NURSE’S KNOWLEDGE, ATTITUDE AND PRACTICE ON THE INITIAL

MANAGEMENT OF ACUTE POISONING AMONG ADULT CASUALTIES: STUDY

AT ACCIDENT AND EMERGENCY DEPARMENT, KENYATTA NATIONAL

HOSPITAL, KENYA.

BY

JAPHETH KIPKOSGEI RUTTO

H56/79007/2009

A DISSERTATION SUBMITTED IN PARTIAL FULFILMENT OF THE

REQUIREMENT FOR THE AWARD OF MASTER OF SCIENCE DEGREE IN

NURSING (CRITICAL CARE NURSING) OF THE UNIVERSITY OF NAIROBI.

NOVERMBER, 2011
DECLARATION
I, Japheth Kipkosgei Rutto declare that this dissertation is my original work and has not been

presented in any other institution for the purpose of obtaining degree or any other award.

Signed………………………………………………Date……………………….

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DEDICATION
I dedicate this work to my wife Caroline and our children Emmanuel and Egan for their

understanding and bearing with my long absence as I pursued my studies.

I also dedicate this work to my parents who instilled the value of education and

fundamental skills of life in me. Thank you for raising me to be who I am today.

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ACKNOWLEDGEMENTS
I wish to extend my sincere gratitude to the Ministry of State for Defence for giving me an

opportunity to further my studies. Great thanks goes to, The Chief Executive Officer of Kenyatta

National Hospital for allowing me to conduct this research at the hospital. Thanks to all nurses of

Kenyatta National Hospital working at Accident and Emergency Department who participated in

the study. I know how tight the schedules are, but thank you for finding time towards completing

the questionnaires.

Special thanks goes to my research assistant Marilyn Langat who ensured that questionnaires

were distributed and returned accordingly. Finally, thanks to Mr. Phillip Ayieko for his

assistance in data analysis.

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SUPERVISORS’ APPROVAL
This dissertation is submitted as partial fulfilment for the award of Master of Science Degree in

Critical Care Nursing of The University of Nairobi with our approval as supervisors.

SUPERVISORS:
1. Dr. James Mwaura
BscN, Msc, PhD
Lecturer, School of Nursing Sciences

Signature ……………………..Date……………………...

2. Mrs. Angeline Kirui

BscN, Msc.
Lecturer, School of Nursing Sciences

Signature …………………..Date……………………..

3. Mrs. Theresa Odero

RN, RM, CCN, HE, BScN, MSc.
Lecturer, School of Nursing Sciences

Signature …………………..Date……………………..

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 TABLE OF CONTENTS
DECLARATION.................................................................................................... II
DEDICATION ....................................................................................................... III
ACKNOWLEDGEMENTS ................................................................................. IV
SUPERVISORS’ APPROVAL .............................................................................. V
TABLE OF CONTENTS ..................................................................................... VI
LIST OF TABLES ................................................................................................ IX
LIST OF FIGURES ................................................................................................ X
LIST OF ABBREVIATIONS AND ACRONYMS ............................................ XI
OPERATIONAL DEFINITIONS ......................................................................XII
ABSTRACT ........................................................................................................ XIV
CHAPTER ONE: INTRODUCTION ..................................................................1
1.1 Background information .................................................................................................................1
1.2 Problem statement ...........................................................................................................................2
1.3 Justification .....................................................................................................................................3
1.4 Study objectives ..............................................................................................................................3
1.4.1 Broad objective ........................................................................................................................................3
1.4.2 Specific Objectives ..................................................................................................................................3
1.5 Research questions ..........................................................................................................................4
1.6 Hypotheses ......................................................................................................................................4
1.7 Study benefits..................................................................................................................................4
1.8 Conceptual Framework ...................................................................................................................5

CHAPTER TWO: REVIEW OF LITERATURE ..............................................6

2.1 Introduction .....................................................................................................................................6
2.2 Epidemiology of poisoning .............................................................................................................7
2.3 Classification of poisoning ..............................................................................................................8
2.4 Signs and symptoms of acute poisoning .........................................................................................9
2.5 Fate and effect of toxicants in the body. ....................................................................................... 10
2.6 General Management of poisoning. .............................................................................................. 11
2.7 Initial nursing assessment and management of poisoning ............................................................ 12
2.7.1 Management of poisoning at AED by nurses ........................................................................................ 14
2.8 Knowledge, Attitude and Practice (KAP) ..................................................................................... 16

CHAPTER THREE: RESEARCH METHODOLOGY ..................................20

3.1 Study design .................................................................................................................................. 20
3.2 Study area...................................................................................................................................... 20

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3.3 Study population and sampling procedure. ................................................................................... 20
3.4 Subject‟s inclusion and exclusion criteria. .................................................................................... 21
3.4.1 Inclusion criteria. ................................................................................................................................... 21
3.4.2 Exclusion criteria ................................................................................................................................... 21
3.5 Sample size determination ............................................................................................................ 21
3.6 Data collection .............................................................................................................................. 22
3.6.1 Study tools ............................................................................................................................................. 22
3.6.2 Research assistant. ................................................................................................................................. 22
3.6.3 Pilot study .............................................................................................................................................. 22
3.6.4 Data collection methods ......................................................................................................................... 23
3.7 Data management .......................................................................................................................... 23
3.7.1 Data cleaning. ........................................................................................................................................ 23
3.7.2 Data Analysis ......................................................................................................................................... 24
3.7.3 Data presentation ................................................................................................................................... 24
3.8 Ethical Consideration .................................................................................................................... 24

CHAPTER FOUR: RESULTS ...........................................................................25

4.1 Social demographic characteristics of A&E nurses. ..................................................................... 25
4.1.1. Accident and emergency trainings ............................................................................................................. 26
4.2 General knowledge on poisoning .................................................................................................. 27
4.3 Initial management of acute poisoning practices among A&E nurses. ......................................... 30
4.4 Self reported nursing practice of A&E nurses............................................................................... 33
4.5 Perception towards patients presenting with acute poisoning ....................................................... 35
4.5.1 Overall attitude of A&E nurses towards poisoned patients ................................................................... 37
4.6 Competency of A&E nurses on the management of acute poisoning ........................................... 39
4.7 Interview with Nursing Officer in Charge AED, KNH. ................................................................ 42

CHAPTER FIVE: DISCUSSION ......................................................................43

5.1 Introduction ................................................................................................................................... 43
5.2 KAP of A&E on the initial Management of Poisoning. ................................................................ 43
5.3 Conclusion .................................................................................................................................... 47
5.4 Recommendations ......................................................................................................................... 47

WORK PLAN IN GANTT CHART ....................................................................49

BUDGET .................................................................................................................51
REFERENCES. ......................................................................................................53
APPENDICES ........................................................................................................59
Appendix I: Consent Explanation ..................................................................................................................... 59
Appendix II: Informed Consent .......................................................................................................................... 60
Appendix III: Research Questionnaires ............................................................................................................... 61

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 SECTION A: Social and Demographic Data .................................................................................................. 61
SECTION B: General Knowledge on Poisoning ............................................................................................ 62
SECTION C: Initial Management of Acute Poisoning Practices .................................................................... 63
SECTION D: Nursing Practice Self Report .................................................................................................... 64
SECTION E: Perception/Attitude towards Patients Presenting With Acute Poisoning. ................................. 65
Appendix IV: Observation Checklist ................................................................................................................... 67
Appendix V: Interview Guides ........................................................................................................................... 70
Appendix VI: Letter to KNH/UoN Ethics and Research Committee ................................................................... 72
Appendix VII: Letter to the Ministry of Education, Science and Technology ...................................................... 73
Appendix VIII: Letter from KNH/ UoN Ethics and Research Committee. ........................................................... 74
Appendix IX: Letter from Ministry of Education, Science and Technology .................................................... 75

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LIST OF TABLES
Table 2.1 Signs and symptoms of poisoning…………………………………………….…….....9

Table 3.1 Distribution of questionnaires…………………………………………………….…...23

Table 4.1 Social demographic characteristics of A&E nurse, KNH………..................................25

Table 4.2 Accident and emergency experience and post qualification training among A&E

nurses, KNH…………….…………………………………………………………………….…27

Table 4.3 Responses of A&E nurses on their general knowledge of poisoning…………………28

Table 4.4 Nursing qualification and length of experience versus general knowledge on poisoning

among A&E nurse………………………………………………………………………………..29

Table 4.5 Nurses trainings on A&E related courses versus general knowledge on poisoning

among A&E nurses………………………….……………………………………………..…….30

Table 4.6 A&E nurses responses on initial management of poisoning practices……..................31

Table 4.7 A&E nurses‟ professional qualification and length of experience versus knowledge on

initial management of acute poisoning practices…………….……………………………….….32

Table 4.8 A&E related training courses versus knowledge on the initial management of acute

poisoning practices among A&E nurses………………………………………………………....33

Table 4.9 A&E nurse‟s perceptions towards patients presenting with acute poisoning…………36

Table 4.10 Nursing qualification, length of experience, formal training on poisoning

management, age group and gender versus attitude of A&E nurses towards poisoned………....38

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LIST OF FIGURES
Figure 1.1 Conceptual framework………………………………………………………………...5

Figure 2.1 Fate and effect of toxicants in the body………………………………………………10

Figure 4.1 Training in different accident and emergency courses among nurses at AED, KNH..26

Figure 4.2 Self reported nursing practices among nurses at A&E, KNH...…….……………......34

Figure 4.3 Need for poisoning training among A&E nurse KN....………………………………34

Figure 4.4 Observation of airway management on poisoned patients at AED, KNH…...............39

Figure 4.5 Management of breathing in acute poisoned patients at AED, KN......................…...40

Figure 4.6 Management of circulation in 15 patients presenting with acute poisoning...……….41

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LIST OF ABBREVIATIONS AND ACRONYMS
A&E Accident and Emergency

ABC Airway, Breathing and Circulation

ACLS Advance Cardiac Life Support

AED Accident and Emergency Department

BLS Basic Life Support

BscN Bachelor of Science in Nursing

CI Confidence Interval

CME Continuous Medical Education

ED Emergency Department

ERC Ethics Research Committee

IDRC International Development Research Centre

KAP Knowledge Attitude and Practice

KMTC Kenya Medical Training College

KNH Kenyatta National Hospital

MAPP Maudsley Alcohol Pilot Project

MscN Masters of Science in Nursing

NICE National Institute for Clinical Excellency

NO Nursing Officer

OPP Organophosphate Poisoning

SPSS Statistical Package of Social Science

WHO World Health Organization

GCS Glasgow Coma Scale

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OPERATIONAL DEFINITIONS
Accident and emergency nurse. Any qualified nurse deployed at accident and emergency

department with or without accident and emergency specialisation during time of study.

Acute poisoning: When the body is exposed to a toxic substance in a high dose, on one occasion

and during a short period of time. Symptoms develop in close relation to the exposure.

Adults: Anyone who is above 18 years.

Attitude: Attitude is positive or negative reaction of health professionals towards poisoned

patients exhibited in their beliefs, feelings, or intended behaviour. Individuals' behaviours are

influenced by their feelings (affective) and beliefs (cognitive).

Deliberate self harm: An act with fatal or non-fatal outcome in which an individual deliberately

initiates a non-habitual behaviour that without intervention from others will cause self harm, or

deliberately ingests a substance in excess of the prescribed or generally recognized therapeutic

dosage.

Emergency department: This is where all casualties brought to the hospital are received.

Evidence-based nursing practice: Applying the scientific evidence that has been found

effective to a specific nursing intervention.

Initial assessment: Management and care given by nurses to poisoned patient on arrival at

accident and emergency department as part of patient stabilization. The care ends when the

patient‟s physiological parameters are within normal and patient is out of life threatening

situations.

Knowledge: Familiarity with acute poisoning management among accident and emergency

nurses. It includes; information, facts and skills acquired through experience and education on

poisoning.

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Nursing practice: Actual provision of nursing care using the nursing process to poisoned

casualties.

