• Users Online: 61
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 17  |  Issue : 1  |  Page : 56-63

Effect of small-group teaching on nurses’ competency level regarding patients undergoing cholecystectomy


Department of Medical Surgical Nursing, Faculty of Nursing, Zagazig University, Zagazig, Egypt

Date of Submission30-Aug-2020
Date of Decision15-Sep-2020
Date of Acceptance10-Sep-2020
Date of Web Publication18-Nov-2020

Correspondence Address:
Rehab R Bayomi
PhD in Medical Surgical Nursing, Department of Medical Surgical Nursing, Faculty of Nursing, Zagazig University, 44519
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_26_20

Rights and Permissions
  Abstract 


Background Competence is a fundamental component of nursing care and plays an important role in the quality of services provided by nurses. Therefore, the aim of the study was to evaluate the effect of small-group teaching on nurses’ competency level regarding patients undergoing cholecystectomy at Zagazig University Hospitals.
Participants and methods A quasi-experimental research design was used to achieve the aim of the study. The study was conducted in Internal and General Surgery Department in New Surgery Hospital at Zagazig University Hospitals. A convenience sample of 30 nurses working in Internal and General Surgery Departments in New Surgery Hospital was included. Two tools of data collection were used: first, a self-administered structured questionnaire (pretest/post-test); and second, observational checklist.
Results There was a statistically significant improvement of nurses’ knowledge after implementation of small-group teaching, with mean±SD of 22.83±0.59, than before, with a statistically significant difference (P=0.00). Moreover, there was a statistically significant improvement of nurses’ competency level after implementation of small-group teaching, with mean±SD of 241.86±3.49, than before, with a statistically significant difference (P=0.00). Moreover, there was a positive correlation between total nurses’ level of knowledge and their level of competency.
Conclusion It can be concluded that small-group teaching for nurses had a positive effect on improvement of nurses’ knowledge, which reflected then on improvement of their competency level.
Recommendation Continuous in-service training programs are recommended to improve and maintain nurses’ competency level regarding patients undergoing cholecystectomy.

Keywords: Cholecystectomy, nurses’, competency, small-group teaching


How to cite this article:
Metwaly EA, Bayomi RR, Taha NM. Effect of small-group teaching on nurses’ competency level regarding patients undergoing cholecystectomy. Egypt Nurs J 2020;17:56-63

How to cite this URL:
Metwaly EA, Bayomi RR, Taha NM. Effect of small-group teaching on nurses’ competency level regarding patients undergoing cholecystectomy. Egypt Nurs J [serial online] 2020 [cited 2020 Dec 3];17:56-63. Available from: http://www.enj.eg.net/text.asp?2020/17/1/56/300783




  Introduction Top


Cholecystectomy is removal of gall bladder through an abdominal incision (usually right subcostal) and thereafter the cystic duct and artery are ligated. It is most commonly performed by inserting special surgical tools through small four incisions to see inside the abdominal cavity and remove the gall bladder (laparoscopic cholecystectomy). In some cases, one large incision may be used to remove the gall bladder (open cholecystectomy) (Smeltzer et al., 2010)

Postoperative care of patient with cholecystectomy as with other major surgeries involves monitoring of vital signs especially respiratory rate because of the effect of general anesthesia and teach patient about deep breathing to relieve pain caused by incision, support operative site when moving or coughing, and give necessary medication as needed. Fluids are given intravenously for 24–48 h after surgery, and the patients are discharged from the hospital within 3–5 days, with return for follow-up approximately 4–6 weeks after the procedure (Cheever and Hinkle, 2013).

Nurses who provide postoperative care must have knowledge of the implications of the procedure, clinical manifestations of complications, and risk factors. Identifying patients at high risk for adverse outcomes allows the nurse to anticipate the needs of the patient and provide a less stressful postoperative experience (Alam, 2016). Moreover, efficient nursing care is important during recovery. Nurses must be prepared to prevent postoperative complications, rather than waiting to treat them. Nurses can provide excellent care if they are able to anticipate a patient’s needs, intervene early when symptoms first appear, provide reassurance to alleviate patients’ unease during the recovery process, and educate patients to alleviate unnecessary anxiety related to discharge expectations (Laupacis et al., 2012).

