الفهرس 
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Abstract
Mechanical low back pain is a universal health problem it occurs in
similar proportions in all cultures; many problems are associated with
MLBP. The first of these consists of the cost involved in evaluating,
diagnosing and treating this medical condition- not only the cost in health
care dollars, but also time lost from work and time spent by clinicians in
treatment and prevention. Because MLBP is a leading cause of pain and
disability it interferes with quality of life and work performance. The
associated problems of low back pain, missed work, medical cost, and
expensive diagnostic imaging, which exist in society in general, are also
prevalent in the correctional climate. Rehabilitation nurses can be as
therapists as any other professional group, specialist knowledge and skills
are required to carry out therapeutic nursing practice within rehabilitation
of clients with MLBP. This acknowledges the importance of rehabilitation
nurses’ need for training to provide the necessary help to clients with
MLBP.
Aim of the study
This study aimed to identify the effect of rehabilitation nurses’ training on
selected health parameter of client’s with mechanical low back pain
through:
1. Assessing nurses’ training needs.
2. Application of an on the job program for the nurses based on their
identified needs.
3. Studying the effect of the interventional training program on
nurses’ knowledge.
4. Studying the effect of the interventional training program on
nurses’ competence level.
5. Assessing the effect of the interventional program on clients’
selected health parameters and satisfaction.
Subjects and Methods:
Research Setting
This study is a cross sectional study conducted in the physical
medicine and rehabilitation military center which is located in Al Helmia
area in Cairo. It is a daycare sport and rehabilitation health care center
which consider one of the most advanced center of the medical military services, providing sport medicine, rehabilitation services to military
personal in deferent ranks and their families in both sex and different ages,
provides assessment and therapy for about 70 client \day.
Sampling:
a) Nurses: A purposive sampling of nurses working/ or assigned to
carry out rehabilitation related tasks in the selected rehabilitation
setting for low back pain clients.
b) Clients: A purposive sample of all adult clients suffering from
mechanical low back pain, registered for receiving physiotherapy
sessions, the clients will be with the following inclusion criteria:
• Sufferers of mild and/or moderate degree of mechanical low back
pain.
• Free from serious pathologies such as (tuberculosis, tumors or
recent fractures of the spine….act). This will be ensued by
checking the doctor‘s referral notes.
• Scheduled for at least 12 sessions or more of physiotherapy
sessions.
• Already had their first or second rehabilitation session only.
• All sessions provided by nurses under study.
Sample size
a) Nurses: All nurses (30) in the rehabilitation center working/ or
assigned to rehabilitation related tasks in the selected rehabilitation
setting.
b) Clients: The targeted sample size of the clients will be 108 MLBP
covering the inclusion criteria, 54 client were considered as control
group with pre training nursing intervention, the other 54 client were
considered the study group upon which nursing interventional
program was implemented.
Sampling Technique:
Nurses: The researcher targeted to interview all nurses in the
rehabilitation center every Thursday, and Monday, because those were the
days which planed from the administration for given lectures and
continuous education in different subjects and different specialists. If any
nurse could not attend in any session of the program, the researcher had to
repeat this session separately with the nurse. For the practical part, it was
done in the gymnasiums of the rehabilitation center, before working hours
during nurses’ performance of their aerobics. And pre-post assessment in
the therapeutic rooms during performance of the care, the researcher had to
assess the nurses separately 3 times and take the average of the
performance.
Clients: during the morning shift after being diagnosis as MLBP. by
the physician, in the examination room, the client with the inclusion criteria
and after his acceptance to share in the study were considered in the sample
and the combined by the researcher to the therapy rooms to be scheduled
for receiving his/her sessions and scheduled the client in a time table to be
assess in their first or second session and listed for assessment in their 12th
session, then the next client was interviewed and passes the same way. The
researcher targeted to interview 6:9 clients/day if this number is not met,
the researcher had to postponed the missed cases to the next visit until the
targeted sample achieved, the researcher visited the pre-mentioned setting
in the 6 working days For assessment of client satisfaction regard their
improvement the clients did not assessed in their 1st or 2nd session but in
their 12th session only regard this item. After completing the program
delivery, the study group (54 clients) with the inclusion criteria and
accepted to participate in the study were taken in the same way and
scheduled to be assessed in their first or second session and be listed to be
assessed in their 12th session.
Tools for data collections:
Data was collected by the researcher using three tools namely:
1. Nurse’s Assessment Questionnaire Sheet:
This sheet was developed by the researcher based on review of recent
literature, experts’ opinion, it consists of two parts:
A) The first part: To collect data about Socio-demographic
characteristics of the studied nurses such as age, sex, educational level, previous working experience, years of experience in rehabilitation nursing
and received training workshops (Appendix I).
