accurate analysis, the physician, and nurses should be knowledgeable on that topic(Thomas, 2017). So, the undergraduate students, the future nurses should have knowledge on Arterial blood gas (ABG) analysis to get their confidence during their working period(Mohammed ; Abdelatief, 2016; Thomas, 2017).
Uncertainty of knowledge regarding ABG analysis and interpretation affect not only Nurses but also, Interns and residents doctors in Emergency Medicine Department (Xafis et al., 2014). Xafis et al, done the study to assess the understanding of the use of ABGs by residents in training, and identify areas of uncertainty in ABG knowledge in order to enhance knowledge and decrease costs of patient care(Xafis et al., 2014). The study consisted of 42 Interns and residents. Results of the study shows Poor understanding of physiological mechanisms underlying A–?a gradient, pH and HCO3 abnormalities (correct answers in 18%, 88% and 81% respectively). Regarding ABG analysis and predicted impact on patient care: 14% showed inadequate diagnostic use; 40% showed inadequate physiological interpretation; 24% showed inadequate therapeutic application. (Xafis et al., 2014).
Similarly, in a survey conducted at a university teaching hospital in Jamaica, 70% of the participating physicians claimed that they were well versed in the diagnosis of acid-base disorders and that they needed no assistance in the interpretation of arterial blood gases (ABGs) (Glenn, 2014). These same physicians were then given a series of ABG measurements to interpret, and they correctly interpreted only 40% of the test samples(Glenn, 2014)
The study done by (Thomas, 2017) shows that, proper teaching Programme can help to improve knowledge to students regarding ABG analysis and interpretation. In the study, 40 II year and III year B.Sc. Nursing students of Bombay Hospital College of Nursing, Indore were selected using convenient sampling technique. After obtaining the necessary permission from the concerned authorities, a pre-test was done on the participants with socio demographic proforma and multiple-choice statements(Thomas, 2017). On the next day, Structured teaching Programme was then given to the experimental group only. After two days’ gap, post-test was conducted with the same tools. Findings revealed that the mean post-test knowledge level of experimental group (24.10) was higher as compared with the pre-test score (14.10) (Thomas, 2017). Thus, the study revealed that the Structured Teaching Programme was effective in improving the level of knowledge of II and III year B.Sc. Nursing students(Thomas, 2017)
Evidence from these literature review shows that Nurses and physicians have unsatisfactory ABG theoretical knowledge and interpretation skills (Basnett et al., 2016; Bhanu P.B et al., 2016; Larkin, 2018; Thomas, 2017), with potential adverse effects on patient care due to misdiagnosis and mistreatment.

3.0 METHODOLOGY
3.1 Study design
The quantitative descriptive cross-sectional study will be conducted to examine nursing students’ knowledge regarding ABG analysis and interpretation of ABG results among third and fourth year undergraduate Nursing students enrolled at MUHAS. This design will help to gather data from the study participants with minimal time and resource wastage. Quantitative descriptive cross sectional study design is the type of study design which involve the collection of data at one point in time (or multiple times in a short time period, such as 2 hours and 4 hours postoperatively) (Polit ; Beck, 2012). Through this design, research data on the independent and dependent variables will be collected concurrently; For sufficient and detailed data from participants to be obtained, a questionnaire will be used as a data collecting tool.
3.2 Study site
The study will be conducted in Dar es Salaam region, Tanzania. Dar es Salaam is found at the coastal region of Tanzania. The census report of 2012 showed that the region has a population of about 4.4 million people which was the highest population in the country by region. Also, it is the most densely populated region with a population density of about 3,100/km2 and an average of annual population growth rate of 5.6%. It is the largest commercial city in Tanzania. It has also many Universities such as Muhimbili University of Health and Allied Sciences (MUHAS), University of Dar es Salaam, Mwalimu Nyerere University, IFM and many others, where students from different parts of the country prefer to come and study in these universities.
3.3 Study setting
This study will be conducted at Muhimbili University of Health and Allied Sciences (MUHAS) found in Ilala district, Dar es salaam, Tanzania. The Muhimbili University of Health and Allied Sciences (MUHAS) is a successor to the Muhimbili University College of Health Sciences (MUCHS), which was a constituent College of the University of Dar es Salaam. MUHAS has a range of programs in basic, clinical and allied health sciences. These programs are taught in the five Schools and one academic Institute of the University. Since MUHAS has large number of Students attending their clinical practices especially nursing students in relation to study design, the study setting is selected because of easier accessibility of the study participants.