Health needs of patients undergoing cholecystectomy include provision of information related to preoperative education, which is an important part to improve postoperative period outcomes and prevent postoperative complications. In addition, provision of information related to postoperative period includes postoperative pain management, exercise, nutrition, activity, and follow-up for evaluation of the care. This postoperative care is very important to prevent postoperative complications that lead to postoperative mortality and prolonged hospital stay, decrease functional and cognitive status, and has a huge effect on hospital costs (Renholm, 2015).

Nursing competence is a professional issue and is central to patient care outcomes. Health care consumers are sophisticated, knowledgeable, and selective. Patients no longer place blind trust in health care providers; today’s consumers negotiate services and compare quality of care among providers. To face these challenges and ensure that the best care is given by nurses, it is necessary to assess the nurses’ clinical competence (Delaune and Ladner, 2011).

Assessments of nurses’ competence are global challenges; assessing clinical competencies involves the utilization of competency assessment methods to determine if a nurse possesses the ability to perform specific tasks in the clinical setting, with every method having its own advantages and disadvantages. A range of indicators and tools have been developed for competence assessment, but self-assessment has been reported to be the most common (Fukada, 2018).

Significance

Along with the increasing complexity of nursing services, hospital employers are demanding qualified and competent staff nurses for high-quality clinical practices. Ensuring staff competency is a critical function of today’s nurse manager. It reduces the risk of error and improves the quality of care (Kahya and Oral, 2018).

The competence of practicing nurses is crucially important in identifying areas for professional development and educational needs and also in making sure that nurse competencies are put to the best possible use in patient care. Competence assessment of practicing nurses should be a core function in quality assurance systems, workforce planning, and human resource management (Leino-Kilpi and Meretoja, 2004). Therefore, this study was conducted to evaluate the effect of small-group teaching on nurses’ competency level regarding patients undergoing cholecystectomy at Zagazig University Hospitals.

Aim The aim of the study was to evaluate the effect of small-group teaching on nurses’ competency level regarding patients undergoing cholecystectomy at Zagazig University Hospitals.:


  Objectives Top


The following were the objectives of the study:
  1. To assess nurses’ knowledge regarding cholecystectomy.
  2. To assess nurses’ competency level regarding cholecystectomy.
  3. To design and implement small-group teaching based on assessment needs.
  4. To evaluate the effect of small-group teaching on nurses’ knowledge and competency level regarding cholecystectomy.


Research hypotheses

  1. Mean score of nurses’ knowledge will be higher after implementing small-group teaching than before.
  2. Mean score of nurses’ competency level will be higher after implementing small-group teaching than before.


Operational definitions

Competency refers to following standards as outlined in policy and procedure manuals regarding cholecystectomy.

Postoperative nurses’ competency refers to competency clusters that will be assessed as postoperative nursing care, wound care, hemovac drain care, pain management, deep breathing exercise, coughing and splinting exercise, and leg exercise. Each cluster consists of numbers of competency elements that represent the steps of competency assessment.


  Participants and methods Top


Research design

A quasi-experimental research design was used to achieve the aim of the study. Before commencement of data collection, a formal request for ethical approval was made to the required departments. First, permission to proceed with the study was attained from the Ethics Committee of the Faculty of Nursing Zagazig University. Subsequently, approval was obtained from the Research Ethics Committee at Internal and General surgery departement in New Surgery Hospital. Next, the researcher distributed letters with a copy of the research proposal at the directors of Nursing and Medical Managers at the research sites requesting permission to conduct the study. Furthermore, the researcher ensured that confidentiality of each participant was maintained throughout the study.

Setting

The study was conducted in Internal and General Surgery Department in New Surgery Hospital at Zagazig University Hospitals.

Participants

A convenient sample of 30 nurses working in Internal and General Surgery Departments in new surgery hospital were included.

