Development of a Nursing Care Protocol for care of neonates with

Esophageal atresia/ Tracheo - esophageal fistula

Liji George, Sukhwinder Kaur, KLN Rao

Abstract: Specialized neonatal nursing care is a challenge in a developing country like India.
The challenge is even greater in the absence of well-defined protocols and policies. As pediatric
surgical nursing is an area where correct nursing practices are largely vague or unknown, this study
aimed to bring out a reliable, feasible and acceptable protocol for the care of neonates with esophageal
atresia (EA)/tracheo-esophageal fistula (TEF). In this study, a preliminary protocol and an observation
checklist for implementing the protocol was prepared and sent to a Delphi panel of experts for
assessment of the content validity of the protocol. Following consensus on the content validity of the
protocol, the staff nurses were trained on its utilization. The internal consistency reliability of the
protocol was assessed by try-out on 35 neonates with TEF/EA using the observation checklist prepared
from the protocol. The Cronbach's alpha for each section of the protocol ranged from 0.69 to 0.90
respectively. Of the nurses trained in the utilization of the protocol, 90% nurses reported that the
protocol was beneficial to them and 96.7% nurses mentioned that the protocol was easy to use. The
present study has thus provided a protocol that is valid, feasible, internally consistent and acceptable
for utilization in practice.
Keywords Introduction
Nursing care protocol, Esophageal atresia, Congenital anomalies are an important
Tracheo-esophageal fistula cause of neonatal mortality both in
developed and developing countries.
Congenital anomalies account for 8-15% of
Correspondence at perinatal deaths and 13-16% of neonatal
1
deaths in India.
Dr. Sukhwinder Kaur
Lecturer, Esophageal atresia/tracheo-
National Institute of Nursing Education esophageal fistula has an overall incidence of
2
PGIMER, Chandigarh approximately 1 in 3000-4500 live births. It
Nursing and Midwifery Research Journal, Vol-10, No.3, July 2014 106
is a fairly common congenital disorder with
3
an incidence of 1 in 4000 live births in India.
At PGIMER, Chandigarh, surgery for EA is
the most common emergency surgery in
neonates, with about 180 cases per year.4
Despite advances in technology and
care modalities for neonates with EA/TEF,
there is an enormous difference in survival
rates of these neonates between developed
and developing countries. In western
countries, associated congenital anomaly is
the main factor which affects the prognosis.
But in India, the preoperative condition,
intra-operative and postoperative condition
and socioeconomic status along with
congenital anomaly affects the prognosis.5
Inadequate nursing care is a factor that
contributes to lower the survival of neonates
6,7
with EA/TEF in developing countries.
Esophageal atresia is perhaps one of
the most challenging pediatric surgery
anomalies. Some argue that the ability to
overcome this malformation, survival and
quality of life for these children are indicators
of the effectiveness of the hospital care. The
prognosis largely depends on the quality of
care that these patients are given during their
hospitalization as well as the presented
associated malformations. Therefore it is
essential to provide quality nursing care for
these children for optimal survival rate.
Incidentally, there is severe dearth of an
evidence-based body of literature available to
pediatric surgery nurses to practice best
possible care for neonates with such
congenital anomalies. Neonates with TEF/EA
require specialized care by nurses who need
in-depth knowledge about the anomaly and
the surgical correction performed.
Evidence suggests that implementation
of nursing protocols directed towards
improving patient care and disease
Nursing and Midwifery Research Journal, Vol-10, No.3, July 2014
management can reduce the stay in duration
of mechanical ventilation, the intensive care
unit and hospital lengths of stay in hospital.8
Studies have also pointed out that use
of protocol-based care has the potential to
impact on nurses' roles, increasing their
autonomy and subsequently impacting on
9
patient service delivery. Also, increased use
of protocols leads to higher survival rates for
10
patients and decreases in ICU costs. Clinical
protocols have also enhanced nursing
efficiency, as nurses need to consult with
physicians less frequently. Nursing
protocols contain a comprehensive, up-to-
date review of the disease process and
provides rationale for each therapeutic
decision. Protocols thus represent an
important educational resource for clinical
staff.
In the Neonatal Surgical ICU (NSICU) of
PGIMER, Chandigarh, there are no
documented guidelines with respect to
nursing care of admitted neonates with
esophageal atresia/ tracheo-esophageal
fistula. The need for a well-developed care
protocol with a checklist for its
implementation was an urgent requirement
in a tertiary care centre like PGIMER,
Chandigarh for providing best possible care.
