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Operating Department Nurses’ Knowledge Of Natural Rubber Latex (NRL) Allergies

The study explored operating department nurses’ knowledge of Natural Rubber Latex (NRL) allergies, and the management of patients at risk of, and with NRL allergies within the operating department.

This research project was undertaken as the final part of a Masters in Nursing degree programme, undertaken with the RCN, London. The study explored operating department nurses’ knowledge of Natural Rubber Latex (NRL) allergies, and the management of patients at risk of, and with NRL allergies within the operating department. The quantitative research approach was adopted for this study, and a simple random sampling approach was taken in selecting 50% (n=466) of the population of operating department nurses, from the mailing list maintained by the Irish Nurses Organisation (INO), for inclusion in this study. A response rate of 68% (N=312) was achieved. A questionnaire was designed for this study. The aim of the questionnaire was to measure operating department nurses’ knowledge of NRL allergies, and the management of patients at risk of, and with such allergies within the operating department. In addition to exploring this knowledge, demographic data was also collected within the questionnaire, which made it possible to explore whether knowledge levels within the domain of NRL had been affected by the demographic characteristics such as level of qualification and attendance at NRL educational sessions, amongst participants. 

Profile of Participants

Analysis of the questionnaire showed that at the time of the study, 30% of participants held nurse manager positions; 25% of these were at CNM I or II level, with 5% being at CNM III or above. 63% of participants were employed at staff nurse grade. The remainder were not working as operating department nurses at the time of the study. 

26% of participants were found to have sufficient knowledge to enable them to safely manage the care of a patient who has a known NRL allergy, in the operating department, once appropriate guidelines/guidance were available to support practice. Just 9% of participants were identified as being capable of identifying patients at risk of NRL allergy and of providing independent care (no guidelines/guidance required), to those requiring NRL safe precautions within the operating department.

As registered nurses, we have a responsibility to provide a safe environment for patients in our care. Having the ability to identify at risk patients is therefore fundamental to being able to provide a NRL safe environment for these patients. Operating department nurses must be able to consistently and accurately identify those exhibiting signs and symptoms of NRL allergic reactions and those at risk of same, to ensure patients are not being put at unnecessary risk while in our care. With just 9% of participants being capable of mounting the appropriate response at the appropriate time, there is little cause for optimism that this will occur.

The evidence from this study, suggests that amongst participants, the most effective way of increasing knowledge relating to NRL allergy, related to attendance at NRL allergy educational programmes. In addition to this, knowledge was shown to increase accordingly with time spent attending such programmes. This is in keeping with other studies exploring knowledge within the domain of NRL. (Kleinbeck et al., 1998; Lewis et al., 1998; Rhodes, 2000).

If the aim is to equip nurses with sufficient knowledge to enable them to identify and manage the care of those at risk of, and with NRL allergy in the operating department, the content of these programmes must be comprehensive enough to ensure that a thorough understanding of the topic in its entirety, is developed.

Before commencing this research study, it could have been expected that this study would find that, attendance at NRL educational programmes would result in increased knowledge within the domain of NRL. Therefore, this finding is not surprising. What makes this into a significant finding, is that the study identified this to be the only factor to have made a significant impact, on knowledge development within the domain of NRL. Even the experience of caring for NRL allergic patients had no measurable influence on knowledge development within the domain of NRL, amongst study participants. 

There is no evidence to suggest that specialist theatre nursing qualifications, or the level of academic achievement, guaranteed anything in terms of knowledge development within the domain of NRL.  Neither was there evidence to suggest that the availability of policies and NRL free trolleys in themselves, positively impacted on knowledge development. However, whilst educational programmes are being developed, and whilst knowledge levels remain low, having a policy to guide practice is critical to ensuring NRL allergic patients are safely managed in the operating department. 

The content of any educational programme, developed to increase knowledge knowledge within the domain of NRL, must include those aspects of knowledge which are critical to the provision of a NRL safe environment, for those patient requiring same. The specific aspects of knowledge found to be deficient in this study, are principally centred round the ability to recognise, the signs and symptoms of NRL allergic responses, and deficiency in the whole area of risk management, from the identification of those at risk, to the identification of healthcare practices that pose risks. This is in keeping with previous studies. Cohen and Kaufmann, (2000) and Lewis et al., (1998) found that deficits existed in the whole area of risk identification and management. Should these deficits be allowed to persist, the implications for patients could be significant. Those with symptoms may not be promptly and accurately diagnosed, and lack of awareness amongst operating department nurses, of even the most basic opportunities, which exist to achieve NRL risk reduction, will see these patients put at unnecessary risk during their management. Programmes should therefore aim to ensure that a thorough understanding of the topic in its entirety is developed, considering it essential to the provision of a safe environment during the delivery of patient care.