Regarding the tools of data collection, two tools were used:

Tool I: a self-administered structured questionnaire (pre/ post-test) was developed in a simple clear Arabic language by the researchers based on literature review (Evans and Jackson, 2012; Nawaz and Papachristou, 2011; Hebra et al., 2011; Bindra et al., 2010; and Davidson and Gurusamy, 2010) and experts’ opinions in light of relevant references to assess nurses’ knowledge regarding cholecystectomy, which consisted of four parts:

First part: demographic characteristics of the studied nurses including eight questions about age, sex, marital status, level of education, years of experience, and training courses.

Second part: nurses’ knowledge regarding cholecystectomy, which consisted of six multiple-choice questions about definition of cholecystectomy, indications, laparoscopic and open cholecystectomy, advantages of laparoscopic cholecystectomy, conversion of laparoscopic cholecystectomy to open cholecystectomy, and complications of laparoscopic and open cholecystectomy.

Third part: nurses’ knowledge regarding care of patients undergoing laparoscopic and open cholecystectomy which consisted of eight multiple-choice questions about wound care for laparoscopic and open cholecystectomy, pain management, fluids, diet, and exercise.

Fourth part: nurses’ knowledge regarding patients’ discharge, which consisted of nine multiple-choice questions about signs and symptoms of wound infection, diet, wound care, methods of pain management, and follow-up.

Scoring system

For the knowledge, a correct answer was scored as one and an incorrect answer as zero. The scores were summed up and converted into a percentage score. A nurse who achieved 60% or higher total score was considered to have satisfactory knowledge, and those with scores lower than 60% were considered as unsatisfactory knowledge based on statistical analysis.

Tool II: an observational checklist was used to assess nurse’s competency level regarding patients undergoing cholecystectomy before and after implementation of small-group teaching. It was based on Chappell and Dickerson (2016) and Leino-Kilpi and Meretoja (2004). It is composed of seven clusters: immediate postoperative care, wound care, hemovac drain care, pain management, deep breathing exercises, coughing and splinting exercises, and leg exercises.

The scoring system was calculated as follow: the frequency with which the competencies are actually used in clinical practice is indicated on a two-point scale (0=not competent and 1=competent). Total competency score as competent was greater than or equal to 85% and incompetent less than 85%.

The total score of items in each cluster was the indicator of competency of nurses in that cluster, and the total scores of all clusters were indicators of the total clinical competency of nurses regarding cholecystectomy.

Content validity and reliability

Once the tools of data collection were prepared, face validity and content validity were ascertained by a panel of three experts (two professors of medical surgical nursing and one professor of internal medicine), who revised the tools for clarity, relevance, applicability, comprehensiveness, and ease of implementation. The agreement percentage was between 80 and 100%. In light of their assessments, minor modifications were applied. The reliability of the competency scale showing reliability with a Cronbach’s α coefficient (r=0.97).

Fieldwork

The study was implemented from May 1, 2019 to the end of December 2019, which is classified as follows: 2 months for pretest (from beginning of May to the end June 2019), 6 months for implementation of small-group teaching, and post-test (from July to December 2019). Data were collected 3 days a week from Internal and General Surgery Departments in New Surgery Hospital at Zagazig University Hospitals.

Procedure: the study was conducted in three phases (preparatory phase, implementation phase, and evaluation phase):

The preparatory phase: the researcher checked on the related materials and literature broadly. Assessments of the nurse’s knowledge and competency tools were made. Small-group teaching was developed by the researcher, and the detected needs, requirements, and deficiencies were translated to aims and objectives of the small-group teaching for nurses. Moreover, teaching materials were prepared, which included audiovisual materials on anatomy of gall bladder, common bile ducts, cholelithiasis, and treatment modalities.
  1. The Implementation and evaluation phase: data were collected at Internal and General Surgery Departments in New Surgery Hospital at Zagazig University Hospitals during the period from May 1, 2019 to the end of December 2019. Selected nurses were met on three times per week basis for monitoring.
  2. The tools were filled out through structured interviewing. The purpose of the study was explained to the nurses before answering the questions. The study was carried out at morning and afternoon shifts. At initial interview, the researcher introduced herself to initiate line of communication, explain the purpose of small-group teaching, and fill out the structured interview questionnaire (tool one) to assess nurse’s knowledge before implementation of small-group teaching, and the researcher filled out the observational checklist (tool two) to assess nurse’s competency level before implementation of small-group teaching. The researcher scheduled with them the teaching sessions for both theory and practice, and the nurses were divided into small groups of 3–4 nurses. Teaching has been implemented for nurses in terms of sessions and teaching on the spot during their official working hours.