Poison: Substance capable of producing damage or dysfunction to the body by its chemical

activity. In this study, it is substance that has been ingested through the oral cavity and produces

damage or dysfunction to the body by its chemical activity.

Quality of care: The degree to which health services for individuals and populations increase

the likelihood of desired health outcomes and are consistent with current professional knowledge

xiii
 Abstract

Acute poisoning is a medical emergency and patients are always rushed to the hospital at the

earliest possible moment, irrespective of the amount and nature of poison. It requires early

management decisions to ensure an optimal patient outcome. Accident and emergency (A&E)

nurses are often at the forefront when it comes to this initial and critical assessment. Their

knowledge, skills and positive self esteem are fundamental to their practice and patient outcome.

The purpose of this study was to determine nurse‟s knowledge, attitude and practice on the initial

management of acute poisoning among adult casualties attended to at accident and emergency

department (AED), Kenyatta National Hospital (KNH).

This was cross sectional study were both qualitative and quantitative methods of data collection

were used. The target population were all nurses working at AED, KNH. Purposive sampling

was used to select the subjects. Sample size comprised of all A&E nurses who met subject‟s

inclusion criteria. Structured questionnaires, observation checklist and interview were used to

collect the data. Data were entered and analyzed in the statistical program SPSS version 16.

Sixty eight A&E nurses participated in the study. The study found out that with higher nursing

qualification and training on courses related to emergency care, knowledge and skills of A&E

nurses on the initial management of acute poisoning increased. A&E nurses with lower nursing

qualification had a higher mean score of positive attitude compared with those nurses with higher

qualification. Majority 60 (88.2%) of the A&E nurses indicated that they required more training

on the initial management of poisoning.

A&E nurses should be trained on various types of poisoning including assessment, their clinical

presentations, management and gut decontaminations. In addition, refresher courses should be

xiv
organised for those already trained. Flowcharts that will enhance easy identification and

management of poisoned casualties should be set and utilized accordingly at AED.

xv
CHAPTER ONE: INTRODUCTION
1.1 Background information
Acute poisoning is common reason for visits to emergency departments and for hospitalization

worldwide and it is a cause of both morbidity and mortality in many parts of the world. The toxic

agents associated with the morbidity and mortality varies from place to place due to the

availability and use of various chemicals and other poisoning agent. Globally it is estimated that

poisoning events are responsible for more than one million illnesses annually (Malangu and

Ogunbanjo 2009).

Study done by Sharma and Bangar (2005) indicates that a high mortality and morbidity rate from

poisoning is a major health service delivery issues in developing countries. Majority of these

patients present in AED for their initial treatment. Their treatment poses some numerous clinical

challenges where severely poisoned patients can be medically unstable and require resuscitation,

specific treatment, close observation and monitoring.

Fernando (2007) and Greene et al. (2008) found out that majority of acute poisoning cases seen

in clinical practice especially in developing countries are a result of deliberate and accidental

ingestion. Homicidal poisoning is rare. Although overall mortality from acute poisoning is low,

poorly managed poisoning-related complications can lead to long-term morbidity and mortality.

Konradsen (2007) found out that, in many countries in Asia, Africa and Latin America the health

system lacks the capacity to manage many cases of acute poisoning and they are in dire need for

more antidotes, respirators, better trained staff and more equipped ambulances.
1.2 Problem statement
A&E nurses are frequently the first health care professionals to come in contact with patients

who have ingested poisons. Proper initial assessment, evaluation and treatment are very essential

for patient survival. Oslon (2004) suggested that, even though they may not appear acutely ill, all

poisoned patients should be treated as if they have a potentially life-threatening intoxication.

Poisoning affects the patient's condition quickly, and the patient's life can be endangered if there

is a delay in initiating urgent treatment. Decisions on appropriate responses to such casualties

have to be appropriate, swift and evidence based (Senarathna, 2008). It is essential that all A&E

nurses are familiar with the clinical priorities in life - threatening situations in order to ensure

that problems are identified and treated accordingly. Therefore, A&E nurses should be equipped

with professional knowledge and skills that enables them to manage poisoned patient

accordingly.

McAllister et al. (2001) explored the personal experience of poison patients in hospitals. They

found out that, when patients are transferred to Emergency Department (ED) they are often

ignored, have to wait, experience judgmental comments and painful treatment. Disturbingly, ED

is an important access point for these clients who might be in dire need for emergent life saving

interventions. Further, they found out that without focused skills training and deeper

understanding of the complexity of self-harm and therapeutic responses of emergency clinicians;

nurses are likely to provide inadequate emergency care for this type of patients.

2
1.3 Justification
Kenya is currently faced with increasing incidences of acute poisoning which range from

aflatoxins ingestion, illicit brews consumption and use of uncertified herbal medicine for

treatments.

A&E nurses are often at the forefront when it comes to this initial and critical assessment of

poisoned casualties. Their knowledge, skills and positive self esteem are fundamental to their

practice and influence the overall patient outcome.

There is no study of the same that has been done in KNH and specifically being the largest

referral hospital in Eastern and Central Africa. The findings of the study therefore will be

invaluable in understanding the capabilities of A&E nurses in management of these patients.

Furthermore, the study will form a basis for improving the quality of service delivery in

management of poisoned casualties at AED, KNH.

1.4 Study objectives

1.4.1 Broad objective

 To determine the nurse‟s knowledge, attitude and practice on the initial management of

acute poisoning among adult casualties seen at AED, KNH.

1.4.2 Specific Objectives

 Determine the nurse‟s knowledge and practice in prioritizing rapid assessment and

intervention in the management of poisoned casualties at AED, KNH.

 To determine the nurses‟ attitude towards poisoned casualties at AED, KNH.

 To determine if nurse‟s social-demographic characteristics has any impact on the initial

management of poisoning at AED, KNH.

3
1.5 Research questions

The study seeks to answer the following questions:

 Do A&E nurses have necessary knowledge and skills on the initial assessment and

management of poisoned patients?

 Does attitude towards poisoned patients affect A&E nurse‟s provision of optimal

assessment and management of poisoned patients?

 Do A&E nurse‟s social- demographic characteristics affect the initial management of

poisoned patients?

1.6 Hypotheses
 There is no difference in the initial management of acute poisoning among nurses of

different education levels.

 Experience in accident and emergency nursing is not a factor in the initial management of

acute poisoning.

1.7 Study benefits

The study findings will provide basic information on the capabilities of A&E nurses in relation

to their knowledge, skills and attitude on the initial management of patients with acute poisoning.

The finding will also help in laying a basis for continuous staff training through continuous

medical education (CME) and refresher courses on issues related to poisoning management

where weakness was identified among A&E nurses.

4
1.8 Conceptual Framework
Individual nurses and situational factors (Independent variables) such as nursing professional

qualification, A&E experience, attitude and social demographic characteristics could enhance

nurses‟ skills and practices on the initial management of acute poisoned casualties (dependent

variables). Attaining the desired goals is indirectly influenced by AED resources, staff

motivation and hospital policy (confounding variables). The relationships between the various

variable are summarized in Figure 1.1

Independent variable Dependent variables

Knowledge
Initial Management of
 Nurses professional
Poisoning
qualifications
 A&E nurses‟
 Assessment
Experience
Attitude of A&E nurses  Diagnosis
 Intervention
A&E nurses social
demographic Characteristic
 Age
 Gender

Resources
 Staffing
 Equipments

Staff motivation

Hospital policy

Confounding variables

Figure 1.1. Conceptual Framework

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CHAPTER TWO: REVIEW OF LITERATURE
2.1 Introduction
Carroll (2007) defines poisoning as chemical injury to organs of the body or a chemically

induced disturbance of the function of the bodies systems. Hodgson (2010) defines it as any

substance that causes a harmful effect when administered, by accident or by design; to a living

organism. The toxic properties of a certain poison are often specific, and hence the clinical

symptoms after exposure to a poison may be quite characteristic. Substances that normally are

considered as harmless may also, if the dose is big enough, cause deleterious effects and thereby

act as poisons (Moller and Karolinska, 2005).

Poisoning may be acute or chronic. In acute poisoning the body is exposed to the toxic

substance in a high dose, on one occasion and during a short period of time. Symptoms of

poisoning develop in close relation to the exposure. In chronic poisoning the organism is

repeatedly exposed to toxic agents during a long period, but every exposure means that just a low

dose of the poison is entering the body.

Poisoning is a medical emergency and patients are always rushed to the hospital at the earliest

possible moment, irrespective of the amount and nature of poison ingested. All the cases of

poisoning are admitted through emergency services where the life of the patient is the main issue

for the medical personnel.

Dally et al. (2006) stated that, “the assessment and management of acute poisoning constitutes a

core emergency medicine. It is a common presentation that requires early management decisions

to ensure an optimal outcome while at the same time avoiding unnecessary investigation and

intervention. In formulation of rational management plan for individual patients, clinician require

understanding of the agent ingested, dose ingested, time since ingestion, clinical features, patient

6
factors, geographical location, and the available medical facilities. A highly organized approach

is essential if the emergency physician is to ensure effective delivery of time-critical

interventions while at the same time devising a management plan tailored to the individual

patient‟s needs.

2.2 Epidemiology of poisoning

According to a study done by Malangu (2008) poisoning is a common cause of presentation to

emergency departments in the United Kingdom (UK) and accounts for up to 10% of acute

medical admissions. However, the mortality from acute poisoning is less than 1% and the vast

majority of patients will make a rapid and complete recovery with good supportive care. The

challenge is to identify those poisonings that are most likely to cause serious complications and

morbidity and to institute appropriate treatment promptly. He found out that deliberate self

poisoning is the commonest cause of poisoning in adults and accidental poisoning is largely due

to chemical exposure at work or at home.

The incidence of acute poisoning has been increasing in recent years in China. The study

conducted by Chen et al. (2010) in one of the referral hospitals, indicates that there has been

tremendous increase in acute poisoning over the years and the male female ratio was 1:1.04, and

their average age was 33.8 years.

In developing countries, especially in Asia, 44% of all deaths amongst 10-50 year old women

were due to poisoning and majority following suicidal ingestion of pesticides (Unnikrishnan

et al., 2005). Pesticide poisoning from occupational, accidental and intentional exposure is a

major world health problem. Millions of people are exposed to danger by hazardous occupational

practices and unsafe storage.

7
In South Africa, recent reports suggest that acute poisoning is responsible for up 17% of total

ward admissions in adults. In Botswana acute poisoning contributes to 7% of morbidity and

ranks third among injuries leading to hospitalization (Malangu, 2008).

The challenge for the attending clinician is to identify as early as possible patients who are at risk

of developing serious clinical toxicity, and who may benefit from decontamination or a specific

intervention ( Greene et al., 2005).

2.3 Classification of poisoning

Proudfoot (1982) stated that the realization of analytic studies requires some knowledge about all

critical determinants of illness, hence the need to specify very precisely the circumstances

surrounding poisoning. He classified poisoning episodes into four categories according to

motive or nature of use of which only two are common. They are:

Accidental poisoning

Accidental poisoning is most frequently encountered in children between the ages of 1 and 5

years and is the usual cause of poisoning in these age groups.

Deliberate self poisoning

Deliberate self poisoning is the commonest form of poisoning in adults and accounts for at least

95 per cent of all poisoning admission to hospitals. It is also referred to as attempted suicide.

This form of poisoning is more common in woman. Such patients intentionally take poison or

overdose of drugs, often impulsively, after a disagreement with a key person in their lives. Most

patients however have no wish to die. The peak age incident for self poisoning is between the

ages of 20 and 35 years, but it is not uncommon before the age of 15 years.

8
Homicidal poisoning

Acute poisoning as a method of homicide is very uncommon. Sporadic cases occur but in most

the poisoning is sub acute or chronic. Any chemical substance has the potential of becoming the

means of committing a poisoning homicide. Clearly, the prime candidate for the most effective

weapon in homicidal poisonings is the chemical with the greatest lethality, the smallest dose, and

the least likelihood of detection.