From this study, it is also evident, that there are a number of ways in which risk managers could be proactive in the whole area of risk reduction. For example, Trape et al. (2000) advocated for the need to ban powdered NRL gloves, to prevent health care providers from making the wrong choices. Having identified that knowledge of the risks inherent in the use of powdered NRL gloves is deficient, the implementation of a powder-free glove policy would result in a significant risk reduction, even before the education of staff commences. In addition to this, the inclusion of carefully selected questions in the preoperative check-list would help in identifying at risk and potential NRL allergic individuals. This would facilitate operating department nurses whose knowledge would not have enabled them to identify those patients for whom a risk exits, and for whom further investigation would be advisable. 

Selecting the appropriate person to drive this educational initiative will be critical to its ultimate success. Within each operating department, the persons identified as having high levels of knowledge, should be encouraged to become the resource nurse for their clinical area. They should be facilitated as they develop a learning programme for their own clinical area, recommendations for which will follow.

Recommendations

Based on the findings of this study, a number of recommendations can be made. With just 9% of the study population achieving the competency level set at the outset, knowledge within the domain of NRL has been shown to be deficient. The deficiencies shown to exist, need to be included in any educational programme designed to increase knowledge within the domain of NRL. These include:

  • Classification and clarification of the signs and symptoms of NRL allergies; 
  • The pathophysiology of the disease process and the potential for progression of the disease; 
  • Identification and clarification of high risk practices such as the role that powder plays in dispersing NRL aeroallergens, and the latex protein content of products; 
  • Identification of ‘at risk’ populations

Knowledge of these areas, will facilitate operating department nurses in making discrete observations and of picking up on potential NRL allergy risk factors, and the signs and symptoms of NRL responses, requiring further investigations. It will enable nurses to understand why, for example, it is necessary to schedule the patient first on the operating department ‘theatre list’, or why it is necessary to remove NRL gloves from the environment in which the patient is to be cared for.

This study has identified that attendance at NRL allergy educational programmes has been a significant factor in influencing knowledge development within the domain of NRL, amongst participants. It is therefore recommended that theatre managers initiate the process of developing NRL allergy educational programmes for their own operating departments. The first step will be to gain an institutional commitment that the appropriate resources will be made available to support the development of educational programmes. The next step should be the identification of a nurse/nurses to become NRL allergy resource persons for their department. These resource nurses should be facilitated in their attempts to develop and deliver educational programmes, utilising the learning opportunities that clinical practice provides, to support the theoretical components within the programme, and to enable plans of care for NRL allergic individuals, to be refined and developed. Consideration should be given to scheduling programmes, to achieve optimum attendance rates. The inclusion of CNM grades at these programmes should be regarded as critical. It is managers who are most commonly approached to guide clinical practice issues, and they must therefore ensure that their knowledge levels are at the optimal level. 

The resource person should be continually looking at ways of maintaining a positive learning curve in relation to developing knowledge within the domain of NRL, within their department.
At all times, opportunities for attending NRL allergy educational programmes should be facilitated by management and availed of by optimum numbers of health care providers, involved in clinical care, to increase the pool of knowledge, and to enable more nurses to develop the knowledge required, to safely manage the care of at risk and NRL allergic patients within the operating department, and to become resource nurses in their own right. An institutional commitment must also exist to support risk reduction initiatives such as the implementation of a hospital wide powder-free glove policy, and the inclusion of carefully selected questions for inclusion in the preoperative check list, to help in identifying at risk and potential NRL allergic individuals for whom further investigation is required. These recommendations are practical and realistic. They reflect what the broader body of literature suggests to be the case, that is, that nurses’ knowledge of NRL allergy remains below an acceptable level and that it is possible to influence knowledge through the provision of various educational strategies. It is incumbent upon managers to consider the findings of this study in relation to the needs, which exist within their own clinical practice setting.

References

Cohen, M. and Kaufman, J. (2000) Latex Sensitivity in Washington State Acute Care hospitals: A needs assessment of the issues, AAOHN Journal, 48(6), pp.297-304.

Kleinbeck, S., English, N., Sherley, M., and Howes, J. (1998) A criterion referenced measure of latex allergy knowledge, AORN Journal 68(3), pp.384-385, pp.388-392.

Lewis, L., Norgan, G., and Reilly, M. (1998), Are nurses knowledgeable in regards to latex allergy? Seminars in Perioperative Nursing, 7(4), pp,239 -253 

Rhodes, A. (2000) Latex allergy awareness and protocol, British Journal of Perioperative Nursing, 10(3), pp.157-158, pp. 160- 163.

Trape, M., Schenck, P., and Warren, A. (2000) Latex gloves use and symptoms in healthcare workers 1 year after implementation of a policy restricting with use of powdered gloves, American Journal of Infection Control, 28(5), pp. 352 – 357.

 
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