Small-group teaching consisted of two parts:

The first part: theoretical part

It included data related to anatomy of the gall bladder and common bile ducts, cholelithiasis, functions of the gall bladder, cholecystitis, cholecystectomy: definition, indications, open and laparoscopic cholecystectomy, advantages of laparoscopic cholecystectomy, complications, signs and symptoms of infection, nursing care before and after operation, dietary instructions, wound care, pain management, and exercises.

For theoretical contents, teaching sessions were conducted; each session takes from 15 to 30 min. The number of sessions was five sessions for each group to acquire the related information. Each nurse was supplemented with the knowledge booklet and utilized each session to ensure understanding and clear any misconception or misunderstanding. The researcher continued to reinforce the gained information, answer any raised questions, and gave feedback. Communication channel was kept open between the researcher and the study group subjects. Then, immediately post-knowledge test was carried out.

The second part: the practical part

It included items related to immediate postoperative care; ongoing care, including assessment of respiratory function, cardiovascular function, neurological function, renal, urinary function, fluid and electrolyte status, gastrointestinal function, wound condition, and pain; wound care, including hemovac drain care; pain management; deep breathing exercises; coughing; splinting exercises (providing support to the incision); and leg exercises. For practical contents, each nurse’s competency level of performance regarding the predetermined procedure was evaluated before provision of any skill teaching (pretest) utilizing the defined observational checklist (second tool). The laboratory setting was equipped and prepared for use. Teaching sessions were conducted; each session took from 30 to 45 min. Demonstrations and re-demonstration were carried on 11 sessions for each nurse. Skills’ manual booklet was given to each nurse, and the immediate post-test was done. An introductory session about cholecystectomy postoperative care was done before the demonstration. Nurses were given the opportunity for re-demonstration. This session was supplemented by problem-solving situations and teaching aids such as posters, videotape, and handouts.

Pilot study

The tools were piloted on five nurses from the study setting to test its understandability and applicability, as well as estimate time needed for its filling. The researcher modified some of the questions and finalized the tool based on the pilot study results.

Administrative and ethical considerations

Necessary approvals to conduct the study were secured using official channels. The Research and Ethics Committee at the Faculty of Nursing, Zagazig University, approved the protocol. At the initial encounter with each nurse, the researchers explained the aim and process of the work and its benefits to obtain an informed oral consent. Each nurse was informed about the rights to refuse or withdraw at any time and about the confidentiality and anonymity of any obtained information. No harm could be anticipated from any maneuver in the implementation of the study; on the contrary, the small-group teaching had potential beneficial effects on participants.

Statistical analysis

All collected data were organized, categorized, tabulated, entered, and analyzed by using Statistical Package for the Social Sciences (SPSS Inc., Chicago, Illinois, USA), a software program version 20, which was applied to frequency tables and statistical significance. The statistical significance and associations were assessed using the arithmetic mean, the SD, Pearson χ2-test, and Pearson correlation (r) to detect the relation between the variables. Significance of the result was as follows: not significant (NS): if P greater than 0.05, significant (S): if P less than 0.05, and highly significant (HS): if P less than 0.01.