Non –accidental poisoning

Non accidental poisoning is the term given to the deliberate administration of a poison to child

by one of its parents and may be regarded as an extension of the battered-child syndromes.

2.4 Signs and symptoms of acute poisoning

In most cases of poisoning, patients are able to tell what they have taken and symptoms are of

little diagnostic value. However, their presence or absents may give some indication of the

severity. Many poison affect multiple body systems and symptoms are frequently numerous and

non specific. Some of the signs and symptoms are listed in Table 2.1 below.

Table 2.1: Signs and symptoms of poisoning

Alimentary features Pain and ulceration of the oral cavity, salivation, dry mouth,
nausea and vomiting, abdominal pain and diarrhea

Cerebral and Staggering and dizziness, coma, convulsions, delirium and

neuromuscular features hallucination

Respiratory features Cyanosis, hypoventilation, coughing, wheezing, breathlessness

Cardiovascular features Loss of pulse, tachycardia and bradycardia, and hypotension

Skin Purpura, sweating

9
2.5 Fate and effect of toxicants in the body.

Toxicant Exposure

Entrance to Body
Ingestion Skin Inhalation

Absorption into Bloodstream and

Distribution to Body Tissues and Organs

Toxicity Storage Excretion

Metabolism

Figure 2.1. Fate and effect of toxicants in the body

Source :( Adapted from Hodgson, 2010)

According to Ahmad et al., (2009), Poisons may enter the body through different routes. The

rapidity of action of a poison depends upon the route of administration, the rate of absorption and

the mode in which it is introduced in to the system. Absorption through the stomach depends on

some factors such as fullness of stomach and presence of pyloric stenosis. The toxic action of the

poison depends on amount of the substance taken, its distribution to the tissues and also the rate

10
of excretion from the body. With massive ingestion or inhalation, symptoms may appear within

five minutes; or may be delayed to half to one hour and a maximum of 2 to 8 hours.

2.6 General Management of poisoning.

In the management of poisoning cases, a quick and correct decision is always desirable. The

familiar adage “TREAT THE PATIENT, NOT THE POISON” is appropriately stated, as it is of

no use to make vigorous attempts at removing the ingested poison from patient‟s stomach in case

there is no breathing or the blood pressure is not recordable (Sharma and Bangar, 2005).

According to the work of (Hodgson 2010; Schwartzstein and Burns, 1999), there are two main

elements in the management of poisoned patients. The first is the provision of good supportive

care and the second is decontamination or elimination enhancement measures. Management

begins with a thorough evaluation, recognition that poisoning has occurred, identification of the

agent involved, assessment of severity and prediction of toxicity. Supportive care is directed at

preventing or limiting the complications of a toxic exposure and is the cornerstone of good

management.

It is essential to ensure a patent airway, adequate ventilation and effective circulation. A

thorough history is essential in determining management and assessing the risk posed by a

particular poisoning. Important historical factors include what exactly was taken, when it was

taken, how it was taken, how much was taken, why it was taken, and what else was taken.

As with any patient attending an emergency department, physical assessment of the poisoned

patient starts with the airway, breathing and circulation (ABC). The patient must be capable of

maintaining and protecting a patent airway. If there is any doubt, active airway management is

required to protect against further compromise or aspiration.

11
Evaluation of breathing involves measuring the respiratory rate and assessing the adequacy of

ventilation. Observation, auscultation of the chest, and oxygen saturation will confirm adequate

ventilation in most cases, though arterial blood gases should be checked if there is any doubt.

Evidence of inadequate ventilation requires immediate correction.

Evaluation of the circulation includes a baseline pulse rate and blood pressure (BP). Serious

poisoning requires continuous electrocardiograph monitoring and regular BP checks. After

assessment of ABC, a complete physical examination is undertaken to look for other signs of

poisoning, injection marks, trauma (head injury or self-injury) and other disease (e.g. sepsis). In

cases where unknown tablets have been taken, clues as to the type of agent taken will often arise

during the course of the examination.

The neurological assessment is particularly important. An altered level of consciousness is a

frequent complication of poisoning and ranges from mild drowsiness to agitation, delirium, coma

and seizures. A Glasgow Coma Scale (GCS) of 8 or less strongly suggests that the patient may

be unable to protect their airway and intubation is required. Pupil size and reaction are affected

in many poisonings, and muscle tone and. Temperature should be recorded as many agents cause

hyperthermia.

2.7 Initial nursing assessment and management of poisoning

Clegg and Hope (1999) explored the first line of response for people who self-poison. They

found out that nurses are often at the forefront when it comes to the initial management of these

casualties and decision on appropriate responses to such individuals are always complex. As a

consequence, nurses need to be confident that such responses are firmly rooted in evidence-based

practice.

12
The process of initial assessment and management of acutely poisoned patients as suggested by

Wood and Rhode (2003) is very fundamental to the role of the A&E nurse. It requires a detailed

knowledge of presenting medical complaints and their underpinning pathophysiology, relevant

investigations and appropriate treatment options. A&E nurses roles in the initial assessment is to

ensure that decisions about a patient‟s need for admission or discharge are made as promptly as

possible and that delays in this process are minimized. Therefore, appropriate skills, knowledge

and positive self esteem are fundamental to their practice.

Assessment is the cornerstone of safe and effective practice and goes hand in hand with the

process of prioritizing patients‟ needs. It has been compared to the process of house building

whereby assessment is the foundation on which all care planning and nursing action is built. The

process of assessment starts as soon as the patient arrives in the accident and emergency

department and incorporates the gathering of information regarding the patient‟s current

physiological status along with a history of the present and any previous episodes.

According to Clegg and Hope (1999) initial management of self-poisoning involves rapid

evaluation of a patient's airway, breathing, circulation, and conscious state. If life-threatening

abnormalities are identified these are corrected using standard resuscitation techniques. Once

stability has been ascertained and established, decisions regarding further treatment regimes can

be formulated. As with all nursing care and treatment, a clear and concise assessment of the

patient's needs must be undertaken prior to the formulation of a treatment regime. The risk of

something detrimental happening to the patient as a result of ingesting a substance will depend

on a variety of factors including the amount ingested, time since ingestion, toxicity of the

particular substance and the age and body weight of the patient. Other factors include alcohol

13
consumption and mixtures of substances, both of which can potentiate the effects of the agents

ingested.

NICE guidance (2007) proposes a „Chain of Response‟ should be in place, which aims at being

timely, effective, and seamless. Different professional groups may contribute to different parts of

the chain according to the local setting. The most important requirement is that the „overall team‟

possesses competencies that cover assessment, recognition, intervention and communication to

ensure help is obtained when needed (Adam et al, 2010).

2.7.1 Management of poisoning at AED by nurses

Lau (2000) suggested that; after arriving at the accident and emergency department(AED), all

poisoned patients are triaged as being in a critical or emergency condition, whether they are

stable or not. This practice will ensure that the patients can be seen almost immediately for

stabilization and consideration of early gut decontamination.

According to Singapore Ministry of Health guideline (2000), on first contact with the poisoned

patient, assessment of the level of consciousness is important. For an unconscious patient, careful

evaluation of the ABC should be followed by active measures to not only secure these, but also

to reverse the unconscious state, if possible.

The cornerstone on the management of poisoning is supportive that is, care of the airway and the

maintenance of breathing and the blood circulation. Toxic symptoms such as convulsion and

arrhythmia should be watched for, as their onset can be quite sudden. If the patient‟s history and

the results of the physical examination support toxic ingestion, gut decontamination should be

considered.

14
In the treatment of trauma patients, there is the „golden hour‟ concept, whereby the first hour

represents the best chance to stabilize and treat potentially life threatening injuries before the

patient‟s condition deteriorates. In the management of ingested poisons, a similar concept should

be emphasized; after the first hour, the amount of poison removed from the body is much

decreased. Medical personnel who care for poisoned patients should keep this concept in mind

by considering early decontamination after the overdose, preferably within the first hour (Lau,

2000).

Schwartzstein and Burns (1999), stated that there are various methods of gastrointestinal

decontamination, which can be used alone or in combination. These include the induction of

emesis by syrup of ipecac, gastric lavage, administration of activated charcoal, whole bowel

irrigation, and endoscopic or surgical removal of the ingested poison. Regardless of the method

employed, efficacy decreases with greater delay between ingestion and treatment. The choice of

a decontamination procedure depends upon its relative efficacy, the associated risks of

complications, and the presence of contraindications

Eddeleston et al. (2004) suggested that we consider the need for gastric decontamination once

the patient has been stabilised. The larvage should not be performed until the patient is stable

and, if necessary, intubated. Fernando (2000) stated that when the toxic agent ingested is not

known, it is not advisable to induce vomiting by the gag reflex or with chemical agents. If the

toxic agent is a corrosive, vomiting will inflict a second insult on the upper gastrointestinal tract.

Furthermore, aspiration of vomit in patients with decreasing consciousness can be fatal.

15
2.8 Knowledge, Attitude and Practice (KAP)
A&E nurses are frequently the first health care professionals to come in contacted with patients

who have ingested poisons. Knowledge of the proper initial evaluation and treatment of these

patients are very essential. A&E nurses should be equipped with the professional knowledge and

skills to enable them to deal with a poisoned patient, and to assess the patient's support system

and family structure professionally.

In order to develop and maintain good management skills and practice, Sun et al. (2007), urge

that nursing education must continue to design and develop units of study for casualty nurses.

The study should focus on the therapeutic care of poisoned patients at pre- and post-registration

levels as well as in continuing professional education programs. Relevant research findings must

be included in the educational programs and specialized teaching units for casualty nurses should

be developed.

Attitudes of A&E nurses towards patients who attempt suicide are particularly important because

they are likely to determine the enthusiasm that will be shown in providing help for such patients

and hence influence the effectiveness of treatment. Thus, health care professionals must be aware

of their attitudes towards this group of patients as part of their professional and therapeutic role

(Sun et al., 2007).

Attitude of an individual consists of three components, namely cognitive, affective and

behavioural. The cognitive component includes beliefs, facts and information about an object.

The affective component describes the emotional reactions toward an object and the behavioural

component includes the behaviour associated with an object. These three components are

interrelated. Individuals' behaviours are influenced by their feelings (affective) and beliefs

(cognitive) (Chung, 2003).

16
Results from factor analysis on the research conducted by McAllister et al. (2002) revealed that

if staff perceive themselves as skilled to address the needs of clients who self-poison, they are

more likely to feel worthwhile working with such clients and less likely to demonstrate negative

attitudes. This is particularly relevant when we consider the work of Malone (1996) who

concluded that ED clinicians tend to feel they are doing nothing for such clients except treating

symptoms.

McAllister et al. (2002) found out that nurses are frequently required to respond to clients

presenting because of deliberate poisoning, but most have no formal training or specialized

preparation for the care. Without focused skills training and deeper understanding of the

complexity of poisoning and therapeutic responses nurses are likely to provide inadequate

emergency care for these clients.

It is imperative that nurses are skilled to perform and record a thorough risk assessment and

emergency response to clients with poisoning. Crawford et al. (1998) cited in McAllister et al.

(2002) found out that even after an hour teaching session staff were more likely to assess

accurately.

Findings from the study done by Sun et al. (2007) indicate that; sample group of casualty nurses

from the middle of Taiwan held positive attitudes toward patients who have attempted suicide. In

addition, they found out that, with higher level of nursing education the more positive the nurses‟

attitudes were. The importance of education and training emerged as a key factor throughout the

study. The evidence indicated that the nurses who were educated to a higher level of education

held more positive attitudes than those who were not. Findings illustrated that this group of

casualty nurses needed further education and training on poisoning and the nursing care of

17
poisoned patients. Results demonstrated that 94·8% (n = 147) of the respondents had not

attended academic programmes on care of self poisoning patients.