This study therefore aims to provide a solid
body of literature for nurses to guide
themselves while providing care to neonates
with esophageal atresia / tracheo-
esophageal fistula.
Objectives
(i) To develop a nursing care protocol for
neonates with Esophageal Atresia /
Tracheo-esophageal fistula.
(ii) To develop an observation checklist for
implementation of the protocol
107
Materials and Methods
A methodological study design was
adopted to carry out the study. The Neonatal
Intensive Care Unit (NSICU) where this study
was conducted has a capacity of 25 beds and
is staffed by nurses and resident
surgeons.Neonates and children with
various congenital anomalies are admitted to
this unit. In the year 2013 alone, the ICU
admitted around 270 neonates with
EA/TEF.The present study was carried out in
four phases.
Phase I – Preparation phase: This
phase comprised of review of literature and
preparation of the preliminary draft of
nursing care protocol and the observation
checklist for implementation of the protocol.
This draft comprised of the domains
‘Definition and types of esophageal atresia/
tracheo-esophageal fistula', ‘Antenatal
diagnosis of EA/TEF', ‘Symptoms following
birth of neonate with EA/TEF', ‘Nursing
management of EA/TEF in the labour room
nursery', ‘Preoperative nursing management
of EA/TEF in NSICU', ‘Surgical procedure in
EA/TEF' and ‘Post - operative nursing
management of EA/TEFin NSICU'.
Phase II - Validation phase: A Delphi
panel was selected which comprised of 10
members (6 members from the field of
nursing education, 1 member from Nursing
staff and 3 surgeons from Dept of Pediatric
Surgery, PGIMER, Chandigarh). The face and
content validity of the nursing care protocol
and checklist for implementation of the
protocol was assessed using Delphi rounds.
Two Delphi rounds were conducted in this
phase.
Nursing and Midwifery Research Journal, Vol-10, No.3, July 2014
Modifications following 1st Delphi round:
Following the first Delphi round,
sections on ‘Transportation of neonate from
labor room nursery/ pediatric emergency to
NSICU', ‘Fluid and electrolyte management',
‘Pre-operative Oro-pharyngeal suctioning',
‘Post-operative oral suctioning', ‘Pain
management with Neonatal pain, agitation
and sedation scale (NPASS scale)' and a
photograph on the cover page were added.
The section on ‘Surgical procedure in
EA/TEF' was removed as suggested by the
Delphi panel members. Also, the domain on
‘Nursing management of neonate with
EA/TEF in labor room nursery' was organized
into sections and specific procedures in the
protocol were presented in a tabulated form.
Modifications following 2nd Delphi round:
Following the second Delphi round,
sections on ^Sham feeding', ^Therapeutic
positioning', ^Postural drainage' were added
and photographs in each domain.
Modifications were made in the content and
layout of the protocol with each Delphi
round.
Phase III – First try out: In this phase,
the researcher applied the guidelines of the
protocol on 5 neonates with EA/TEF to
assessits feasibility. The procedures and
nursing care methods given in the protocol
were found to be feasible in the NSICU
setting. Following this, a final Delphi round of
the protocol was conducted. Consensus was
reached between all experts regarding
content of the protocol and no modification
was further suggested by any Delphi panel
member.
108
 Phase IV – Final try out: Training of 30
NSICU nurses in the care of neonates with
EA/TEF was conducted using a laptop with
MS Power Point presentations made from
the protocol content. A total of 8 training
sessions were held for the nurses in over a
period of two weeks. Each session was of 30
minutes duration.The training was held in
groups of of 4-5 members and each staff
nurse was given one round of training along
with a printed copy of the prepared protocol.
To assess the internal consistency
reliability of the checklist prepared for
implementation of the protocol, 30 Bedside
nurses working in NSICU, Advanced
Pediatric Centre, PGIMER, Chandigarh and
35 neonates diagnosed with congenital
EA/TEF were taken as the try-out sample (30
neonates who underwent primary repair and
5 neonates who underwent cervical
esophagostomy and gastrostomy). All 30
bedside nurses available during the study
period were included in the study and the
sampling of neonates with EA/TEF was done
using total enumeration i.e. neonates with
EA/TEF admitted from mid-August to mid-
October (two months).
Following the training on utilization of
the protocol, observation of nursing care
provided by the 30 trained nurses for 35
neonates was done using observation
checklist prepared for implementation of the
protocol. The data was collected by
observation of the nurses from 8 am to 8 pm
everyday till the discharge of the neonate.
This data was collected over a period of two
months.