B) The second part: Is related to assessment of pre - post nurse’s
knowledge regarding:
a) Rehabilitation nursing meaning and importance with total score of 10
grads (Appendix II).
b) MLBP and managements of MLBP with total score of 25 grads
(Appendix II).
c) Basic Anatomical structure of the low back and healthy postures with
total score of 24 grads (Appendix II).
d) Communication skills adapted and adopted from (Cynthia, 2007) and
modified by the researcher. The total score was 48 grads (Appendix II).
For basic knowledge scoring, one was given for incorrect or
incomplete answer, two grades was given for correct and complete answer
and total scores less than 75% was considered not satisfactory knowledge
and score more than 75% or equals considered satisfactory knowledge.
2. Observational Checklist: to assess nurses‘ competency level in
conducting basic rehabilitation skills such as:
a) Body mechanics: adapted and adopted from, Karahana and
Bayraktar (2004), the tool was and modified by the researcher based
on review of the recent literature, experts’ opinion, with total score 26
grads (Appendix III).
b) Therapeutic back Massage: Adapted and adopted from, Thomson
(2002), with total score 60 grads (Appendix IV).
c) Active and passive exercises with total score 30 grads (Appendix V).
For performance scoring, one grad was given to (done incorrect or not
done) two grades for done correctly and scores less than 75% was
considered unacceptable performance and score equals or more than 75%
considered acceptable performance.
3- Client’s assessment questionnaire format: It was developed by the
researcher based on review of the recent literature and experts’ opinion,
consists of four parts:
A) The first part to collect Socio-demographic data, past and present
medical history of the clients (Appendix VI).
For the purpose of this study three health parameters were selected, the
following tools were used:
B) The second part: Pre - post Low back pain disability questionnaire
adopted from Roland and Fairbank (2000) and adapted, modified and
translated by the researcher. It was used to assess level of disability in
performing daily life activities. Client completed questionnaire consisting
of 24 statements with the addition of the phrase (because of my back). It is
a self-administered questionnaire with yes/no items. Clients are asked
whether the statements related to perceived limitations in daily life
activities, it consists of 24 items scored at 0 or 1 as zero for negative
response or (no disability) and one for positive response, ranges from 0-24
with higher scores representing worse dysfunction where 24 (maximal
disability. the total points were analyzed and scored into three degrees of
severity: mild (0-8); moderate (9-16); to highly (17-24), ((Appendix VII).
C) The third part: Pre - post Universal pain assessment tool adopted
from Faulds and Moore, (2006) for pain intensity: adapted and translated
by the researcher and reviewed by the experts for validity, it is self-reports
tool of pain using faces or behavioral self reaction it also involves the
numeric rating scale for asking clients to rate their pain intensity by
selecting a number on a scale from 0-10 where zero would mean ’no pain’
and 10 mean pain as bad as it could be. Pain intensity was described on a
10-point scale (Appendix VIII).
D) The fourth part: Client’s satisfaction scale questioner adopted by
(Alasad & Ahmad, 2003 and Grant et al.,2000), and adapted and
translated by the researcher, it is a three point scale divided into
dissatisfied, moderately satisfied or neutral and satisfied, zero was given
to unsatisfied, one for neutral, and two grades for satisfied.. For the
purpose of this research, the researcher categorized the satisfaction levels
(Appendix IV) as follows:
Dissatisfied = 0 – 8.
Neutral = 9 – 16.
Satisfied = 17 – 24 total points.
Operational design The operational design included the preparatory phases, pilot study,
fieldwork, and limitation of the study.
Preparatory phase:
During the preparatory phase, content validity was carried out.
Reviewing of the past and current available literature was done relevant to
the various theoretical aspects of the problem by using books, articles,
periodicals and magazines, and getting the expert’s opinion in order to get a
clear picture of the research problem, as well as, to develop the study tools
for data collection.
Pilot study
A Pilot study was done on 10 clients and 5 nurses, to examine and test
applicability of the study tools and test the suitability and feasibility of the
setting, availability of the study population (clients and nurses) the
researcher found that questionnaire with one client filled in about 30
minutes for each client. For nurses the observational chick lists were
performed in about 20 minutes for each skill for each nurse. Modification
of the tools was done based on the findings of the pilot study. Some
questions and items were omitted, added, or rephrased, and then the final
from was developed, the subjects included in the pilot study were excluded
from the study sample.
