Assessment of knowledge and practice of oxygen therapy among doctors and nurses: A survey from Ondo State, Southwest Nigeria

INTRODUCTION

Oxygen is a component of ambient air at 21.00% concentration. It makes up about 65.00% of human body mass and essential to all tissues of the body for energy production. It is one of the essential drugs listed by the World Health Organization (WHO). Oxygen therapy is the administration of oxygen at concentrations greater than that in the ambient air with the intent of treating or preventing hypoxia. Oxygen therapy is very useful in managing acutely ill patient hence an essential and an emergency drug for adequate resuscitation.^[1]

As a drug, it has its own toxicity hence should be used only when indicated and must be prescribed. The prescription should include; dose, duration, method of delivery, device of delivery, defined target arterial oxygen saturation range (SaO₂), and monitoring process. Like other drugs order, oxygen order must be included in a treatment chart before administration.^[2-4]

The administration of supplemental oxygen is an essential element for appropriate management of many clinical conditions.

The previous studies have reported varying degree of gaps in knowledge and practice among health-care professionals regarding oxygen therapy.^[5-7] In a study carried out by Lemma,^[7] the level of knowledge of oxygen therapy was good in only about a third of 152 nurses.

There is paucity of local studies assessing the knowledge and practice of oxygen therapy among healthcare workers in Nigeria. Given that oxygen is a key element in the treatment of acutely unwell patients and its appropriate use or otherwise can affect patients’ outcome use, we set out to find out how much the doctors and nurses in our locality know and how well they practice regarding correct use of oxygen in line with globally acceptable standards.

MATERIAL AND METHODS

It was a descriptive cross-sectional study. We used the oxygen study group questionnaire which had been previously validated among doctors and nurses.^[2] It was a self-administered questionnaire. The sample size was calculated using the Leslie Kish formula for sample size determination for proportion with prevalence of 12.4% in a previously studied knowledge of oxygen indication.^[1] The degree of accuracy (precision) was set at 5% (0.05) and compensating for non-response rate was set at 30%, the calculated sample size required was 136.

Data were collected electronically using the Monkey survey application from consenting doctors and nurses. We used a convenient sampling method by forwarding the link of the questionnaire to the WhatsApp and Telegram pages of doctors and nurses in Ondo State, and South West Nigeria, respectively. We sent daily reminders for 2 months.

There were 252 doctors on the WhatsApp page of doctors of which 112 of them responded giving a response rate of 44% while there were 341 nurses on the Telegram page for nurses of which 64 responded giving a response rate of 19%.

The questionnaire included the educational background, awareness and use of oxygen therapy guidelines, knowledge of oxygen therapy, indication for acute oxygen, and oxygen delivery practices (see appendix for the complete version of the questionnaire). There were 17 structured questions that assessed the knowledge of participants which include indications of acute oxygen therapy, indications for acute oxygen therapy and recognizing hypoxemia, while practice was assessed using four structured questions on oxygen delivery practices. The knowledge assessment, all questions had two wrong answers and one correct answer. The correct answer scores 1 point and the wrong answer scores 0. The total marks ranged from 0 to 17. The respondents’ overall knowledge was then categorized using Bloom’s cutoff point method, and classified into three levels of knowledge: High level if the score was between 80 and 100% (14–17 points); moderate level, if the score was between 60% and 79% (11–13 points), and poor level if the score was <60% (<11 points).^[8] The Bloom’s cutoff method was also used to categorized the overall respondents’ level of practice scores into good practice, moderate practice, and poor practice. Data were analyzed using descriptive statistics for the socio-demographic characteristics, information on training, prescription and administration of oxygen therapy and knowledge and practice of oxygen therapy for the frequency and associations between the knowledge and practice of oxygen therapy among doctors and nurses’ and previous exposure to formal oxygen therapy were explored with Chi-square test at P < 0.05 level of significance.

Ethical approval was obtained from the Human Research and Ethics committee of the Federal Medical Centre, Owo, before commencement of the study.

RESULTS

DISCUSSION

This study focused on assessing the knowledge and practice of oxygen therapy among doctors and nurses in hospitals in Ondo State, South West Nigeria.

Formal training of healthcare workers on oxygen therapy was poor as 79% of our respondents had not received additional training on administration of oxygen therapy. This is an important gap as lack of training and education of medical and nursing staff have been identified as a factor that affects the effective administration of oxygen therapy adversely, resulting in poor patient outcomes.^[9] In a survey of clinicians working in resource-limited countries, it was reported that 63% of clinicians practicing in Africa, Asia, and South America do not use oxygen supplementation appropriately due to lack of training.^[10] Similarly, lack of training on oxygen therapy was also identified as a limitation to the provision of safe and effective oxygen therapy to children in Nigerian hospitals^[11] while 86.00% of nurses identified lack of training as a barrier to safe administration of oxygen in a study from Egypt.^[5] The implication is that until appropriately planned training and retraining activities on oxygen therapy are enshrined into schedules of healthcare workers, better health outcomes are not expected in patients requiring oxygen therapy.