Ouzouni and Nakakis (2009) referring to Sun et al. (2007) findings, pointed out that there were

three different types of attitudes towards suicidal patients. Some nurses were angry and held

judgmental attitudes towards patients who attempted suicide. They did not like caring for

suicidal patients and felt they could be of no benefit to this group of patients. A number of nurses

demonstrated empathy and sympathetic feelings for suicidal patients. They accepted suicidal

behaviors and felt that their nursing care had meaning. They also found few nurses perceived that

suicidal patients were troubled people therefore, they felt powerlessness and fearful when they

were providing care. Thus, they distanced themselves from caring for people who had attempted

suicide.

In a survey carried out to assess doctors and nurses attitudes to self poisoning, Ouzouni and

Nakakis (2009) found out that both professionals held negative attitudes towards self poisoning

patients and did not enjoy caring for them. In particular, nurses and doctors held the most

negative attitudes to patients who made multiple attempts to commit suicide. McAllister et al.

(2002) found out that, nurses held negative attitude towards clients who self-harm and there was

correlations between years of ED experience.

According to Anderson (1997) more experienced accident and emergency nurses held more

positive attitude towards deliberate poisoning behaviour compared to less experienced nurses,

this was echoed by Mclaughlin (1994) who found out that there were significant differences in

two variables in relation to nurse‟s length of experience in casualty.

Sun et al. (2007) found out that, nurses who had experience in caring for deliberate poised

patients had more positive attitudes towards suicidal patients than nurses who had nursed above

18
10 patients who had attempted suicide. Alston and Robinson (1992) disputed this findings and

pointed out that increasing age and broader educational exposure may often prompt nursing from

different specialties, to question issues around the subjects of deliberated poisoning. In his study

he found out that less experience nurses held more positive attitude towards poisoned casualties

than experience nurses.

Study done by McCarthy and Gijbels (2010) found out that ED nurses held positive attitudes

towards individuals presenting with deliberate self harm. There was no correlation between total

scores and gender, ED experience, history of self-harm education but older nurses and hospital

trained nurses held less positive attitudes. Age and length of clinical experience produced a trend

in which attitudes increased, reached a peak and then declined. McCann (2006) found out that,

older and more experienced nurses had more supportive attitudes than younger and less

experienced nurses and nurses who had attended in-service education on deliberate poisoning

had more positive attitudes than non-attendees.

19
CHAPTER THREE: RESEARCH METHODOLOGY
3.1 Study design
This was a cross sectional study that employed both qualitative and quantitative methods of data

collection.

3.2 Study area

The study was conducted at KNH, AED. KNH is a referral hospital with a bed capacity of

approximately 2000 patients. It gathers for patients within Eastern and Central Africa.

For effective and efficient administration, Nursing services in KNH have been categorized into

Accident and Emergency, Obstetrics/Gynaecology/Radiotherapy, Paediatrics, Operating Room

Nursing, Surgery (General and Specialized), Orthopaedics, Ear/Nose and Throat,

Eye/ophthalmology, Medicine, Private (Amenity) wing, Patient Health Education and Research

Unit, Counselling and Continuing Education departments.

KNH, AED is the gateway to the hospital. The department operates 24 hours and handles an

average of 350 patients in a day. Out of these, 25% are accident victims and the rest are treated

as outpatients, directed to consultant clinics for senor reviews or admitted to respective wards

depending on their presenting condition. It operates in collaboration with the University of

Nairobi (UON) College of Health Sciences and Kenya Medical Training College (KMTC) in

offering teaching, training and research to students in their respective medical field.

3.3 Study population and sampling procedure.

The study population were all nurses working in AED during the time of study. To select the

subjects, non probability sampling was used and specifically purposive sampling. Basavanthappa

(2007) defines purposive sampling as a type of non probability sampling where subjects are

selected because they are identified as knowledgeable regarding the subject under investigation.

20
3.4 Subject’s inclusion and exclusion criteria.
Participant subject that were included in this study met the following subject‟s characteristics;

3.4.1 Inclusion criteria.

 Nurses working at Kenyatta National Hospital.

 They were either enrolled, registered, BscN or MscN nurses.

 They were deployed in AED during the time of study.

 They were directly involved in patient care management.

 They gave a written consent to participate.

3.4.2 Exclusion criteria

 Nursing students in AED placement doing basic trainings.

 Nurses who were on study leave, maternity leave, and annual leave during time of study.

 All AED nurses who declined to participate in the study.

 AED nurses who were not involved directly in immediate patient management like those

permanently deployed in radiology, minor theatre etc.

3.5 Sample size determination

According to Israel (1992) sample size determination for small populations is achieved by use of

census. He states that census is attractive for small population of less than 200 subjects under

investigation. Census is where entire population under study is used as a sample. In AED all the

82 nurses working there were eligible to participate in this study so long as they met the subject‟s

inclusion criteria

21
3.6 Data collection
3.6.1 Study tools
Structured questionnaire, observation checklist and interview schedules were used to collect the

data.

3.6.2 Research assistant.

One research assistant holding a Bachelor of Science in Nursing (BscN) qualification, BLS and

ACLS was recruited to assist in data collection. She was trained on how to collect the data using

various data collection instruments.

3.6.3 Pilot study

Approval authority to carry out the study was sought from KNH/UON- Ethics and Research

Committee (ERC). Pilot study was done at Mbagathi District Hospital. Fifteen questionnaires

were administered to nurses who were deployed at AED to test validity and reliability of the

instrument. Mbagathi District hospital was chosen because it is close proximity to KNH and

shares the same catchment area of poisoning cases. Poisoned casualties attending both hospitals

share the same cause characteristics in one way or another as they are served by the same

catchment area of Nairobi. Initial nursing management of these patients by AED nurses at both

hospitals held near similar management pattern due to their poisoning characteristics and goals.

22
3.6.4 Data collection methods
3.6.4.1 Questionnaires
Structure of the questionnaire comprised five sections as indicated in Table 3.1

Table 3.1 Distribution of questionnaires

Section No of items Aspect to be covered

A 8 Social and demographic data

B 14 General Knowledge on poisoning

C 10 Initial management of acute poisoning practices

D 7 Nurses practices self report

E 12 Nurses attitude. Components were drawn from a number

of previously validated attitudinal measures

3.6.4.2 Observation Checklist

The focus of the observations was to asses‟ actual practice of nurses on how they apply and

implement their knowledge and skills on the initial management of acute-poisoning. Checklist

was used to ascertain what the nurses were doing to the patient at that given moment.

3.6.4.3 Interviews
Nursing Officer in-charge of AED was interviewed on various aspects related to the department

and specifically on the management of acute poisoning.

3.7 Data management

3.7.1 Data cleaning.
Data were cleansed, checked for completeness and entered into Statistical Package of Social

Sciences (SPSS) version 16.

23
3.7.2 Data Analysis
Data were entered and analyzed in the statistical program SPSS version 16. Statistical measures

of Central tendency, T-test and ANOVA were used in determining the association between

independent and dependent variables.

3.7.3 Data presentation

Data were presented as frequency tables, bar graphs and figures. Inferential statistics were

presented in relation to their level of significance.

3.8 Ethical Consideration

Ethical clearance of the proposal was granted by KNH/UON –ERC. Permission to carry out the

study was granted by the Ministry of Science and Technology and KNH administration.

All A&E nurses were informed in advance that participation in the study was voluntary and the

identities of those who participated were withheld throughout the study. Purpose of the study

was explained to them, and those who were willing to participate provided a written consent by

signing a consent form provided.

24
CHAPTER FOUR: RESULTS
4.1 Social demographic characteristics of A&E nurses.
Out of 82 nurses providing nursing care at AED, KNH, 68 of these nurses participated in the

study, which was 82% response rate. The social demographic characteristics of the nurses are

presented in Table 4.1 below. There were 41 (60.3%) female nurses and 27 (39.87%) male

nurses in the study.

Table 4.1. Social demographic characteristics of A&E nurses, KNH.

Frequency Percent (%)

(n)
Gender
Female 41 60.3
Male 27 39.7
Age
20-29 years 3 4.4
30-39 years 48 70.6
40-49 years 15 22.1
50 years and above 2 2.9
Level of Education
Certificate 5 7.4
Diploma 30 44.1
Higher diploma 23 33.8
Degree 10 14.7

The mean age of participants was 36.8 years and standard deviation (SD) of participants (SD 5.6)

with a range of 25 to 53 years. Majority 48 (70.6%) of participants were aged between 30 to 39

years. Fifteen (22.1%) of the nurses were in the age group 40 to 49 years. The five remaining

participants were either aged below 30 years or above 50 years. Thirty (44.1%) of the nurses held

25
diploma nursing qualifications, 23 (33.8%) had higher diplomas, 10 (14.7%) had degree and 5

(7.4%) had certificates in nursing.

The average number of years (SD) since qualification was 11.9 years (SD 5.7 years). The

recently qualified nurse had attained nursing qualifications three years prior to the time of study

while the earliest qualified 30 years ago.

4.1.1. Accident and emergency trainings

Figure 4.1 below presents available accident and emergency training courses that nurses in this

study had attended. Majority (95.6% (65 out of 68) of the nurses had attended one of the A&E

courses. The most commonly attended A&E course was basic life support training (BLS)

attended by 52 (76.5%) of participants. Forty one (61.2%)) nurses had been trained in advance

cardiac life support (ACLS), 17 (25%) in accident and emergency nursing.

Figure 4.1. Training in different accident and emergency courses among nurses at AED,

KNH.

Table 4.2 below shows that 29 (42.7%) of nurses had been formally trained in management of

acute poisoning after their basic nursing qualifications.

26
Table 4.2. Accident and emergency experience and post qualification trainings among A&E

nurses, KNH.

Frequency (n) Percent (%)

Accident and emergency experience
0-4 years 40 58.8
5-9 years 16 23.5
10 years and above 12 17.7
Current training related to accident and
emergency
Yes 16 23.5
No 52 76.5
Formal training in management of acute
poisoning
Yes 29 42.7
No 39 57.3

4.2 General knowledge on poisoning

The general knowledge of nurses on poisoning was assessed using the 14 items. The item for

which nurses displayed the lowest knowledge level was the relationship between gender and

ingestion of poison in the general population. Only 35 (51.5%) of the nurses were aware that

women were more likely to take poison than men. Another question that was poorly scored was

the alimentary signs and symptoms of acute poisoning during early stages, most nurses could not

differentiate signs affecting gastrointestinal system and those affecting other body systems. Also

39 (57%) of nurses were not aware that poisoning can be classified as non accidental and 44

(64.7%) thought that there was a euthanasia poisoning.

27
Table 4.3. Nurses responses to items on general knowledge on poisoning

Knowledge on poisoning Response

Correct Incorrect
(%) (%)
Poison is any substance capable of producing damage or 61(89.7) 7(10.3)
dysfunction in the body by its chemical activity (T)
Dose ingested and time of ingestion are not very necessary 63(92.6) 5(7.4)
consideration when managing an adult poisoned patients (F)
As an A&E nurse it is always important to treat the poison not the 56(82.3) 12(17.7)
patient (F)
The commonest cause of poisoning in developing countries is 56(82.3) 12(17.7)
pesticide poisoning (T)
Women are more likely to take poison in the general population to 35(51.5) 33(48.5)
commit suicide than men (T)
Cause of poisoning among casualties attending any AED,
according to motive and nature of use, can be classified as:
Deliberate poisoning (T) 55(80.9) 13(19.1)
Accidental (T) 48(70.6) 20(29.4)
Homicidal poisoning (T) 48(70.6) 20(29.4)
Non accidental poisoning (T) 29(42.7) 39(57.3)
Euthanasia poisoning (F) 24(35.3) 44(64.7)
Alimentary signs and symptoms of acute poisoning during early
stages include:
Dry mouth, abdominal pain and salivation (T) 52(76.5) 16(23.5)
Nausea, vomiting, hallucination and convulsions (F) 13(19.1) 55(80.9)
Coughing, cyanosis, hyperventilation and salivation (F) 14(20.6) 54(79.4)
Tachycardia, hypotension, diarrhoea and breathlessness (F) 12(17.6) 56(82.4)

Based on responses to the 14 general knowledge items, a score (range 0 to 14) was calculated for

each nurse. The mean score out of 14 for the entire sample was 8.3 with SD of 2.3 and a range of

2 to 13.