Nursing and Midwifery Research Journal, Vol-10, No.3, July 2014
The prepared final protocol was made
available for use in the NSICU. The final draft
consisted of 8 domains which were
^Definition of esophageal atresia/ tracheo-
esophageal fistula', ^Types of esophageal
atresia/ tracheo-esophageal fistula',
^Antenatal diagnosis', ^Symptoms following
birth', ‘Nursing management of EA/TEF in the
labour room nursery', ^Transportation from
labour room nursery/ pediatric emergency to
NSICU',^Pre-operative nursing
management' and ^Post operative nursing
management'.
Following two months of try-out, the
acceptability of the developed nursing care
protocol amongst the nurses was evaluated
through a feedback questionnaire.
Reliability of Checklist prepared for
implementation of the ‘Nursing care
protocol for neonates with EA/TEF'
Table 1 to Table 6 depicts the item
statistics of the Checklist prepared for
implementation of the ^Nursing care protocol
for neonates with EA/TEF'.Table 1-2 shows
the item-total correlation and Cronbach's
alpha values of the checklist on deletion of
each item in the domain ^Pre-operative care'.
Many items show corrected item-total
correlation of <0.2(poor discrimination) but
when these items were deleted one by one,
the value of Cronbach's alpha did not
increase significantly, therefore it is evident
that all the items had significant contribution.
The highest value of alpha that could be
obtained on deletion of an item was 0.767
and the lowest was 0.730. Deletion of any
item did not significantly increase the overall
value of alpha from 0.760. Therefore, none of
the items were deleted.
109
 Table 1: Item statistics of Checklist for implementing 'Nursing care protocol for care of
neonates with EA/TEF'– Pre-operative care
N=30
Sr. PRE-OPERATIVE CARE Corrected Item- Cronbach's Alpha
No. Total Correlation if item Deleted
Preparation for receiving child in NSICU
1. Receives prior information from paediatric emergency .402 .750
regarding shifting of neonate to NSICU
2. Keeps ready clean radiant warmer with autoclaved linen .432 .745
3. Pre-warms radiant warmer .483 .740
4. Keeps articles for suction ready (suction unit, appropriate catheter etc.) .402 .750
5. Keeps ready an oxygen source with adequate distilled water .402 .750
Receiving child in NSICU
6. Verifies documents and census entry done .000 .760
7. Weighs the child .000 .760
8. Shifts the child under prepared radiant warmer .000 .760
9. Places the child in a lateral/prone position .291 .753
10. Assesses neonate for color and respiratory status .000 .760
11. Clears airway of secretions .000 .760
12. Keeps child NPO .000 .760
13. Keep the child's head covered .286 .755
14. Keep the newborn's head elevated at 30-45° .000 .760
15. Places identification card with details of the neonate .027 .764
Pre-operative oral/upper pouch suctioning
16. Assesses the need for upper pouch suctioning .402 .750
17. Places the child in a lateral position with the head turned to one side -.046 .764
18. Uses a size 6F/7 F suction catheter .000 .760
19. Wears a pair of gloves .191 .758
20. Gently passes the suction catheter into the esophagus until .391 .747
resistance is felt
21. Withdraws the suction catheter by 0. 5 cm and applies suction .623 .730
22. Limits each attempt of oral suctioning to 5-7 seconds .409 .745
23. Provides sufficient time between each attempt to help in .518 .738
re-oxygenation of the infant
24. Performs suctioning within 30 mins intervals .181 .767
25. Performs gentle suctioning .000 .760
Assessment of the respiratory status/ distress of the child
26. Assesses the child's respiratory status correctly using a neonatal .362 .748
respiratory distress score
Oxygen therapy
27. Administers oxygen as prescribed .000 .760
28. Administers humidified oxygen .000 .760
29. Documents rate of oxygen flow hourly .000 .760
- Overall Cronbach's alpha for the checklist section 'Pre-operative care' was 0.76
Lowest Value Highest Value

Nursing and Midwifery Research Journal, Vol-10, No.3, July 2014 110
 Table 2 (Contd. from previous): Item statistics of Checklist for implementing ‘Nursing
care protocol for care of neonates with EA/TEF'– Pre-operative care
N=30
Sr. PRE-OPERATIVE CARE Corrected Item- Cronbach's Alpha
No. Total Correlation if item Deleted
Fluid and electrolytes
30. Administers I.V. fluids as prescribed .000 .760
31. Assesses hydration status of the child using clinical signs .017 .762
Monitoring pulse oximetry
32. Documents SpO2 level hourly .000 .760
33. Assesses the probe site for maintenance of skin integrity .402 .750
34. Rotates the probe site every 2 hourly .350 .749
Measurement of temperature
35. Places thermometer in the roof of axilla parallel to the body .258 .754
36. Keeps the thermometer in place for at least 5 minutes before reading .270 .754
37. Documents measured temperature hourly .000 .760
Care of neonate under radiant warmer
38. Applies temperature probe on the abdomen securely .402 .760
39. Puts the radiant warmer on the servo mode .165 .758
40. Documents radiant warmer's temperature hourly .000 .760
Skin care and hygienic needs
41. Changes position of the neonate 3 hourly .270 .754
42. Provides sponge bath daily to baby with warm water .000 .760
43. Uses sterile bowl and water .000 .760
44. Provides oil massage to child after sponging (if child not under phototherapy) .000 .760
