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Moxibustion plus acupuncture improves the efficacy and quality of life of patients with polycystic ovary syndrome: A randomized controlled trial
Qian ZHANG, Li-Xiu LIU
Journal of Integrative Nursing    2021, 3 (4): 148-154.   doi: 10.4103/jin.jin_47_21
Abstract71)      PDF(pc) (543KB)(69)      
Objective: To observe the effect of moxibustion combined with acupuncture on the efficacy and quality of life of spleen-kidney-yang-deficiency patients with polycystic ovary syndrome (PCOS).
Materials and Methods: A total of 90 patients with PCOS of spleen-kidney yang deficiency type from January 2020 to March 2021 were selected and randomly divided into three groups, 30 patients each in the moxibustion group, acupuncture group, and moxibustion combined with acupuncture group (combined group). The changes of body mass index (BMI), waist-to-hip ratio (WHR), fasting insulin (FINS), fasting plasma glucose (FPG), homeostasis model assessment-insulin resistance index (HOMA-IR), follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone (T), triglycerides (TG), total cholesterol (TC), traditional Chinese medicine (TCM) clinical symptom score, efficacy, and quality of life score in the three groups were observed before and 3 months after treatment.
Results: After treatment, (1) compared with the moxibustion and acupuncture groups, the combined group was more effective in reducing BMI (F = 5.274, P < 0.05) and WHR (F = 8.246, P < 0.05) in PCOS patients; (2) FINS, FPG, and HOMA-IR were reduced in all three groups, and the reduction in these three indicators was more pronounced in combined group (FINS: F = 5.637, P < 0.05, FPG: F = 4.915, P < 0.05, HOMA-IR: F = 3.817, P < 0.05); (3) The FSH, LH, and T levels of patients in the combined group were better than those in the remaining two groups (FSH: F = 4,163, P < 0.05, LH: F = 5.098, P < 0.05, T: F = 7.038, P < 0.05); (4) The TG and TC of patients in the combined group were lower than those in the remaining two groups (TG: F = 4.806, P < 0.05, TC: F = 3.828, P < 0.05); (5) The TCM clinical symptom score of the combined group was significantly lower than those of the moxibustion and acupuncture groups (F = 4.547, P < 0.05); (6) The quality of life of patients in the combined group improved more significantly than the moxibustion and acupuncture groups (F = 6.239, P < 0.05); (7) The total effective rate of the combined group was higher than that of the moxibustion and acupuncture groups (χ2 = 6.947, P = 0.031).
Conclusion: The combination of moxibustion and acupuncture can effectively reduce the BMI and WHR of PCOS patients, improve the endocrine function, sex hormone level, TCM symptoms and quality of life of patients, and has significant efficacy and high safety, which is worthy of wide clinical application.
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Knowledge on malaria among caregivers with children aged under 5 years at Kenyasi Health Cente
Cecilia Ackon ANSONG, Frank Bediako AGYEI, Ramatu AGAMBIRE, Jonathan BAYUO
Journal of Integrative Nursing    2021, 3 (4): 176-180.   doi: 10.4103/jin.jin_45_21
Abstract70)      PDF(pc) (695KB)(83)      

Background: Malaria remains one of the leading causes of morbidity and mortality among children under 5 years old in many low- and middle-income countries. According to the Ghana National Malaria Control Program, malaria kills at least three children every day and also tops the outpatient department cases in Ghana.
Objective: The present study sought to determine the knowledge of malaria among caregivers of children under 5 years at Kenyasi Health Center, Ghana.
Materials and Methods: The study was a descriptive, cross-sectional study. One hundred and three caregivers with children under 5 years old were recruited using the systematic random sampling technique, and data were collected using a structured questionnaire.
Results: The findings revealed that majority (98%) of the respondents knew at least one cause of malaria. Furthermore, all respondents knew at least one complication of malaria and majority (97%) knew at least one preventive measure of malaria.
Conclusion: Caregivers of children have adequate knowledge about malaria and its mode of transmission. Further education on the implementation of the preventive methods is still needed to help reduce the incidence of malaria among children.