Table 4.4 compares the mean general knowledge score for nurses according to nursing training

and length of A&E experience. Degree nurses had the highest mean score (9.0) on the general

28
knowledge of poisoning while the certificate nurses scored a mean of 8.0 representing the lowest

score. Similarly nurses with 5-9 years of A&E experience had a higher mean scores than those

with less or more than 10 years of experience.

Table 4.4: Nursing qualification and length of experience versus general knowledge on

poisoning among A&E nurse.

Number Mean (SD) Range ANOVA

(n)
Nursing qualification
Certificate 5 8.0 (2.4) 2-9 F = 0.43; p = 0.74
Diploma 30 8.1 (2.4) 2-13
Higher diploma 23 8.3 (2.4) 3-12
Degree 10 9.0 (1.7) 7-12
Accident and emergency
experience
0-4 years 40 8.0 (2.1) 3-12 F = 2.27; p = 0.11
5-9 years 16 9.4 (2.2) 5-13
10 years and above 12 8.0 (2.8) 2-12

Nursing trainings and poisoning knowledge was measured basing on 14 general knowledge

items. Table 4.5 below compares the mean general knowledge score for nurses according to

nursing trainings they had attended.

29
Table 4.5. Training on A&E related courses versus general knowledge on poisoning among

A&E nurses.

Number Mean (SD) Range P value; t-test

(n) Confidence
interval (CI)
<0.05
Formal training in management
of acute poisoning
Yes 29 8.5 (2.7) 2-12 p = 0.55
No 39 8.2 (2.0) 3-13
BLS Yes 52 8.5 (2.3) 2-13 p= 0.31
No 16 7.8 (2.2) 3-11
ACLS Yes 41 8.7 (2.1) 3-12 p= 0.14
No 27 7.8 (2.6) 2-13
ATLS Yes 13 9.1 (9.1) 5-12 p=0.19
No 55 8.2 (2.4) 2-13
A&E Nursing Yes 17 8.4 (2.5) 3-12 p=0.95
No 51 8.3 (2.2) 2-13
CCN Yes 14 8.7 (2.1) 5-12 p=0.48
No 54 8.2 (2.4) 2-13

4.3 Initial management of acute poisoning practices among A&E

nurses.
Out of the 68 nurses included in the study, 13 (19.2%) gave the correct response to all the ten

questions on initial management of acute poisoning practices. The area in which nurses displayed

the least knowledge was in management of patients who had ingested controlled release

preparations with 40 (58.8%) of nurses recognizing that these patients may benefit from

decontamination even after a longer delay. Conversely, 64 (94.1%) of nurses rightly identified

that the priority in managing severe acute poisoning is maintaining adequate airway, breathing

and circulation.

30
Table 4.6. A&E nurses responses to items on initial management of poisoning practices

Initial management of acute poisoning Response

Correct Incorrect
(%) (%)
In severe acute poisoning, maintaining adequate airway, respiration 64(94.1) 4(5.9)
and circulation is always a priority (T)
In case of organophosphate poisoning atropine should not be 59(86.8) 9(13.2)
administered in any circumstances (F)
Nearly all poisoning encountered in A& E have their specific antidote 40(58.8) 28(41.2)
(F)
The decision to perform Gastro Intestinal (GI) decontamination should 60(88.2) 8(11.8)
be based upon the specific poison(s) ingested, time from ingestion to
presentation, and the presenting and predicted severity of poisoning
(T)
Emesis is to be considered in an alert, conscious patient who has 38(55.9) 30(44.1)
ingested a substantial amount of a toxic substance within 60 minutes
of presentation (T)
Activated charcoal can increase absorption of a wide range of poisons 48(70.6) 20(29.4)
from the gastro-intestinal tract to the entire human system (F)
Gastric lavage is indicated in patients who have ingested kerosene or 47(69.1) 21(30.9)
corrosive substances within an hour of presentation (F)
The efficacy of gastric lavage increases as the time between ingestion 52(76.5) 16(23.5)
and treatment increases (F)
The volume of lavage fluid returned should approximate to the 50(73.5) 18(26.5)
amount of fluid given (T)
Patients presenting following ingestion of controlled release 40(58.8) 28(41.2)
preparations may benefit from decontamination even after a longer
delay (e.g. more than 2-4 hours) (T)

Based on the responses to the 10 items on initial management of acute poisoning, a score (range

0-10) was calculated for each nurse. The mean score for all nurses in the study was 7.3 (SD 1.5),

range 3 to10.

31
Table 4.7 below summarizes the knowledge of nurses on the initial management of acute

poisoning according to nursing trainings, attendance of formal courses on the management of

poisoning and length of experience in A&E.

Table 4.7. A&E nurses professional qualification and length of experience versus

knowledge on initial management of acute poisoning practices.

Number Mean (SD) Range ANOVA

(n)
Nursing qualification
Certificate 5 7.2 (1.3) 6-9 F = 0.29; p = 0.97
Diploma 30 7.3 (1.5) 4-10
Higher diploma 23 7.4 (1.6) 3-10
Degree 10 7.4 (1.5) 5-9
Accident and emergency
experience
0-4 years 40 7.1 (1.4) 3-9 F = 1.10; p = 0.35
5-9 years 16 7.7 (1.7) 5-10
10 years and above 12 7.5 (1.6) 4-9

There was very little variation in nurses‟ knowledge on the initial management of acute

poisoning. The mean scores for acute poisoning knowledge ranged from 7.2 among certificate

nurses to 7.4 for higher diploma and degree nurses (F = 0.09; p = 0.97). Nurses with 0 to 4 years

accident and emergency experience scored 7.1 (SD 1.4), 5 to 9 years scored 7.7 (SD 1.7) while

those with experience over 10 years scored 7.5 (SD 1.6).

32
Table 4.8. A&E related trainings courses versus knowledge on the initial management of

acute poisoning practices among A&E nurses.

Number Mean (SD) Range P value; t-test

CI <0.05
Formal training in management
of acute poisoning
Yes 29 7.4 (1.4) 4-10 0.83
No 39 7.2 (1.7) 2-10
BLS Yes 52 7.4 (1.6) 3-10 0.33
No 16 7.0 (1.4) 4-9
ACLS Yes 41 7.1 (1.6) 3-10 0.59
No 27 7.2 (1.5) 4-9
ATLS Yes 13 7.2 (1.5) 5-10 0.65
No 55 7.4 (1.5) 3-10
A & E Nursing Yes 17 7.6 (1.4) 5-10 0.31
No 51 7.2 (1.6) 3-10
CCN Yes 14 7.1 (1.6) 3-9 0.62
No 54 7.4 (1.5) 4-10

As shown in Table 4.8 above there was variation in those who had done specific courses with

those who had not done. Nurses who had done formal training on poisoning, BLS and accident

and emergency nursing scored higher mean score than those who had not done.

4.4 Self reported nursing practice of A&E nurses

Out of the 68 interviewed nurses only 9 (13.2%) reported that they felt insecure dealing with

poisoned casualties because they lack necessary skills and confidence (Figure 4.2) below. Thirty

two (64.7%) of nurses however indicated that, though they were confident in their ability they

required the presence of a staff member trained or experienced in poison management while

responding to poison related emergencies in AED.

33
 80
65(95.6) 67(98.5)
Number (%) of nurses 70
56(82.4)
60(88.2)
60
50 44(64.7)
40 32(47.1)
30
20 9(13.2)
10
0
Inadequate Require Guideline Professional Need training Guideline Improve
skills chaperon availability skills necessity identification
and
management
of casualties

Nurses Practices self report

Figure 4.2. Self reported nursing practices among nurses at AED, KNH

Fifty six (82.4%) of nurses felt that they had professional skills to handle patients with acute

poisoning but 60 (88.2%) still indicated that they required more training in initial management of

poisoning. Sixty five (95.6%) nurses indicated that guidelines on management of poisoning in

the AED were necessary. Concerning triage of poisoning casualties 67 (98.5%) nurses felt that it

was necessary to develop procedures for improving the identification and management of acute

poisoning of patients attending AED, KNH.

120

100
Number of Nurses (%)

80

60

40

20

0
Degree Higher Diploma Diploma Certificate

Nursing qualification

Figure 4.3. Need for poisoning trainings among A&E nurses.

34
As shown in figure 4.3 above, all certificate nurses indicated that they needed further training on

the management of acute poisoning , eight (80%) degree nurses, twenty (91%) diploma nurses

and twenty seven (92.5%) higher diploma indicated that they needed more training on

management of poisoning.

4.5 Perception towards patients presenting with acute poisoning

The responses to 12 items on perception of nurses towards patients presenting with acute

poisoning were obtained on a five-point Likert scale presented in Table 4.9 below. The item with

the highest rate of strong agreement among nurses (76.5%) was that a person who has made

numerous suicide attempts by taking poison is at high risk of succeeding in the future and needs

help and understanding. On the other hand, the item that most nurses (67.7%) disagreed with

strongly was that once a person takes poison, he is suicidal forever and staff can do nothing

about it.

35
Table 4.9. A&E nurse’s perceptions towards patients presenting with acute poisoning

Key: SA A U D SD
SA- Strongly agree, A- Agree, U-Undecided, D- Disagree, (%) (%) (%) (%) (%)
SD- Strongly disagree
Patients presenting with poisoning occupy more staff 19.1 30.9 2.9 33.8 13.2
time, so staff are unavailable to patients who are in
greater need of help
Sometime I fell nervous and uncomfortable when I have 14.7 20.6 5.9 33.8 22.1
to care for a poisoned patient especially those with
deliberate poisoning
A person who has made numerous suicide attempts by 76.5 14.7 1.5 1.5 5.9
taking poison is at high risk of succeeding in the future
and needs help and understanding
I am happy to care for poisoned patients and I feel the 33.8 45.6 8.8 5.8 5.8
same sympathy as I care for other patients in accident
and emergency department
It is frustrating to treat patients who have taken poison 17.7 38.2 5.9 20.6 17.7
each time they present themselves in casualty.
Hospitalized intentional poisoned patients will make 14.7 19.1 11.8 45.6 8.8
future attempts regardless of how supportive health care
professionals were to them.
Patients presenting with poisoning must be treated using 11.8 26.5 13.2 32.4 14.7
“strict” methods to curb the practice
Empathy demonstrated by the health professional may 32.4 33.8 4.4 22.1 7.4
positively influence patients who have intentionally
taken poison to reconsider future poison attempt
Poisoned patients are not responsible for their actions 32.4 30.8 13.2 19.2 4.4
but are victims of their environment and they need
understanding and utmost care.
Honestly, I prefer not to get involved with patients who 5.9 2.9 1.5 45.6 42.7
have taken any form of poisoned , irrespective of the
intention and cause
Nurses consider it less important to treat self poisoning 5.9 16.2 7.4 35.2 35.2
patients compared to accidental poisoning whom they
can give more attention to.
Once a person takes poison, he is suicidal forever. Staff 2.9 1.5 1.5 26.5 67.7
can do nothing about it.

36
4.5.1 Overall attitude of A&E nurses towards poisoned patients
On a scale ranging from 12 to 60 with higher scores representing positive attitude the nurses in

this sample scored a mean of 42.1 (SD 6.7) representing a generally positive attitude on

management of acute poisoning. The attitude score had a range from 21 to 57. The comparison

of attitude scores among nurses according to their nursing professional qualification, A&E

experience, age group, gender and attendance of formal course on management of acute

poisoning is presented in Table 4.10 below.

37
Table 4.10. Nursing qualification, length of experience, formal training on poisoning

management, age group and gender versus attitude of A&E nurses towards poisoned

patients.