  Results Top


[Table 1] shows that all of the studied nurses were females, and their age ranged between 24 and 55 years, with mean±SD of 39.46±10.7 years. Moreover, 90% of them were married, and 66.7% had diploma degree. In addition, it showed that studied nurses had years of experience ranging between 1 and 38 years, with mean±SD of 14.5±12.9 years, whereas 70% of them did not attend any previous training courses regarding caring of patients undergoing cholecystectomy.
Table 1 Demographic characteristics of studied nurses (n=30)

Click here to view


[Table 2] cleared that there was a statistically significant increase in the mean score of nurses’ knowledge related to general knowledge about cholecystectomy, knowledge about care of patient undergoing cholecystectomy, and knowledge about discharge instructions after small-group teaching than before, with statistically significant difference (P=0.00).
Table 2 Nurses’ knowledge Mean score before and after small-group teaching

Click here to view


[Table 3] presents that there was a statistically significant improvement of total nurses’ knowledge regarding patients undergoing cholecystectomy after small-group teaching than before, with statistically significant difference (P=0.00).
Table 3 Total nurses’ knowledge mean score pre and post small-group teaching

Click here to view


[Table 4] reflects a statistically significant increase in the mean score of nurses’ competency regarding immediate postoperative care, wound care, drain care, pain management, deep breathing exercise, cough and splinting exercise, and leg exercise, with a statistically significant difference (P=0.00).
Table 4 Nurses’ competency mean score before and after small-group teaching (n=30)

Click here to view


[Table 5] illustrates that there was a statistically significant improvement of total nurses’ competency regarding patient undergoing cholecystectomy after small-group teaching than before, with a statistically significant difference (P=0.00).
Table 5 Total nurses’ competency mean score before and after small-group teaching (n=30)

Click here to view


[Table 6] identified that there was a strong positive correlation between total nurses’ knowledge and their total competency level (r=0.918), with a statistically significant difference (P=0.000).
Table 6 Correlation between total nurses’ knowledge and total competency before and after small-group teaching

Click here to view



  Discussion Top


The nurse is responsible for the quality of nursing care given to patients; therefore, the nurse should be knowledgeable and a safe practitioner of nursing to meet the standards of care with all patients. Clinical competence in nursing leads to a high relationship with improved nurses’ performance, increased quality of care, improved patient satisfaction, decreased medication errors, and less mortality and postoperative complications (Anboohi et al., 2017).

The results of the current study revealed that age of the studied nurses ranged between 24 and 55 years, with mean±SD of 39.46±10.7 years. Moreover, most of them were married, and all of them were females. This may be owing to the increase in the number of female nurses as compared with males. Concerning educational level, more than two-thirds of them had diploma degree. This result was in the same line with Ahmed et al. (2013) who reported in a thesis entitled ‘Assessment of nurses’ knowledge and practice regarding postoperative open cholecystectomy patients at Assiut University Hospital, in Egypt’ that the mean age of the studied nurses was 33.03±8.60 years, and their qualification were nursing diploma; moreover, the majority of them were married and females.

In the present study, more than two-thirds of the studied nurses did not receive any training courses about caring of patients undergoing cholecystectomy. This may be related to the insufficient scientific courses related to cholecystectomy, and also this may be attributed to lack of continuous education and in-service training program. This interpretation was supported by Chappell and Dickerson (2016), who stated that nurses need to participate in educational courses continuously to improve knowledge, skills, and attitude of nurses, additionally improving quality of care given to the patients.

The current study clarified that data collected about general knowledge of cholecystectomy before small-group teaching on nurses (pretest) showed decrease in mean score of knowledge, which reflected the lack of educational programs for nurses to improve and update their knowledge. After implementation of small-group teaching, this study revealed that there was a significant improvement of nurses’ knowledge. This indicates the improvement of nurses’ knowledge based on implementing small-group teaching, which might rehabilitate the nurse to provide optimal care. This result was in agreement with Alaa and Kadhim (2014), who revealed that the continuation education of nurses who work in surgical wards and the use of guidelines for interventions after surgery improved the quality of care provided by nurses for patient and increased their level of information regarding prevention of complications of the laparoscopic cholecystectomy. Therefore, effective intervention cannot be achieved as long as the nurses have deficient knowledge.

American Nurses Association (2010) believed that education has a significant effect on the knowledge and competencies of the nurse. Moreover, Gilani et al. (2017) in another study discovered that knowledge could be obtained through continuing in-service educational programs, which should be conducted by the hospital organization to update the evidence-based knowledge and practices of nurses in the surgical department.