45. Provides education to attendants regarding preparation of cotton napkins .000 .760
46. Changes cotton napkin when soiled .000 .760
47. Takes measures for temperature maintenance of the neonate .000 .760
(radiant warmer/ warm covering )
Informed consent
48. Ensures informed consent prior to sending child for surgery .000 .760
Patient identification and preparation pre-operatively
49. Places identification band on the child's left wrist .000 .760
50. Confirms the patient's identity using at least two identifiers .000 .760
before sending the child to surgery .000 .760
51. Sends the correct blood bag issued for the child .000 .760
52. Sends file and radiological reports along with the child .000 .760
53. Ensures maintenance of temperature during transport to the OT .000 .760
- Overall Cronbach's alpha for the checklist section 'Pre-operative care' was 0.76
Table 3 shows the item-total correlation and evident that all the items had significant
Cronbach's alpha values of the observation contribution. The highest value of alpha that
checklist on deletion of each item in the domain could be obtained on deletion of an item was
‘Post-operative care after primary repair'. Many 0.777 and the lowest was 0.678. Deletion of any
items show corrected item-total correlation of item did not significantly increase the overall
<0.2 (poor discrimination) but when these items value of alpha from 0.700. Therefore, none of the
were deleted one by one, the value of Cronbach's items were deleted.
alpha did not increase significantly, therefore it is
Nursing and Midwifery Research Journal, Vol-10, No.3, July 2014 111
 Table 3: Item Statistics of Checklist for implementing ‘Nursing care protocol for care of
neonates with EA/TEF'– Post- operative care after primary repair
N=30
Sr. POST-OPERATIVE CARE (PRIMARY REPAIR) Corrected Item- Cronbach's Alpha
No. Total Correlation if item Deleted
Receiving the child from OT
1. Obtains advance information of the child's condition from the OT prior to receiving .624 .719
2. Pre-warms radiant warmer prior to receiving the child .425 .693
3. Obtains information on the surgical procedure done .517 .678
4. Specifies surgery performed on the identification card/chart of the child .392 .678
5. Carries out immediate post-operative orders .000 .761
6. Documents vital signs hourly .000 .761
7. Documents child's respiratory status using a neonatal respiratory distress scale -.132 .777
8. Records the nasogastric aspirates .000 .761
Care of surgical anastomosis following primary repair
9. Carefully handles child without hyper-extending neck .000 .761
10. Places child's head-rest in a way that child's neck is neither flexed nor extended .212 .653
11. Places a soft cotton roll under the head of the child to stabilize it .000 .761
12. Restrains the hands of the child with ball bandage .000 .761
13. Secures the trans – anastomotic nasogastric tube with adhesive tape .000 .761
14. Avoids pacifier before 48 hours of post – operative period -0.31 .769
15. Initiates chest physiotherapy following 48 hours of surgery .624 .719
16. Practices minimal handling .000 .761
Therapeutic positioning of a neonate post-operatively
17. Practices minimum handling of child with pooling of nursing activities .000 .761
18. Provides comfortable nested position to the child .000 .761
Post-operative oro-pharyngeal suctioning
19. Performs oral suctioning only when needed .420 .626
20. Inserts the feeding tube only within 5-6 cm into the oral cavity .082 .669
21. Performs gentle suctioning .000 .761
Care of neonate with chest drain
22. Secures the chest drain of the child below the crib .000 .761
23. Measures and records child's chest drain output every 24 hours .073 .762
24. Documents characteristics of the chest drain exudates .000 .761
Assessment and management of pain
25. Assesses pain/ sedation level of child using neonatal pain scale .564 .701
26. Documents pain/ sedation level of child using neonatal pain scale .212 .653
27. Administers analgesics as prescribed .000 .761
Chest physiotherapy
28. Identifies the area to be drained on the basis of physical findings and chest x-ray .178 .654
29. Covers the child with a thin layer of clothing prior to percussion .019 .677
30. Provides CPT prior to oral suctioning .000 .761
31. Provides nebulization to the child prior to CPT .624 .619
32. Performs gentle percussion with fingers/infant mask .000 .761
33. Provides CPT with positional drainage -.031 .769
- Overall Cronbach's alpha for the checklist section 'Post-operative care after primary repair' was 0.70
Lowest Value Highest Value

Nursing and Midwifery Research Journal, Vol-10, No.3, July 2014 112
Table 4 describes the item-total correlation it is evident that all the items had significant
and Cronbach's alpha values of the checklist contribution. The highest value of alpha that
on deletion of each item in the domain ^Post- could be obtained on deletion of an item was
operative care after esophagostomy& 0.840 and the lowest was 0.696 which was
gastrostomy'. Many items show corrected undesirable. Deletion of any item would not
item-total correlation of <0.2 (poor bring a significant improvement in the overall
discrimination) but when these items were alpha value of 0.820. Therefore, none of the
deleted one by one, the value of Cronbach's items were deleted.