Number Mean (SD) Range ANOVA

(n)
Nursing qualification
Certificate 5 44.4(6.0) 36-52 F = 1.05; p = 0.38
Diploma 30 44.2 (7.1) 27-58
Higher diploma 23 43.6 (4.3) 33-52
Degree 10 40.5 (7.5) 21-46
Accident and emergency
experience
0-4 years 40 41.9 (6.8) 21-57 F = 0.09; p = 0.91
5-9 years 16 42.1 (4.8) 35-54
10 years and above 12 42.8 (8.5) 27-56
Formal training in management
of acute poisoning
Yes 29 43.2 (4.9) 34-56 F = 1.31; p = 0.26
No 39 41.3 (7.7) 21-57
Age group
20-29 years 3 41 (4.6) 36-45 F = 0.09; p = 0.91
30-39 years 48 42 (6.8) 21-57
40-49 years 15 43.7 (6.1) 36-54
50 years and above 2 35 (11.3) 27-43
Gender
Male 27 42.07(5.7) 27-56 F = 0.001; p=0.98
Female 41 42.12(7.3) 21-57

As tabulated in table 4.10 above, the results were not statistically significant, however, the mean

scores for various cadres varied. Degree nurses had the least mean attitude score compared to

certificate nurses. Mean score for attitude increases with accident and emergency experience.

38
Female nurses scored slightly higher positive mean scores than men. Positive attitude for age

group increases until certain limit, training on poisoning management increases mean positive

attitude score.

4.6 Competency of A&E nurses on the management of acute

poisoning
The emergency management of fifteen poisoned casualties attended at KNH by different teams

of A&E nurses was observed. The essence was to observe and document the actual nursing

practices during this initial management of acute poisoning. The findings of the observations was

conducted using structured checklists are presented in this section.

a) Airway

The team of nurses checked for the level of consciousness and airway patency in all the fifteen

patients as shown in Figure 4.4. Intubation was not required in 7 out of the 15 patients, and

pharyngeal airway, regular suctioning and checking gag reflex were also not always necessary.

It was observed that nursing teams commonly failed to assist with inserting pharyngeal airways,

intubation, performing regular suctioning and checking gag reflex.

14
Number of patients

12
10
8
6
4
2
0 Done
Not done
Not necessary

Observation of Airway Checklist

Figure 4.4: Observation of airway management on poisoned patients at AED, KNH.

39
b) Breathing

Oxygen therapy was not necessary in 8 patients and was not given in three of the patients who

required it (Figure 4.5), but after my interventions the three patients were given oxygen. At least

2 patients did not have their normal breathing checked which included the rate and rhythm.

Respiratory distress was also not recognized in two patients.

14
12
Number of patients

10
8
6
Done
4
Not done
2
0 Not necessary
Rate and rhythm Recognition of Recognise Oxygen
normal breathing distressed therapy, given
Breathing
Observation of respiration Checklist

Figure 4.5: Management of breathing on acute poisoned patients at AED, KNH.

c) Circulation

The circulation system of poisoned patients were generally well managed (Figure 4.6). Blood

pressure was checked in all 15 patients. The following was not done in one patient only,

checking of pulse and rhythm and recognition of cardiovascular system. There was no obvious

bleeding in 11 patients and such bleeding was stopped in half of cases with the bleeding (n = 2).

40
 16
14
Number of Patients 12
10
8
6 Done
4 Not done
2
Not necessary
0
Pulse rate Blood Recognise CVS Fluids given Stop
and rhythm pressure CVS signs monitoring obvious
bleeding

Observation of Circulation Checklist

Figure 4.6: Management of circulation in 15 patients presenting with acute poisoning

d) Neurological status

Neurological assessment using Alert, Verbal, Pain and Unresponsive (AVPU) scale and Glasgow

Coma Scale (GCS) was done in all the 15 patients. Altered level of Consciousness (LOC) was

recognized in 11 patients.

e) Drugs

Drugs were administered to eight out of the 15 patients. Five out of the eight patients received at

least two drugs and three received only one drug. Four patients received normal saline, seven

receive 5% dextrose solution; two received both 5% dextrose and normal saline. Two were not

given any fluid therapy.

f) Medical history

During the history taking it was established that 9 patients had suffered from organophosphate

poisoning, 2 food poisoning, 3 hydrocarbons poisoning and one unknown poison. In two cases

the dose or amount of poison ingested was indicated in the medical history. Time of ingestion

was specified in 12 out of the 15 cases. 12 patients had intent of committing suicide, three were

accidental. Five patients had been treated before presenting to AED, KNH and 10 had not

41
received any treatment. Casualties presenting signs and symptoms of acute poisoning were rarely

noted down by A&E nurses.

g) Gut decontamination

Gut decontamination was done in six patients who underwent gastric lavage. All the six patients

were cases of organophosphate poisoning and had ingested the poison within the last 1 to 4 hours

except one whose time of ingestion was not indicated. Emesis was induced in one patient.

4.7 Interview with Nursing Officer in Charge AED, KNH.

Nurse in charge of AED was interviewed and several issues were raised; there was acute

shortage of nurses at AED. This increase the workload of the nurses who were sometimes forced

to work extra hard to meet all the patients needs and demands.

A&E nurses are sometimes faced with both internal and external challenges. Internal challenges

faced by nurses during this initial management of acute poisoning include, shortage of specific

antidotes, shortage of staff, shortage of supportive drugs. External challenges faced by nurse‟s

range from hostile patients, hostile relatives, uncooperative patients and relatives. Sometimes

A&E nurses receive conflicting medical history of the poisoned casualties and some vital

information‟s are withheld from them by the accompanying persons, this makes the management

of this casualties complicated.

Courses, seminars and trainings revolving around management of poisoning for A&E staff are

very minimal. Flowcharts from National Poison Control Centre are available at AED, but they

are designed specifically for management of organophosphate poisoning. AED have not design

their own flowchart for easy identification and management of the various types of poisoning.

42
CHAPTER FIVE: DISCUSSION

5.1 Introduction
The aim of the study was to determine nurse‟s knowledge, attitude and practice on the initial

management of acute poisoning among adult casualties seen at AED, KNH.

5.2 KAP of A&E on the initial Management of Poisoning.

The mean general knowledge score for nurses according to their professional qualifications,

trainings on courses related to emergency care and A&E experience was measured. Those nurses

with higher qualifications had higher mean scores than the ones with lower professional

qualifications. Further, those who had done courses or trainings related to emergency care like

BLS, ACLS, ATLS, A&E nursing and CCN scored higher than those who had not done these

courses. A&E nurses who had done formal training on the management of poisoning had a

higher mean score (8.5) than those without the training (8.2). A Study done by Turnbull and

Chalder (1997) showed that after implementation of a teaching package on poisoning, the

general knowledge of staff improved while attitudes did not become more favorable.

A&E nurses with experience of 5-9 years had higher mean score than those with experience

below 5 years and above 10 years. It is evident from the study that with any form of nursing

training and substantial years of experience, knowledge of nurses on poisoning increased. This is

consistent with Benner (1982) who introduced the concept that nurses develop skills and

understanding of patient care over time through a sound educational base as well as a multitude

of experiences. Study results indicated that 60 (88.2%) of A&E nurses needed training on the

management of poisoning.

The mean knowledge score of A&E nurses on initial management of poisoning practices were

measured. A&E nurses with degree and higher diploma qualification scored higher than those

43
with diploma and certificate qualification. A&E nurses who had had formal training on

poisoning, BLS and had specialization in A&E nursing had higher mean scores than those who

had not done. It was further found that A&E nurses who had done ACLS, ATLS and CCN had

lower mean score than nurses who had not done the same.

The area in which nurses displayed the least knowledge was in management of patients who had

ingested controlled release preparations with 40 (58.8%) of nurses recognizing that these patients

may benefit from decontamination even after a longer delay. The main characteristic of

poisoning with controlled release formulations is the delay in presentation and onset of clinical

effects. There is a prolonged absorption phase, which leads to delay time to maximum plasma

concentration. Absorption may continue for more than 24 hours (Buckley et al., 1995).

The results of the study demonstrate that A&E nurses held positive attitudes towards individuals

presenting with acute poisoning, corresponding with the findings of earlier studies (McLaughlin,

1994; Anderson, 1997; McCann et al., 2006; Sun et al., 2007; and McCarthy and Gijbels., 2010).

However, a third (35.3%) of nurses reported that they sometimes felt nervous and uncomfortable

when caring for a poisoned patient especially those with deliberate poisoning. Over half of the

A&E nurses agree that it is frustrating to treat patients who have taken poison and around 40% of

the participants are for the opinion that they should be treated using „strict‟ method to curb the

practice. Study findings contradicted earlier studies by McAllister (2002) and Onzoni and

Nakakasi (2009) who found that nurses held negative attitude towards suicidal casualties.

From the study it was found out that attitude of A&E nurses decreased with higher level of

education. Certificate nurses had more positive attitude than degree nurses. This was consistent

with the findings of Alston and Robinson (1992) cited in Anderson (1997) who reported that

broader educational exposure often prompted nurses from different specialties to question issues

44
around the subject of deliberate poisoning. The results were contrary to the findings of Sun et al

(2007), who discovered that the higher the level of nursing education, the more positive the

nurses‟ attitudes were.

Study findings indicated that the mean positive attitude of A&E nurses increased with years of

experience, age and poisoning related courses. The findings are consistent with those of earlier

studies (McCann, 2006; McLaughlin, 1994) who reported that older and more experienced

nurses had more supportive attitudes than younger and less experienced nurses. They further

reported that nurses who had attended in-service education on deliberate poisoning had more

positive attitudes than non-attendees. The results contradict McCarthy and Gijbels‟s (2010)

findings who reported that there was no correlation between total scores and gender, ED

experience, or a history of self-harm education, although older nurses and hospital trained nurses

had less positive attitudes. Age and length of clinical experience produced a trend in which

attitudes increased, reached a peak and then declined.

It was observed that teams of A&E nurses managing poisoned casualties from time to time failed

to assess, make diagnosis, plan, intervene and evaluate appropriately. Further, it was found that

A&E nurses occasionally failed to check patient respiration rate and rhythm, pulse rate and to

recognize distressed patients. History taking was done well by team of nurses except on two

areas: - nurses were not very keen on noting down the dosage of poison the patients had taken as

well as not paying attention to any signs and symptoms presenting at that given time. It was

noted that most A&E nurses could not differentiate between alimentary signs and symptoms of

acute poisoning and those that affect other body systems.

Gastric lavage was the most preferred way of gut decontamination for patients who had taken

poison within 1- 4 hours of ingestion. Most (60; 88.2%) A&E nurses were aware that the

45
decision to perform Gastro Intestinal (GI) decontamination should be based on the specific

poison(s) ingested, time from ingestion to presentation and the presenting and predicted severity

of poisoning. According to American Academy of Clinical Toxicology and the European

Association of Poison Centers (1997), gastric lavage is of benefit and is acceptable if a patient

has ingested a potentially toxic amount of substance and the procedure is performed within one

hour of ingestion. From the study results, 21 (30.9%) of A&E nurses concurred that lavage can

be performed on patients who have taken kerosene or any other corrosive substance. Sixteen

(23.5%) of A&E nurses were of the idea that the effectiveness of gastric lavage increased as time

from ingestion elapses; demonstrating ignorance about the efficacy and benefits of this

procedure.

Although there is variation in KAP mean scores for A&E nurses as per their education level, this

variation was not statistically significant. The P-value for study variable were; Knowledge

(p=0.74), Attitude (p=0.38) and Practice (p=0.97) where the level of statistical significance is

p<0.05.We therefore accept our null hypothesis that there is no difference in the initial

management of acute poisoning among nurses of different education levels.

Although the KAP mean scores for A&E nurses increases with years of experience, this increase

was not statistically significant. The P-value for study variable were; Knowledge (p=0.11),

Attitude (p=0.91) and Practice (p=0.35) where the level of statistical significance is p<0.05. On

that note, we accept our null hypothesis that, experience in accident and emergency nursing is

not a factor in the initial management of acute poisoning.

46
5.3 Conclusion
The study revealed that social demographic characteristic of A&E nurses such as education level,

gender, age, length of ED experience and course trainings impacted the initial management of

acute poisoning in diverse ways. Higher level of nursing education, A&E experience, training on

courses related to emergency care enhanced the knowledge and practice of A&E nurses on the

initial management of poisoning.