This study showed that there was a decrease in mean score of nurses’ competency before small-group teaching. This may be interpreted as nurses have skills but do not use them in practice. This finding was in the same line with Mohammed (2011), who revealed that most nurses had unsatisfactory practice level before implementing teaching protocol.

After implementation of small-group teaching for nurses, there was a statistically significant improvement of nurses’ competency compared with pre-implementation period. This may have indicated that the attendance of the small-group teaching was the only independent predictor that positively influenced the competency level. In agreement with these findings, Arvydas et al. (2011) clarified that most surgical nurses were often using their competence of managing situations and work role in their practice.

The results of the present study showed that there was a strong positive correlation between the total nurses’ level of knowledge and their total competency level with a statistically significant difference. This may be owing to the effectiveness of small-group teaching on improving nurses’ knowledge that reflected on improvement of their level of competency. However, Ahmed et al. (2018) revealed that there was a significant relation between nurses’ knowledge and their competence level in which the highest level of competence was apparent among nurses’ who had good level of knowledge.

Several authors reported that possessing and integrating nursing knowledge into practice is essential to nurse competence. Donilon (2013) pointed out that competence in nursing is essential to provide safe and quality patient care. Nurses are at the forefront of recognizing and responding to changes in patient condition, which may be life-threatening and often subtle. Educational strategies that facilitate the development of nurses’ knowledge, skill, and competence in managing patient situations are important to identify and measure.


  Conclusion Top


This study concluded that the implementation of small-group teaching on nurses had a positive effect on improvement of nurses’ knowledge, which then reflected on the improvement of their competency level.

Recommendations

  1. Continuous in-service training programs are recommended to improve and maintain nurses’ competency regarding patients undergoing cholecystectomy.
  2. More researches are needed to determine the best evaluation methods for the different facets of nursing competence.
  3. Further research is needed to identify educational strategies that will facilitate the continuing of nursing competence.


Acknowledgements

The first author contributed toward sample collection; provided the pretest and post-test; applied small-group teaching for nurses; prepared videos, color brochure, and posters; participated in data collection; participated in the reference collection and analysis of data; and administered the small-group teaching; the second author contributed to the conception of the research; development of tools; performance of statistical analysis; commentary on the tables; translation of the tools and booklet into Arabic; participated in the references and data collection; and administered the small-group teaching; and the third author contributed toward development of tools, statistical analysis, data collection, and application of small-group teaching for nurses.[24]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ahmed AM, Ahmed WR, Essaa AE (2013). Assessment of nurses’ knowledge and practice regarding postoperative open cholecystectomy patients at Assiut University Hospital. Assuit Sci Nurs J 2:62–68.  Back to cited text no. 1
    
2.
Ahmed MT, Desoky AA, Mohammad ZA, Saied AM (2018). Assessment of nurses’ performance competency for patients undergoing cholecystectomy. Assuit Sci Nurs J 6:53–61.  Back to cited text no. 2
    
3.
Alaa J, Kadhim Y (2014). Assessment of postoperative nurses’ interventions for the patients with laparoscopic cholecystectomy at Baghdad Teaching Hospitals. Irag Natl J Nurs Specialties 27:11–22.  Back to cited text no. 3
    
4.
Alam I (2016). Individualized care in patients undergoing laparoscopic cholecystectomy. Int J Med Health Res 2:69–72.  Back to cited text no. 4
    
5.
American Nurses Association (2010). Scope and Standards of Nursing Practice, Standards of Professional Nursing Practice. 2nd ed. Maryland: Lippincott Williams & Wilkins Company; Chap. 10. PP31–PP39.  Back to cited text no. 5
    
6.
Anboohi B, Jahanshi F, Nasiri Z, Sarabi A (2017). The correlation between the clinical competency and empathy of nurses: case study, Intensive Care Units of the Educational Hospitals of Kerman Medical Sciences University, Iran. Ann Trop Med Public Health 10:694–701.  Back to cited text no. 6
    
7.
Arvydas M, Istomina N, Kilpi H, Meretoja R, Razbadauskas A, Suominen T (2011). Competence of nurses and factors associated with it. Nurs J (Manila) 47:230–237.  Back to cited text no. 7
    