Ethical considerations
Ethical considerations were followed in relation to client’s oral
agreement, client’s privacy and client’s data confidentiality. The objectives
of this study were explained to the clients and nurses. Participation in this
study was gained through oral agreement and it was on a voluntary basis,
participants were informed of the purpose of the study and they were told
their right to withdraw at any point. Confidentiality of the information was
maintained and anonymity was ensured. Permission was sought for
recording of the interview data and respect was granted to issues
considered to be sensitive by the respondents.
Filed work
For the purpose of this study, MLBP was defined as an experience of
an episode or episodes of pain, stiffness, or discomfort of the low back
anytime during the previous 1 month. Data collection for this study was
carried out within a period of six months, the actual field work was carried out from the beginning of January 2009, to June 2009; the researcher
interviewed about 6-9 clients / day for 6 days / week, from 8 am to 3 pm, in
the studied rehabilitation center, through the visits, the researcher selected
the subjects according to the inclusion criteria, which include adult females
clients scheduled to attend the rehabilitation session. According to a time
scheduled for nurses two days/week and a time scheduled for clients six
days/week, after taking their oral agreement, using a questionnaire-based
survey from the clients, who were receiving physiotherapy for their MLBP
started to be assessed in their first or second session and scheduled to be
reassessed in their 12 session, the use of a questionnaire allows every
participant to get a similar assessing tool to complete which may result in
standardized responses. The researcher started to get clients out of the
medical records daily to be assessed in their first or second session with
introducing herself and explaining the aim of the study for the selected
subjects and begins to scheduled them to be reassessed in their 12th
session, then researcher begin to collected data from nurses, when the
researcher finished collecting data from the last client in the control group
in her 12th session, the researcher started to deliver the program to the
nurses and reassess them after one week of their last training session, then
the researcher begin to get clients out of the medical records and be
scheduled to be assessed in their first or second session and scheduled to be
reassessed in their 12th session, as study group .
Program construction
1. Program developmental phase:
The nurses training program was designed by the researcher and based
on the results obtained from nurses training needs, it was revised and
modified according to the related literature also cultural and sociodemographic
aspects of the study sample was considered to cover nurse‘s
knowledge and practice. The program was revised by experts in
(community health nursing and rehabilitation medicine).
2. Program implementation phase
Program implementation based on conducting session plans using
different educational methods, and Medias in addition to the use of guided video media specially designed and developed by the researcher based on
the nurses pre detected needs.
Program sessions
The actual work started by meeting the nurse throughout working
hours, the researcher first introduce herself to the nurses and gave them a
brief idea about the study and its aim. For the work reasons the nurses
were divided into 2 groups to had the sessions separately. The data was
collected using an Arabic questionnaire-based survey. The program
content has been sequenced through 8.5 hours for theoretical part and 15
hours for practical one, divided into 11 sessions (one session for
introduction of course out lines, 1 sessions for pre-test, 5 sessions for
theoretical part and 4 sessions for practice part). The sessions was
conducted in the lectures room where there was some educational
facilities as data show, video and skeleton, the practical part was
conducted in the gymnasiums.
Methods of teaching were; modified lectures, group discussion, brain
storming and simulation demonstration and re-demonstration, role play
and suitable teaching aide in a form of an educational video tape prepared
especially for the program were used.
3. Program evaluation phase
Evaluation was applied before and after the program, in order to
identify difference, similarities and areas of improvement, as well as
defects. This was done through pre and post administration of the selfadministrative
questionnaires and observational checklists.
Program implementation related barriers
a. The researcher had to deliver the sessions in 2 languishes (Arabic for
the diploma school nurses and English for the technical nurses) so the
effort was duplicated.
b. It was so difficult to gather all the nurses in the same time, so they
were divided into 2 groups.
c. Some clients were not attached to their scheduled time so the
researcher had to phone them and rescheduled them to be assessed.
Administrative design:
Before starting the fieldwork for conducting this study, a formal letter
was issued from faculty of nursing Ain Shams University to
administrative of the physical medicine and rehabilitation military center
in Al Helmia area and to medical services department.
The results of this study found that:
- The sample consists of 30 rehabilitation nurse, with main age 27.30 SD
± 4.6 yrs, main years of experience in rehabilitation were 4.6 SD ± 3.16
yrs. And (108) client of MLBP clients, 54 clients considered as control
group and 54 clients as study one, all of them were females with mean
age 57.8 SD±5.91 yrs and 58.3 SD±5.71 yrs. respectively.
- Concerning nurses’ previous training, It was found that most of nurses
(93.3%) did not received any training about introduction or principles
of rehabilitation nursing, while less than two third (60%) did not
received any training about MLBP managements.