A&E nurses, overall, held positive attitudes towards individuals presenting with acute

poisoning. Those with lower nursing qualifications were more positive than those with higher

qualifications. Positive attitude increases with age, A&E experience, training on courses related

to poisoning.

5.4 Recommendations

 It is acknowledged that the study was situated in one ED and utilized a convenience

sample of A&E nurses, thereby limiting the ability to generalize the findings beyond the

current study. A similar study, within Kenya referral centres/ Provincial hospitals is

recommended.

 A&E nurses should be trained on various types of poisoning including assessment, their

clinical presentations and management. In addition, refresher courses are required in

order to maintain the positive changes with regard to the nurses‟ confidence, knowledge

and attitudes.

 Although A&E nurses‟ attitudes were on the whole positive, variations and differences

between some of the variables merit further investigation.

47
 Flowcharts that will enhance easy identification and management of poisoned casualties

should be set and utilized. Such guidelines will improve identifications and management

of these casualties.

 A&E nurses should be trained on different types of gut decontamination focusing on the

type, efficacies, indications, contraindications and complications. They are obligated to

choose the best gut decontamination that is evidence based and best suited for a specific

patient.

48
WORK PLAN IN GANTT CHART

Month Nov Dec Jan Feb Mar Apr May June July- Sep -
2010 2011 Aug Nov
Activity

Concept paper

Proposal writing
and literature
review

Forwarding of
proposal for
approval to
KNH-ERC
Correction of
final proposal
and forwarding
to KNH-ERC
Training of
research
assistants and
pre- testing
questionnaires
Data collection

Data processing
and analysis
Report writing

Draft report
presentation and
correction

49
Final report
presentation and
submission
Thesis Defence

50
BUDGET

COMPO- ACTIVITY ITEM UNIT OF UNIT COST TOTAL

NENT DESCRIPTION MEASUREME (KSH) (KSH)
NT
Literature Search for Transport and 15 days @300 4,500
review literature in subsistence
libraries
Internet services Browsing for 5 hours 40 days @200 8,000
in cyber cafe
Stationeries A 4 notebook 4 @100 400

Foolscaps 2 reams @250 500

Photocopy papers 2 reams @450 900

Proposal typing 4 drafts @400 1600

Proposal printing 4 drafts @400 1600

Photocopying 200 pages @3 600

Approvals KNH ethics committee 1,000
Ministry of Science 1,000
and technology
Sub -total 20,100

Research Pre-testing Transport and 1 day 300×3 persons 900

subsistence
Typing, Printing 20 copies @40 800

Questionnaires Photocopying 400 copies @3 1200

Data Collection Transport and 30 days 300× 3 persons 27,500

subsistence
2 research assistance 30 days @400 12,000
allowance
Data processing 20,000
and analysis
Sub –total 62,400
Reports Draft reports Typing, printing 200 @20 4,000

51
 Photocopying 5 copies @400 2,000

Final reports Correction and 200 pages @ 10 2,000

printing
photocopying 5 copies @ 400 2,000
Binding 5 copies @ 500 2,500
Sub total 97,000
Contingencies 10% 9700
Grand 106,700
total

52
REFERENCES.

Ahmad, M., Rahman, F.N., Ashrafuzzaman, M., Chowdhury, D.K., Ali, M. (2009).

Overview of organophosphorus compound poisoning in Bangladesh and medico legal

aspects related to fatal cases. JAFMC Bangladesh. June, 5(1).

American Academy of Clinical Toxicology, European Association of Poisons Centres and

Clinical Toxicologists. Position statement: Gastric Lavage. Journal of Toxicology Clin

Toxicol 1997; 35:711.

Anderson, M., (1997). Nurses attitude towards suicidal behaviour- A comparative study of

Community health nurses and nurses working in an accident and emergency department.

Journal of Advanced Nursing. 25, 1283- 1291.

Basavanthappa, B.T., (2007). Nursing Research. 2nd ed. New Delhi: Jaypee Brothers

Publishers.

Benner, P., (1984). From novice to expert: Excellence and Power in Clinical Nursing

Practice. California: Addison-Wesley publishers.

Buckley, N.A., Dawson, A. H., Reith D. A., (1995). Controlled release drugs in overdose,

clinical considerations. Drug Safety 12(1); 73-84.

Burns, J. M., and Schwartzstein, M., (1999). Decontamination of poisoned patients.

Carroll, L., (2007). Acute Medicine: A Handbook for Nurse Practitioners. West Suxxes:

John Wiley and Sons Publication.

53
Chen, F., Wen, J.P., Wang,X.P., Lin,Q.M., Lin, C.J., (2010). Epidemiology and

characteristics of acute poisoning treated at an emergency center. World Journal of

Emergency Medicine. 1(2), 154-156.

Chung, J.Y.M., Chan J. T. S., Yeung R.S.D., Wan, R.C.H., (2003) Nurses' attitude toward

alcoholic patients in accident and emergency department in Hong Kong. Hong Kong

Journal of Emergency Medicine. 10,104-112.

Clegg, T., and Hope K., (1999). The first line of response for people who self-poison:

exploring the options for gut decontamination Journal of Advanced Nursing. 30(6), 1360-

1367.

Daly, F.S., Little, M., and Murray, L., (2006). A risk assessment based approach to the

management of acute poisoning. Journal of Emergency Medicine. 23, 396-399.

Daly, J. et al., (2005). Professional Nursing; Concepts, Issues, and Challenges. Springer

Publishing Company: New York.

Eddleston, M., Dawson, A., Karalliedde, L., Dissanayake, W., Hittarage, A., Shifa Azhe,

S., Buckley, N.K., (2004). Early management after self-poisoning with an

organophosphorus or carbamate pesticide – a treatment protocol for junior doctors.Critical

Care, 8:391-397.

Eddleston, M., Sheriff, M.H., Hawton, K., (1998). Deliberate self harm in Sri Lanka: An

overlooked tragedy in the developing world. British Medical Journal. 317(7151), 133-135.

54
Epidemiologic Assessment of Acute Poisoning In Developing Countries. Report of an

International Development Research Centre/International Program for Chemical Safety

Scientific Group, Manuscript Report 219e. 1989.

Fernando, R., (2007). Management of Poisoning. 3rd ed. Colombo: The National Poisons

Information Centre National Hospital of Sri Lanka.

Greaves, I., Graham, J., (2002). Practical Emergency Medicine. New York: Oxford

University Press.

Greene S.L., Wood, D.M., Gawaramanna, I.B., Gash, W.C., Drakes, N., Jones, A.L.,

Dargan, P.I (2008). Improvement in the management of acutely poisoned patients using an

electronic database: Prospective audit and targeted educational intervention. Postgraduate

Medical Journal. 84,603-608.

Greene, S.L, Dargan, P.I, Jones, A.L., (2005). Acute poisoning: understanding 90% of cases

in a nutshell. Postgraduate Medical Journal. 81,204-216.

Hesook, S.K., and Ingrid, K., (2006). Nursing Theories: Conceptual Philosophical. 2nd ed.

New York: Springer Publishing Company.

Hodgson, E., (2010). Textbook of Modern Toxicology. 4th ed. New Jersey: A John Wiley &

Sons Publication.

Israel, D., Glenn J., (2003). Determining Sample Size. Florida: University Florida.

55
Konradsen, F., (2007). Acute pesticide poisoning - A global public health problem. Danish

Medical Bulletin.54 (1), 58-59.

Lamb, S., Arensman, E., and Mullally, B., (2006). Accident & emergency nursing

assessment of deliberate self harm. Ireland: National Suicide Research Foundation.

Lau, F.L., (2000). Emergency management of poisoning in Hong Kong. Hong Kong Journal

of Emergency Medicine.6, 288-92.

Lin, H.W., Chou, H.L., (2007). Nursing care for an organophosphate poisoning suicidal

woman, Hu Li Za Zhi Journal. 54(5), 104-10.

Malangu, N., (2008). Characteristics of acute poisoning at two referral hospitals in

Francistown and Gaborone. SA Fam Prac. 50(3), 67-68.

Malangu, N., Ogunbanjo G.A., (2009). A profile of acute poisoning at selected hospitals in

South Africa. South Africa Journal of Epidemiology. 24(2),14-16.

McAllister, M., Creedy, D., Moyle, W., Farrugia, C.,, (2002). Nurses‟ attitudes towards

clients who self-harm. Journal of Advanced Nursing. 40(5), 578–586.

McCann, T., Clark, E., McConachie, S., Harvey, I., (2006). Accident and emergency

nurses‟ attitudes towards patients who self-harm. Accident and Emergency Nursing 14, 4–10

McCarthy, L., Gijbels, H., (2010). An examination of emergency department nurses‟

attitudes towards deliberates self-harm in an Irish teaching hospital. International

Emergency Nursing. 18, 29– 35.

56
McLaughlin C., (1994). Casualty nurses' attitudes to attempted suicide. Journal of Advance

Nursing. 20(6):1111-8.

Möller, L., Karolinska, I., (2005). Environmental Medicine. 3rd ed. London: Harvard

university press.

Oslon, R.K., (2004). Poisoning and Drug Overdose. 4th ed. New York: Medical Publishing

Division.

Ouzouni, C., Nakakis, K. (2009). Attitudes towards attempted suicide: the development of a

measurement tool. Health Science Journal. 3(4), 222-231

Proudfoot, A., (1982). Diagnosis and Management of Acute Poisoning. London: Blackwell

scientific publication.

Senarathna, L., Jon, A., Dhammika D.S., Buckley, N., Dawson, A., (2008). Personal and

professional challenges in the management of deliberate self-poisoning patients in rural Sri

Lanka: a qualitative study of rural hospital doctors' experiences and perceptions. British

Medical Journal of Public Health. 8,373.

Sharma B. R., Bangar S., (2005). Management of common poisoning: Changing trends &

challenges. IIJFMT 3(1).

Sheila, A., Odell M., Welch J., (2010). Rapid Assessment of the Acutely ill Patient. United

Kingdom: Blackwell Publishing.

Singapore MOH, (2004). Management of drug overdose and poisoning: Based on clinical

practice guideline 2 of 2000. Singapore: Ministry of Health Publishers.

57
Sun, F.K., Long A., Boore, J., (2007). The attitudes of casualty nurses in Taiwan to patients

who have attempted suicide. Journal of Clinical Nursing.16, 255-263.

Turnbull, G., Chalde, T., (1997). Effects of education on attitudes to deliberate self-harm.

Psychiatric Bulletin 21:334-335.

United Kingdom, (2004). National Institute for Clinical Excellence (NICE).Clinical

guideline 16.London: National Institute for Clinical Excellence Publishers.

Unnikrishnan, B., Singh., Rajeev., (2005). Trends of acute poisoning in south Karnataka.

Kathmandu University Medical Journal. Vol. 3, No. 2(10), 149-154.

WHO Management of Poisoning: A handbook for health care workers.

Wong, T.W., Lau, C.C., Yong, B.H., IKS Tan I.K., JHB Konget, J.H.B., (2000). Knowledge

base of doctors and nurses participating in a trauma workshop. Hong Kong Journal of

Emergency Medicine. 7,81-84.

Wood, I., Rhode, M., (2003). Medical Assessment Units: The Initial Management of Acute

Medical Patients. London: Whurr Publishers Ltd.

58
APPENDICES
Appendix I: Consent Explanation

I am Japheth Kipkosgei Rutto a second year postgraduate student at the University of Nairobi,

College of Health Sciences pursuing a Masters degree in Critical Care Nursing.

Dear participant

I intend to carry out a study on “The initial nursing management of acute poisoning among

adult casualties seen at accident and emergency department at Kenyatta National Hospital” as

part of my course requirement. The study seeks to evaluate nurses‟ skills, knowledge and attitude

on the initial management of acute poisoning among adult casualties seen at accident and

emergency department, KNH. The study has no any material or monetary benefits.