alpha did not increase significantly, therefore
Table 4: Item Statisticsof Checklist for implementing ‘Nursing care protocol for care of
neonates with EA/TEF'– Post operative care after esophagostomy & gastrostomy
N=30
Sr. Nursing care for ESOPHAGOSTOMY & GASTROSTOMY Corrected Item- Cronbach's Alpha
No. Total Correlation if item Deleted
1. Obtains advance information of the child's condition from the .000 .693
OT prior to receiving
2. Pre-warms radiant warmer prior to receiving the child .958 .696
3. Obtains information on the surgical procedure done .000 .693
4. Carries out immediate post-operative orders .000 .693
5. Specifies surgery performed on the identification card/chart of the child .444 .840
6. Records the gastrostomy aspirates .000 .693
7. Covers esophagostomy following removal of surgical dressing .000 .693
with petroleum jelly gauze
8. Changes the gauze covering over esophagostomy every 2 hours .444 .840
9. Clears secretions from esophagostomy through suctioning .000 .693
10. Performs gentle suctioning of esophagostomy .000 .693
11. Performs gentle oral suctioning .000 .693
12. Limits each attempt of oral suctioning to 5-7 seconds .444 .840
13. Initiates chest physiotherapy after 48 hrs of surgery .000 .693
14. Teaches parents regarding care of esophagostomy and gastrostomy .000 .693
15. Washes hands before administering feeds .000 .693
16. Administers feed in a clean feeing container .000 .693
17. Administers feed over one hour .000 .693
18. Flushes the gastrostomy tube with 1 ml of warm sterile water .000 .693
after administration of feed
19. Provides education to parents regarding administration of .000 .696
gastrostomy feeds
20. Provides sham feeding with pacifier/ spoon feed when prescribed .000 .693
21. Educates the parents regarding the administration of sham .958 .696
feeds to the child
- Cronbach's alpha for the checklist section 'Post-operative care after esophagostomy & gastrostomy' was 0.82
Lowest Value Highest Value

Nursing and Midwifery Research Journal, Vol-10, No.3, July 2014 113
Table 5 shows the item-total correlation and
Cronbach's alpha values of the checklist on
deletion of each item in the domain ^Care for
intubated neonates with EA/TEF'.Many items
show corrected item-total correlation of <0.2
(poor discrimination) but when these items
were deleted one by one, the value of
Cronbach's alpha did not increase
significantly, therefore it is evident that all the
items had significant contribution. The
highest value of alpha that could be obtained
on deletion of an item was 0.698 and the
lowest was 0.677. Deletion of any item would
not bring a significant improvement in the
overall alpha value of 0.690. Therefore, none
of the items were deleted.