- Concerning nurses knowledge less than two third (60%) of nurses had
satisfactory knowledge as regard body mechanics, before training,
improved to become 96.7% after training, differences observed were
statistically significant (1X2=15.20 at P < 0.05). While about one quarter
(26.7%) of them their score level of knowledge was satisfactory as
nursing role in MLBP before training, improved to become 96.7% after
training. Differences observed were statistically significant (1X2=12.46
at P < 0.05).
- In relation to nurses knowledge, less than one third (40.0%) of nurses
their knowledge score level as regards communication skills was
satisfactory in pre training assessment, improved to became 76.7%
after training, the differences observed were statistically significant
(1X2=6.08 at P < 0.05).
- In relation to nurses‘ competency level in performance of rehabilitation
skills, less than two third (60%) of nurses had satisfactory score level of
performance of therapeutic back massage before training, improved to
become 97.7% after training Also this table indicated that difference
was statistically significant (X2=4.17, P. value > 0.05).
- Also the results reflects that; regarding nurses performance of body
mechanics less than one fifth (13.3%) of nurses their performance score
was satisfactory before training, improved to become 96.7% after
training Also this table indicated that difference was statistically
significant (1X2=21.55, P. value > 0.05).
- Also the results reflects that; as regards nurses‘ competency level in
performance of rehabilitation skills, less than half (43.3%) of nurses
had satisfactory score level of performance of passive and active
exercises before training, improved to become 96.7% after training
Also this table indicated that difference was statistically significant
(1X2=8.82, P. value < 0.05).
- Concerning clients’ selected health parameters it was found that; the
majority of clients of study group (83.3%) reported high disability in
their 1st session, with trained nurses, this reduced and scattered to
become 64.8% mild disability, difference was statistically insignificant
(2X 2=5.4, P. value > 0.05). Compared with 89.8% in control group
before nurses’ training, reduced to become 3.7%, and scattered to
become 64.8% for moderate disability, difference was statistically
significant (2X2=4.4, P. value < 0.05).
- Also the results reflects that; self reported ”severe pain” among control
group was 42.6% in their 1st session, decreased to became 20.4% in
their 12th session before nurses’ training, compared with 44.4% among
study group in their 1st session; which decreased to became 0.0%, after
training of nurses. Self reported ”no pain” increased to became 44.4%
among study group compared to 22.2% in the study group in their 12th
session. Also this table clarified that; differences were statistical
significance between control and study clients in their 12th (4X2
= 20.23
Significant at P. value < 0.05).
- As regards client’s satisfaction; 59.3% of clients in the study group
were satisfied in their 1st session, which improved to become 90.7%
after training of nurses, differences observed were statistically
significant (1X 2= 7.1 at P Value < 0.05). Comparing to 46.3% of
clients in the control group were satisfied in their 1st session, which
improved to become 70.4 % before training of nurses, differences
observed were statistically significant (1X 2 = 1.8 Not Significant at P
Value >0.05).
Conclusion:
Based on the finding of the current study, the following can be
concluded:
- Before training program implementation, nurses had unsatisfactory
knowledge score level as regards basic knowledge concerning
rehabilitation nursing and MLBP rehabilitation. After training program,
results showed significant statistical differences between Pre-post
knowledge score level of all nurses.
- Before training program implementation, nurses had unsatisfactory
performance score level as regards basic MLBP rehabilitation skills.
After training program, results showed significant statistical differences
between Pre-post performance of basic rehabilitation nursing skills total
score level of all nurses.
- Concerning clients’ selected health parameters or indicators of program
effectiveness, results showed significant statistical differences between
1st and 12th session in both control and study group. Meanwhile, results
showed statistical significant differences between control and study
group in their 12th session as regards pain intensity and disability in
performing Daily Life Activities and clients satisfaction.
Recommendations:
The results of the study led to the following recommendations:
• Application of the program used in this study to be guidance for the
rehabilitation nurses for better rehabilitation giving skills, in most
rehabilitation facilities.
• Availability of educational materials for clients during waiting time for
medical services such as CD, video films and\ or posters to increase
their knowledge about proper body mechanics and methods of
prevention of MLBP.
• Application of organized and continuous On-the-Job training program
for nurses to improve their knowledge and performances of
rehabilitation nursing skills regards MLBP clients.
• Development of job description of nurses in the rehabilitation settings
to enhance rehabilitation nurses role.
• Results of the study suggest that; the MLBP training Program for the
nurses improved knowledge and performance of nurses under study at
least in the short term. Further study will be necessary to determine if
the improved knowledge and performances change persists.