8.
Bindra SS, Chamberlain RS, Sakpal SV (2010). Laparoscopic cholecystectomy conversion rates two decades later. JSLS 14:476–483.  Back to cited text no. 8
    
9.
Chappell K, Dickerson P (2016). Principles of evaluating nursing competence. Available at: http://www.td.org/magazines/principles of Evaluating Nursing Competence. [Accessed on 2019 December 20].  Back to cited text no. 9
    
10.
Cheever KH, Hinkle JL (2013). Brunner Suddarth, Text Book of Medical- Surgical Nursing. 13th ed. Philadelphia, PA: Lippincott Williams & Wilkins company; p. 1212.  Back to cited text no. 10
    
11.
Davidson BR, Gurusamy KS (2010). Surgical treatment of gallstone. Gastroenterol clin N Am 39:229–244.  Back to cited text no. 11
    
12.
Delaune SC, Ladner PK (2011). Fundamentals of Nursing: Standards and Practice. 4th ed.USA: Delmar cengage Learning Company; P66.  Back to cited text no. 12
    
13.
Donilon DM (2013). Nurses perceptions of their competence in managing patient situation in acute care [published doctora thesis]. University of Rhode Island, P102.  Back to cited text no. 13
    
14.
Evans S, Jackson PG (2012). Biliary system. In: Townsend CMJr, Beauchamp RD, Evers BM, Mattox KL, (editors). Sabiston Textbook of Surgery. 19th ed. Philadelphia, PA: Saunders Elsevier; 55.  Back to cited text no. 14
    
15.
Fukada M (2018). Nursing competency: definition, structure and development. Yonago Acta Med 61:1–7.  Back to cited text no. 15
    
16.
Gilani SA, Kousar R, Muhammad A, Sadia H, Waqas A (2017). Assessment of nurses’ knowledge and practices regarding prevention of surgical site infection. Saudi J Med Pharm Sci 3:585–595.  Back to cited text no. 16
    
17.
Hebra A, Miller M, Schwarz S (2011). Pediatric cholecystitis, medscape reference. Available at: http‘/article/ / emedicine. Medscape .com/ 927340-overview. [Accessed 19 September 2019]  Back to cited text no. 17
    
18.
Kahya E, Oral N (2018). Applicable performance criteria to evaluate clinical nurses. Hacettepe J Health Administration 21:289–304.  Back to cited text no. 18
    
19.
Laupacis A, Mestral C, Rotstein O (2012). A population-based analysis of clinical course of 10, 304 patients with acute cholecystitis, discharged without cholecystectomy. Trauma Acute Care Surg 74:26–30.  Back to cited text no. 19
    
20.
Leino-Kilpi H, Meretoja R (2004). Nurse competence scale: development and psychometric testing, methodological issues in nursing research. J Adv Nurs 47:124–133.  Back to cited text no. 20
    
21.
Mohammed GT (2011). Infection control: effect of designed teaching protocol on nurses knowledge and practice regarding to hematemesis patients. thesis submitted for partial fulfillment of the requirements of the master degree in Adult Nursing Faculty of Nursing Asssuit University, pp. 67  Back to cited text no. 21
    
22.
Nawaz H, Papachristou GL (2011). Endoscopic treatment of post cholecystectomy bile leaks; updates and recent advances. Ann Gastroenterol 24:161–163.  Back to cited text no. 22
    
23.
Renholm M (2015). Continuity of patient care in day surgery. Department of Nursing Science, Faculty of Medicine, University of Turku, Finland Annals Universities Turkulensis, Painosalama Oy, Turku.website  Back to cited text no. 23
    
24.
Smeltzer SC, Bare BG, Hinkle JL, Cheever KH (2010). Brunner and Saddarth’s Text Book of Medical-Surgical Nursing. 12th ed. Philadelphia, PA: Lippincott Williams Company; p1169.  Back to cited text no. 24
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Objectives
Participants and...
Results
Discussion
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed159    
    Printed4    
    Emailed0    
    PDF Downloaded20    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]