Your participation is on voluntary basis and will not result in any physical or psychological

harm. You will have the right to withdraw at any time without any penalty. We will require you

to fill a questionnaire which will take about 30 minutes and you will be guided through. You are

free to ask any question about the study any time. Study findings will be used to develop

strategies on how to improve poisoning management and service quality.

The information you provide will be kept confidential and anonymous, and on that note, you will

not write any of your personal particulars. Your participation will be highly appreciated

In case of any questions or clarifications feel free to contact the principal investigator on mobile

number 0721-747895 or contact the Secretary to the KNH/UON- ERC at 2726300 Ext 44102.

Thank you

Japheth K Rutto (Principal investigator)

59
Appendix II: Informed Consent

I have read the consent explanation and understood its content. I have been given opportunity to

discuss all my concerns with the investigator. I do therefore agree voluntarily to participate in the

study on “The initial nursing management of acute poisoning among adult casualties seen at

accident and emergency department at Kenyatta National Hospital”.

Signature of participant __________________________________Date______________

Signature of researcher__________________________________ Date_______________

60
Appendix III: Research Questionnaires
Date__________________________

Directions: You are requested to fill this form about some of your demographic data. Please
answer every question if possible.

SECTION A: Social and Demographic Data

1. 1. Gender: Female 1. Male 2.

2. What is your age?

1. 20-29 yrs.

2. 30-39yrs

3. 40-49yrs

4. 50 > Yrs

3. Highest nursing education earned:

1. Certificate
2. Diploma
3. Higher diploma
4. Degree
5. Masters
6. Post-Masters
4. Number of years since you first qualified as a nurse: ____________
5. How many years of experience do you have in accident and emergency environment

1. < 2 years 4. 6-7 years

2. 2-3 years 5. 8-9 years

3. 4-5 years 6. >10 years

6. Have you done any of the following courses since you first qualified as a nurse:
1. BLS which year_____________

2. ACLS which year ____________

61
 3. ATLS which year ____________

4. Accident and emergency nursing which year______________

5. Critical care nursing(CCU) which year______________

6. Any other course relevant to your field? 1. Yes 2. No

If yes which course? _____________________

7. Is there any course you are currently pursuing related to your nursing field?
1. Yes
2. No

If yes which course? _____________________

8. Have you had any formal training on the management of acute poisoning since you first
qualified as a nurse?
1. Yes
2. No

SECTION B: General Knowledge on Poisoning

Direction: Indicate whether the following statements are True, False or you are Not Sure
regarding poisoning. Tick the correct response in the space provided.

No Question Statement True False Not

Sure

1. Poison is any substance capable of producing damage or

dysfunction in the body by its chemical activity.

2. Dose ingested and time of ingestion are not very necessary

consideration when managing poisoning cases in AED

3. As an A/E nurse it is always very important to treat the poison

not the patient

4. The commonest cause of poisoning in developing countries is

pesticide poisoning

5. Women are more likely to take deliberate poison in general

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 population to commit suicide than men.

6. Cause of poisoning among casualties attending any AED,

according to motive and nature of use, can be classified as:

i. Deliberate poisoning

ii. Accidental poisoning

iii. Homicidal poisoning

iv. Non accidental poisoning

v. Euthanasia poisoning

7. Alimentary signs and symptoms of acute poisoning during

early stages include ;

i. Dry mouth, abdominal pain and salivation

ii. Nausea, vomiting, hallucinations and convulsions

iii. Coughing, cyanosis, hyperventilation and salivation

iv. Tachycardia, hypotension, diarrhoea and breathlessness

SECTION C: Initial Management of Acute Poisoning Practices

When managing acute poisoned patient, indicate your management view if the following

statements are True, False or you are Unsure. Indicate the correct answer at the beginning of

each statement, T for true, F for False and US for Unsure

1. ______In severe acute poisoning, maintaining adequate airway, respiration and

circulation are always a priority.

2. ______ In case of organophosphate poisoning atropine should not be administered in any

circumstance.

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 3. ______ Nearly all poisoning encountered in accident and emergency department have
their specific antidote.

4. _____The decision to perform Gastrointestinal (GI) decontamination should be based

upon the specific poison(s) ingested, time from ingestion to presentation, and the
predicted severity of the poison.

5. _____Emesis is to be considered in an alert, conscious patient who has ingested a

substantial amount of a toxic substance within 60 minutes of presentation.

6. ______Activated charcoal can increase absorption of a wide range of poisons from the
gastro-intestinal tract to the entire human system.

7. ______Gastric lavage is indicated for patients who have ingested kerosene or corrosive
substances within an hour of presentation.

8. ______ The effectiveness of gastric lavage increases as the time between ingestion and
treatment increases.

9. ______ The volume of lavage fluid aspirated should approximate to the amount of fluid
given.

10. _____ Patients presenting following ingestion of controlled/ slow released substances
may benefit from decontamination even after a longer delay (e.g. more than 2-4 hours).

SECTION D: Nursing Practice Self Report

Instruction: Indicate by ticking the correct box either Yes or No

Nurses Practice Yes No

I have professional skills to handle patients with acute poisoning
1.

I feel insecure dealing with poison patient as I lack necessary skills and
2.
confidence
I need more training/education pertaining to the management of acute
3.
poisoned casualties.

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 While responding to poison related attendances in A&E, I require the
4.
presence of a staff member trained or experience in poison management
It is necessary to developing procedures for improving the identification
5.
and management of acute poisoning on casualties seen at A&E
department
Are there any guidelines or flowcharts in place at AED to assist you in
6.
management of poisoned casualties?
Are guidelines to A&E staff on the management of poisoning really
7.
necessary?

SECTION E: Perception/Attitude towards Patients Presenting With Acute

Poisoning.
Indicate to what extent you personally agree or disagree with the following questions/
statements using the five point likert scale
1. Strongly agree (SA)
2. Agree (A)
3. Neither agree or disagree i.e. Undecided (U)
4. Disagree (D)
5. Strongly disagree (SD)

No Question statement SA A U D SD
(5) (4) (3) (2) (1)

1. Patients presenting with poisoning occupy more staff time,

so staff are unavailable to patients who are in greater need
of help.
2. Sometime I feel nervous and uncomfortable when I have to
care for a poisoned patient especially those with deliberate
poisoning.

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3. A person who has made numerous suicide attempts by
taking poison is at high risk of succeeding in the future and
needs help and understanding
4. I am happy to care for poisoned patients and I feel the same
sympathy as I care for other patients in accident and
emergency department
5. It is frustrating to treat patients who have taken poison each
of the time they present themselves in casualty.
6. Hospitalized intentional poisoned patients will make future
attempts regardless of how supportive health care
professionals were to them.
7. Patients presenting with poisoning must be treated using
“strict” methods to curb the practice
8. Empathy demonstrated by the health professional may
positively influence patients who have intentionally taken
poison to reconsider future poison attempt
9. Poisoned patients are not responsible for their actions but
are victims of their environment and they need
understanding and utmost care.
10. Honestly, I prefer not to get involved with patients who
have taken any form of poison, irrespective of the intention
and cause

11. Nurses consider it less important to treat self poisoning

patients compared to accidental poisoning whom they can
give more attention to.

12. Once a person takes poison, he is suicidal forever. Staff can

do nothing about it.

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Appendix IV: Observation Checklist

OBSERVATION CHECKLIST ON THE MANAGEMENT OF POISONED PATIENT.

Indicate whether the following activities were done, not done or not necessary by ticking the

appropriate box. Provide comment on the performance if any,

Date______________________ Done Not Not Comment

Check list Done Applic (s)/

able Remarks
A Emergency Management

1.Airway
i. Check the patient level of consciousness
ii. Check airway patency
iii. Check gag reflex
iv. Assist in insertion of oro-pharyngeal or naso-
pharyngeal tube
v. Regular suctioning.
vi. Oral cavity inspected and any obvious
foreign bodies such as food or broken
dentures removed.

2. Breathing
i. Rate and rhythm of respiration
ii. Recognition of normal breathing patterns

iii. Recognition of compromised/Distressed

Breathing

iv. Oxygen therapy, given

3. Circulation

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 i. Checked pulse rate and rhythm
ii. Checked blood pressure
iii. Recognition of normal and abnormal
cardiovascular status

iv. Cardiovascular monitoring of any changes

v. Resuscitation fluids given

vi. Stop obvious bleeding

4. Neurological status ( use of AVPU and GCS)

i. Recognition of normal and abnormal

neurological status

ii. Neurological assessment and monitoring

iii. Recognition of altered LOC

5. Drugs

i. Given specific antidote ( Specify)

ii. Given any other drug ( Specify)
iii. Fluid therapy ( Specify)
Medical History: ascertain whether the following
B where noted during history taking; ( Specify where
necessary)
i. Type of drug or poison ingested
ii. Dosage and amount if available
iii. Time of ingestion
iv. Reason for taking the drug or poison
v. Any presence of suicide intent ( yes/no)
vi. Current symptoms noted (yes/ no)
vii. Any treatment received prior (yes/none)
viii. Past suicide attempts ( yes/ no)

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C Gut decontamination:
Indicate the gut decontamination used by ticking at Decontaminator Comment(s)
the appropriate box and give comment if used
appropriately used.
i. Gastric lavage
ii. Emesis
iii. Activated charcoal
iv. Whole bowel irrigation

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Appendix V: Interview Guides
Introduction to Nurse In- Charges/ Section Heads

I am a post graduate student pursing Critical Care Nursing. I am here to get more information on

how acute poisoning is managed at your department and the day to day challenges you are faced

with. Note that, Participation in the interview is completely voluntary and you are free to

withdraw any time. If you have any questions, you are welcome to ask me any time.

Thank you

Japheth Kipkosgei Rutto (Principal investigator)

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Nurses In- Charge Interview Guide

Probing questions

 How is the staffing in your department

 What are some of the challenges you face in the management of acute poisoning at AED

ie

 Challenges as nurses.

 Challenges from patients and relatives

 Do you have enough resources i.e. antidotes like atropine, pralidoxime etc, resuscitation

drugs, oxygen, IV fluids.

 Do you sometimes have seminars, courses, CME‟s for your staff on the management of

poisoning?

 Are there any flowcharts in place to assist staff in decision making regarding

management of various types of poisoning

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Appendix VI: Letter to KNH/UoN Ethics and Research Committee

Japheth Kipkosgei Rutto,

University of Nairobi,
School of Nursing Science

To,
The Chairperson,
KNH Ethics & Research Committee,
P.O. Box 20723-00202,
Nairobi.

Dear Sir/Madam,

RE: RESEARCH AUTHORISATION REQUEST

I am a second year postgraduate student pursuing Masters in Critical Care Nursing (MscN).
I am writing to request your permission to carry out research on “Nurses knowledge, attitude
and practice on the initial management of acute poisoning among adult casualties”. I am
planning to carry out the research at Accident and Emergency Department, KNH.

Your consideration will be highly appreciated and it will go a long way in facilitating my study
completion and also research findings will be utilized both locally and internationally in
provision of optimal patient care.

Thank you.
Yours faithfully

Japheth K Rutto

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Appendix VII: Letter to the Ministry of Education, Science and
Technology

Japheth Kipkosgei Rutto,

University of Nairobi,
School of Nursing Science

To,
The Chairperson,
The Ministry of Education, Science and Technology,
P.O. Box 30623-00100,
Nairobi.

Dear Sir/Madam,

RE: RESEARCH AUTHORISATION REQUEST

I am a second year postgraduate student pursuing Masters in Critical Care Nursing (MscN).
I am writing to request your permission to carry out research on “Nurses knowledge, attitude
and practice on the initial management of acute poisoning among adult casualties”. I am
planning to carry out the research at Accident and Emergency Department, KNH.

Your consideration will be highly appreciated and it will go a long way in facilitating my study
completion and also research findings will be utilized both locally and internationally in
provision of optimal patient care.

Thank you.
Yours faithfully

Japheth K Rutto

73
Appendix VIII: Letter from KNH/ UoN Ethics and Research
Committee.

74
Appendix IX: Letter from Ministry of Education, Science and
Technology

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