3.4.0 Study population
Study population is a group of individuals taken from the general population who share common characteristics, such as age, sex, or health condition(Polit ; Beck, 2012). The population selected for this study will be both third year and fourth year undergraduate Nursing Students at MUHAS who attending their clinical practices at Muhimbili National Hospital (MNH).
3.4.1 Inclusion criteria
Inclusion criteria refer to the criteria that specify particular characteristics of an individual to be included into the study population (Polit ; Beck, 2012). The inclusion criteria for this study is MUHAS third and fourth year Nursing Students who had clinical experiences at EMD, ICU, APCU, JKCI, Mwaisela and Kibasila block at MNH.
3.4.2 Exclusion criteria
Exclusion criteria refer to the characteristics that a particular person in a selected target population must not possess and leading him or her non eligible for the study (Polit ; Beck, 2012). The exclusion criteria for this study will be MUHAS third and fourth year Nursing Students who will be sick during the time of data collection and those who will not be ready to be study participant.
3.5 Sample size.
For this particular study the sample size calculation will base on the following statistical formula below(Andresen, 2011)
n= Z2P (100-P)/ d2
n= Sample Size
z= confidence level (Z=1.96)
p= Expected proportion of prevalence of participants
d = maximum likely error (margin of error).
For this study, the value of the 95% spread limit that will be used i.e. z = 1.96; this value is the more preferred level of confidence for scientific comparison.
The expected proportion (p) was obtained from a previous study done in Nellore University, Andhra Pradesh, India. From this study, it was indicated that, 5.1% of Nurses had grade D (Unsatisfactory) knowledge regarding ABG analysis and Interpretation of ABG results (Bhanu P.B et al., 2016). Similarly, most of the Undergraduate Nursing students at MUHAS were thought to have unsatisfactory knowledge regarding ABG analysis and Interpretation of ABG results. Therefore, the expected proportion for this study is considered to be 5.1% (0.051)

The margin of error that will be tolerated in this study, i.e. d = 5% (0.05).
n= (1.96×1.96) 0.051(1-0.051)/0.05
n=73.
Then,
Add 10% of this value to take care for possible non respondents give:
n= 73 + (10/100 x 73)
n = 80
Therefore, the sample size of 80 nursing students will be required for this study.
3.6 Sampling procedure
The study will employ a consecutive convenient sampling technique to gather information from study participants provided that they met the criteria of inclusion and signed the consent form. Data for this study will be collected at Muhimbili University of Health and Allied Sciences in Dar es Salaam, Tanzania. The study will recruit 31 third year Bachelor Nursing students and 49 Bachelor Nursing Students from fourth year. These participants will be recruited depending on their availability and readiness to participate in the study voluntarily until when the required sample size will be obtained. This sampling procedure is selected to access participants easily and to obtain detailed information since the participant has the freedom to engage or not, hence this sampling procedure respect people’s decision.
3.7 Data collection tool
The tool will have two parts: Part I and part II
Part I
Deals with socio demographic variables of knowledge regarding ABG analysis and interpretation in caring for critically ill patients among nursing students. These variables include, age, gender, level of studying, Year of study, and presence of clinical specialty.
Part II
Deals with written self-administered structured questionnaires with close ended questions to assess the level of knowledge regarding ABG analysis and interpretation of the results among Undergraduate Third and Fourth year nursing students. The questionnaire will consist of 25 close ended multiple choice questions This method is selected with reference to previous studies conducted on assessment of nurses’ knowledge regarding ABG analysis and Interpretation of ABG results.
The tool consists of 25 items; each correct response will be scored with one mark. The total possible score will be 25 and each wrong answer will be scored with 0 mark. The participant will fill questionnaires on their own with full instructions from the researcher. The questions will be rechecked well before being distributed for the study to avoid some errors.
Score Interpretation: The score will be interpreted as follows:
Grade Score
A+ ;85%
A ;75%
B+ ;65%
B ;55%
C ;50%
D