Table 5: Item statistics of Checklist for implementing ‘Nursing care protocol for care of
neonates with EA/TEF'- Care of intubated neonates with EA/TEF
N=23
Sr. CARE FOR INTUBATED NEONATES Corrected Item- Cronbach's Alpha
No. Total Correlation if item Deleted
1. Uses appropriate size suction/feeding tube for ET suctioning .000 .677
2. Inserts suction catheter only 1 cm more than the total length .425 .612
of the ET tube
3. Sets suction pressure between 80-100 mm of Hg .691 .690
4. Specifies the depth of ET tube insertion for each neonate on the .631 .698
bedside of the child
5. Avoids instillation of saline in the ET tube .000 .677
6. Practices aseptic procedure for endotracheal suctioning .000 .677
7. Provides oral care with normal saline every shift .022 .682
8. Takes adequate measures for oxygenation throughout procedure .000 .677
9. Documents ventilator parameters hourly .000 .677

- Cronbach's alpha for the checklist section 'Post-operative care after esophagostomy & gastrostomy' was 0.82
Lowest Value Highest Value

Table 6 shows the item-total correlation and
Cronbach's alpha values of the checklist on
deletion of each item in the domain
^Discharge advice given to parents/
guardian'. Many items show corrected item-
total correlation of <0.2 (poor
discrimination) but when these items were
deleted one by one, the value of Cronbach's
alpha did not increase significantly, therefore
Nursing and Midwifery Research Journal, Vol-10, No.3, July 2014
it is evident that all the items had significant
contribution. The highest value of alpha that
could be obtained on deletion of an item was
0.904 and the lowest was 0.260. Deletion of
any item did not have a significant
improvement in the overall Cronbach alpha
value of 0.900. Therefore, none of the items
were deleted.
114
 Table 6: Items statistics of Checklist for implementing ‘Nursing care protocol for care of
neonates with EA/TEF' - Discharge advice given to parents/guardian
N=11
Sr. DISCHARGE ADVICE GIVEN TO ATTENDANTS Corrected Item- Cronbach's Alpha
No. Total Correlation if item Deleted
1. Provides education regarding positioning (head - end raised) of child .000 .904
2. Provides education regarding administration of antacids as prescribed .000 .904
3. Provides education regarding danger signs in the child .828 .260
4. Provides education regarding immunization of the child .828 .260
5. Provides education regarding follow up of the child .000 .904
- Cronbach's alpha for the checklist section 'Discharge advice to parents/guardians' was 0.90
Lowest Value Highest Value

Table 7 describes the overall Cronbach's
alpha value of each section of the
observation checklist prepared from the
protocol. For the section of ^pre-operative
care', the sample size for analysis was 30 (i.e.
30 pre-operative neonates were observed).
The Cronbach's alpha coefficient for this
section was 0.76.In the section of ^post-
operative care after primary repair', the
sample size for analysis was 30 (i.e. 30
neonates who underwent primary repair
were observed) The Cronbach's alpha
coefficient for this section was 0.70. In the
section of ^post-operative care after
esophagostomy and gastrostomy', the
Table 7: Internal consistency reliability of Observation
checklist for protocol implementation
Section of Protocol
Pre operative care for neonates with EA/TEF
Post operative care for neonates who underwent primary repair
Post-operative care for neonates who underwent
esophagostomy + gastrostomy
Nursing care for intubated neonates with EA/TEF
Discharge advice given to parents/guardians
sample size for analysis was 5 (i.e. 5
neonates who underwent esophagostomy
and gastrostomy were observed). The
Cronbach's alpha coefficient for this section
was 0.82.In the section of ‘Nursing care for
intubated neonates with EA/TEF', the sample
size for analysis was 23 (i.e. 23 neonates who
needed mechanical ventilation were
observed) The Cronbach's alpha coefficient
for this section was 0.69.In the final section
of ^discharge advice given to
parents/guardians', the sample size was 11
(i.e. 11 neonates who were discharged from
NSICU were observed)The Cronbach's alpha
coefficient for this section was 0.90.
Cronbach's Alpha
0.76
0.70
0.82
0.69
0.90

Nursing and Midwifery Research Journal, Vol-10, No.3, July 2014 115
Acceptability of ^Nursing care protocol for
care of neonates with EA/TEF': Following
assessment of reliability, the final draft of the
^Nursing care protocol for neonates with
EA/TEF' was made available for use in NSICU.