Several guidelines^[12,13] on oxygen therapy exist including the WHO guidelines and the British Thoracic Society Guideline for oxygen use in adults in healthcare and emergency settings.^[14] Regarding awareness and use of oxygen therapy guidelines, about half of our study participants were totally oblivious of oxygen therapy guidelines which was better than the result of the Nepal survey where 81.0% of resident doctors were not aware of the WHO or any other guideline on oxygen therapy.^[6] This means that very few healthcare workers had ever read any guideline on oxygen therapy. This becomes very pertinent as it is unlikely that one will follow a guideline without knowing it even exists. That further fuels in itself, sub-standard practice with regard to oxygen therapy.

As shown in our study, the knowledge of the respondents on oxygen therapy is significantly related with their practices of oxygen administration; implying that those with good knowledge do better in the area of practice. This findings was similar to what was reported by Piryani et al.^[6] of good knowledge by the respondents. Oxygen is a medication which should be used only for specific indications.^[5,6] This is an important background knowledge which influences how a health-care think of and use oxygen. Ideally, oxygen should be accorded same care with which other regular medications are administered. This implies that attention should be given to the correct dose, duration, and route of administration to get the maximum benefits from its use.

Pulse oximetry is a non-invasive, painless, and reliable method for measuring arterial oxygen saturation and it is important as a point of care access hence very useful in emergency conditions; however, it has clinical variations in practice. The respondents in our study had better knowledge on pulse oximetry as a useful tool in detecting hypoxemia and monitoring adequacy of oxygen administration when compared to the study done by Orimadegun et al.^[15] This is quite important as pulse oximeter helps to determine when oxygen use is needed and also helps to aim for appropriate target during oxygen administration. That a greater percentage of our respondents are aware of its use is quite reassuring whether this is actually been used is another thing to consider. The increase in the knowledge of use of pulse oximetry in our study could be explained by the time difference of 11 years in the study and possibly gradual improvement in the equipping of hospitals in Nigeria.

Recognition of hypoxemia is one of the requirements for provision of safe and effective oxygen therapy to sick children and adults.^[16] Oxygen which can be lifesaving is associated with deleterious side effect, especially if the right concentration is not administered and properly monitored, hence the need for blood gas analysis. It should be prescribed to achieve a target saturation of 94–98% for most acutely ill patients or 88–92% for those at risk of hypercapnic respiratory failure.^[7] Nearly two-third of our respondents had good knowledge of hypoxemia; its clinical signs and the use of blood gas analysis. This is higher compared to the study done by Piryani et al.^[6] in which only 44.4% agreed that oxygen prescription should be to a target saturation range rather than a fixed dose. The observed difference in the two studies could be explained by the different cadre of healthcare workers as most respondents in this study were from the tertiary institution.

The need for proper documentation of oxygen flow rate, source, delivery device, and frequency was emphasized in a study done by Desalu et al. in Ilorin.^[17] This reduces the risk of oxygen toxicity and hypercapnic respiratory failure. In a study from Australia, appropriate oxygen delivery was said to improve as prescription rates increased and the number of patients at risk of Type II respiratory failure with saturation levels above 92% decreased from 47% at initial audit to 18% following a multicomponent intervention which included implementation of a local hospital oxygen policy, introduction of a specific oxygen prescription chart and targeted staff education.^[18] It is, therefore, good to note that a substantial number of the respondents in our study had good knowledge that oxygen flow rate, source, delivery device, and frequency should be documented in the treatment chart of patients.

Result from our study showed that the respondents had slightly higher level of knowledge of oxygen therapy when compared to the result from Lemma’s study in Ethiopia where 36.2% of nurses studied had moderate knowledge.^[7] Overall, only about a third (33.0%) of our respondents had good practice level of oxygen therapy, which was lower than 43.4% reported in Ethiopia.^[7] This is quite an important finding as a larger percentage of the respondents were from tertiary centers where standard of care is expected to be high suggesting that quality of oxygen therapy might be lower in other secondary and primary care centers. The implication of this is the likelihood of potentially harmful oxygen practices that may adversely affect patients’ outcome if appropriate interventions are not applied.

CONCLUSION

We concluded that there is gap in knowledge and practice of oxygen therapy among nurses and doctors. Hence, extensive educational and training programs about oxygen therapy are needed to raise awareness among health-care professionals. Furthermore, regular practical training sessions should be organized for health workers to update their knowledge on the latest guidelines on oxygen therapy. Regular clinical audit of oxygen therapy by nurses and doctors in the various units in the hospital should be carried out with the aim to review the indications, dose, and eventual outcome of patients that had oxygen therapy.

Publications on prescription, dose, duration, method of delivery, and device of delivery of oxygen should be readily available in wards of various units in the hospital to serve as a reminder for healthcare worker when administering oxygen.

The limitation of this study included the low response rate from nurses which mostly occurred because the study was conducted only by doctors. This study was also not stratified according to specialties which may have helped to further characterize difference in knowledge and practice. This was because, the aim of this study was to highlight important aspect of clinical practice on an area, we considered basic and common to all medical practitioners regardless of specialty. We hope to explore this area in future studies. In spite of these limitations, the study provided an important insight into the gaps in the area of oxygen therapy among the most relevant healthcare workers involved in patient care.