The nurses who were trained and observed
for implementation of protocol guidelines
were asked to fill a feedback proforma to
assess their views on the protocol.Table 8
describes the level of acceptance among the
staff nurses who were trained on the protocol
and had utilized it for the care of neonates
with EA/TEF. Out of the 30 nurses
Table 8: Acceptability of ‘Nursing care protocol for care of neonates
with EA/TEF' among nurses
Characterstics Extremely
Beneficial 27 (90%)
Improved nursing skills 10 (33.3%)
Easy to use 14 (46.7%)
Need for implementation 27 (90%)
of protocol in practice
Discussion
Esophageal atresia/ tracheo-
esophageal fistula presents a grave
11
challenge to the pediatric surgery nurses. It
accounts for around 6% of all congenital
anomalies and its incidence in India is
estimated at 18,000 per year. In the year
2013 alone, around 270 babies with EA/TEF
were admitted in the Neonatal surgical ICU of
PGIMER, Chandigarh. It is believed that only
10% of neonates with this anomaly reach a
12
tertiary care centre. The overall survival rate
of neonates with EA/TEF is reported to be
Nursing and Midwifery Research Journal, Vol-10, No.3, July 2014
participating in the study, 90% of the
participants believed that the protocol was
extremely beneficial to them. 93.3% of the
participating nurses said that the protocol
had extremely/highly improved their nursing
skills while 6.7% said that it had moderately
done so. 96.7% nurses also stated the
protocol to be extremely/ highly easy to use
whereas 3.3% said that it was moderately
easy to use. 100% of the participating nurses
highly/ extremely recommended that the
protocol needs to be implemented in NSICU
in practice.
Highly Moderately Slightly Not at all
3 (10%) - - -
18 (60%) 2 (6.7%) - -
15 (50%) 1 (3.3%) - -
3 (10%) - - -
13
around 36%. Specialized neonatal nursing
care is a challenge in a developing country
like India. The challenge is even greater in the
absence of well defined protocols and
policies.
During the period of study i.e. within 2
months, a total of 167 children with various
congenital anomalies were admitted in
NSICU. Out of these children, 36 neonates
(21.5% of total admissions) were diagnosed
with congenital EA/TEF. In NSICU, PGIMER
Chandigarh, there are no documented
guidelines with respect to nursing care of
116
admitted neonates with esophageal atresia/
tracheo-esophageal fistula. Therefore, the
researcher developed a nursing care
protocol for care of neonates with EA/TEF. A
checklist is also essential to assess the
implementation of the protocol guidelines.
Hence, a checklist was also developed for
implementation of the protocol. Similarly, in
the study conducted by El Sayed et al in Cairo
utilized an observation checklist to assess
the nursing practice in Neonatal ICU for the
purpose of developing basic standards of
care for nurses working in the Neonatal
14
intensive care unit.
The validity of the protocol and the
checklist was assessed with three
subsequent Delphi rounds with experts in the
field of nursing and pediatric surgery.
Mannix TG in 2011 employed the Delphi
technique to develop standards for Neonatal
Intensive care nursing education for the
Australian College of Neonatal Nurses
(ACNN). The Delphi panel had comprised of
13 experts who were consulted over a period
of seven months.15 In the present study, the
Delphi panel comprised of 10 members who
were consulted over a period of two months.
Consensus between the members regarding
the content of the protocol was achieved in
the third round.
Pravikoff et al, following a study on
registered nurses in the United States
reported that only 46% of the respondents
were familiar with the term evidence-based
practice. Older nurses lacked computer,
literature search and research training and
there were generational differences in the
approach to technology and research
16
utilization. In the present study, it was found
Nursing and Midwifery Research Journal, Vol-10, No.3, July 2014
that in the NSICU, 46.7% of the total nursing
staff had job experience of less than three
years. 36.7% of the nursing staff comprised
of diploma holders and above all, none of the
nursing staff in their career span had ever
attended any continuing education program
for the care of pediatric surgical patients.
This emphasized the need of a training
program on the utilization of the nursing care
protocol for the nurses of NSICU
Internal consistency reliability of the
observation checklist for implementation of
the ^Nursing care protocol for care of
neonates with EA/TEF' was assessed by
observation of nursing practice on neonates
with EA/TEF. Though there were a number of
items in the checklist that showed an item-
total correlation of <0.2 (poor
discrimination),deletion of these items did
not increase the overall Cronbach's alpha
value of the checklist. The experts also
considered these items important.
Therefore, no item was deleted from the
checklist and the final checklist comprised of
5 domains (pre-operative care, post-
operative care after primary repair, post-
operative care after esophagostomy and
gastrostomy, care of intubated neonates and
discharge advice given to parents/
guardians) with 121 items.This checklist had
an overall Cronbach's alpha between 0.69
and 0.90 which was acceptable. A
Cronbach's alpha value of >0.70 is
considered reliable for use. Similarly, Akuma
and Jordan had conducted a survey
regarding knowledge and practice regarding
procedural pain management using a
checklist. Their internal consistency of their
checklist was found to be high (overall
Cronbach's alpha 0.976).17
117
 The present study also obtained
feedback regarding the protocol from the
nurses working in NSICU. Most of the nurses
reported that the protocol was beneficial to
them and was easy to use. All nurses
recommended that the prepared nursing
protocol should be implemented in practice
to provide high quality and evidence based
care to neonates with EA/TEF.
Since this protocol was found to be
valid, feasible and acceptable, it can be used
in nursing practice for providing care to the
neonates with EA/TEF. This protocol can also
be used to provide induction training to new
nursing staff who join pediatric surgery
department and who are unfamiliar in caring
for such neonates. The observation checklist
developed for the implementation of the
protocol was found to be reliable for use.
Therefore, it can be used by nursing
supervisors to bring about effective
implementation of the protocol. The
checklist will also be helpful to staff nurses
for correct implementation of the protocol
guidelines.
It can also be recommended that
another study can be conducted to assess
the effect of implementation of the protocol
in terms of patient care and outcome,
knowledge gain among nurses and extent of
change in nursing practice resulting from the
protocol. Also, protocols can be further
developed for nursing care of neonates with
other anomalies to provide are liable body of
literature for nurses to guide themselves
while providing care.
Nursing and Midwifery Research Journal, Vol-10, No.3, July 2014
References
1. Sarkar S, Patra C, Karmakar PR.
Prevalence of Congenital Anomalies in
Neonates and Associated Risk Factors in a
Tertiary Care Hospital in Eastern India. J
ClinNeonatol 2013 Jul-Sept; 2(3): 13-134
2. Guiney EJ. Esophageal atresia and
tracheo-esophageal fistula. In: Puri P, editor.
Newborn Surgery. 1st ed. Oxford. Butterworth
– Heinemann publishing; 1996
3. Kohli M, Murali T, Malik A, Singh S.
Factors Affecting Anaesthetic Management And
Early Post-Operative Outcome In Patients With
Esophageal Atresia And Tracheo-Esophageal
Fistula – A Prospective Study. The Internet
Journal of Anesthesiology 2011; 28(2).
4. Menon P, Rao KLN. Esophageal surgery
in newborns, infants and children. Indian J of
Pediatr 2008 September; 75: 939-43
5. Ghai OP. Essential pediatrics. 7thedn.
New Delhi: CBS publishers; 2009.
6. Sharma AK et al. Esophageal atresia and
tracheoesophageal fistula: a review of 25 years'
experience. PediatrSurgInt2000 ; 16 ( 7): 478-
82.
7. Al-Salem AH et al. Esophageal atresia
with or without tracheoesophageal fistula:
success and failure in 94 cases. Ann Saudi Med
2006 Mar-Apr; 26(2):116-9
8. Brook AD et al. Effect of a nursing-
implemented sedation protocol on the duration
of mechanical ventilation. Crit Care Med 1999
Dec; 27(12)
9. Rycroft – Malone J, Fontenla M, Bick D,
Seers K. Protocol-based care: impact on roles
and service delivery. J EvalClinPract 2008 Oct;
14 (5) 867-73
10. Plost G, Nelson DP. Empowering critical
care nurses to improve compliance with
protocols in the intensive care unit. Am J Crit
Care. 2007 March; 16(2)
118
11. Hawley AD. Long-gap oesophageal 15. Mannix TG. Using the Delphi technique
atresia- a nursing perspective.J Child Health to develop standards for neonatal intensive care
Care 2001 Summer; 5(2):53. nursing education. NeonatPediatr Child Health
Nurs 2011; 14(3): 25-36.
12. Tandon RK, Sharma S, Rawat JD.
Esophageal atresia: factors influencing 16. Pravikoff DS, Tanner AB, Pierce ST.
survival-experience at an Indian tertiary care Readiness for U.S. Nurses for Evidence-Based
centre. J Indian AssocPediatrSurg 2008 Jan- Practice. Am J Nurs 2005 Sep; 105(9): 40-51.
Mar; 13(1): 2-6.
17. Akuma AO, Jordan S. Pain management
13. Krishna A, Murali MV, Ahuja S, Kaur N. in neonates: a survey of nurses and doctors. J
Factors influencing survival in esophageal AdvNurs 2012 Jun; 68(6): 1288-301.
atresia. Indian Pediatr 1994 Jan; 31(1): 80-3.
14. El Sayed MS, Sabry YY, Sharkawy HM,
El Sayed EM, Ali T. Establishing Basic
Standards of Nursing care protocol at Neonatal
Intensive care unit. Nature and Science 2013;
11(4): 86-91.

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