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Application of five-element music therapy in pain coping skills training in patients with knee osteoarthritis
Suqian LI, Jingjin XU, Ling TANG, Ye LI, Huaxin WANG, Lixue ZHAO, Jianshuang YAO, Shuying WANG, Nan LI
Journal of Integrative Nursing    2021, 3 (4): 161-164.   doi: 10.4103/jin.jin_34_21
Abstract70)      PDF(pc) (577KB)(96)      

Objective: The objective of this study is to assess the application effect of five elements music therapy introduced in the pain coping skills training of knee osteoarthritis (KOA).
Materials and Methods: Totally, 80 patients with KOA were selected and randomly divided into the experimental group (39 cases) and the control group (41 cases). The control group was only given routine nursing measures, and the experimental group was additionally treated with five-element music therapy on the basis of the control group, twice a day, 28 days in total. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was used to evaluate the functional status of the knee joint of the two groups. The clinical efficacy of the two groups was evaluated by Guiding Principles for Clinical Research of New Chinese Medicine in the Treatment of Osteoarthritis.
Results: WOMAC score statistically significantly decreased in the experimental group (35.92 ± 9.48 vs. 16.17 ± 5.43, P < 0.01) and the control group (36.73 ± 6.42 vs. 22.53 ± 7.51, P < 0.01) after 28 days of intervention when compared with that before intervention; WOMAC score in the experimental group was lower than that of the control group after 28 days of intervention (16.17 ± 5.43 vs. 22.53 ± 7.51, P < 0.01). The total effective rate of the experimental group was statistically higher than that of the control group (82.0% vs. 51.2%, χ2 = 11.97, P= 0.003).
Conclusion: The combination of five-element music therapy and routine nursing measures has better effect in relieving pain and bad emotions of patients with KOA when compared with routine nursing measures alone.

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Insignificant small can still be mighty: Trend of chronic kidney disease in Nigeria
Oluwaseyi Abiodun AKPOR, Abigael Oluwaseyi ADEOYE, Blessing AWHIN, Olaolorunpo OLORUNFEMI
Journal of Integrative Nursing    2021, 3 (4): 141-147.   doi: 10.4103/jin.jin_43_21
Abstract66)      PDF(pc) (852KB)(81)      

The global burden of chronic kidney diseases (CKDs) kept increasing, and it is a leading cause of mortality and morbidity rate in most African countries. The burden of CKD is felt more in developing countries where there is no adequate social security system or health insurance to meet the huge financial demands the disease places on its sufferers and their families. It is also noted that this disease affects the economically productive age group unlike in developed countries where the elderly are more affected. The prevalence of CKD was found to be highly related to age, gender, hypertension, obesity, history of diabetes mellitus, use of herbal medicines, and prolonged use of nonsteroidal anti-inflammatory drugs in Nigeria. The majority of CKD cases were not clinically recognized promptly, mainly because of the lack of patients’ awareness about CKD and associated risk factors. Therefore, health awareness should be intensified by the nurses on lifestyle modification by individuals at risk of CKD, prompt management, good compliance with prescribed medications, avoidance of self-medication, and indiscriminate use of over-the-counter drugs. In addition to that, nurses also need to advocate for regular population screening, and efforts should be made at all levels of care to reduce the negative impact of the disease and complications on the patients.


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Self-management of cataract extraction among diabetes patients
Funke Elizabeth AKINTUNDE, Olaolorunpo OLORUNFEMI, Rasidi Akinade SALAWU, Mary Olabisi OYEKANMI, Babatunde Abdul-latef ADEYENI, Olawale Rasheed OLADAPO, Jeminat Omotade SODIMU
Journal of Integrative Nursing    2021, 3 (4): 170-175.   doi: 10.4103/jin.jin_39_21
Abstract64)      PDF(pc) (488KB)(85)      

Background: Diabetes-related cataract extraction is a minor surgery required to regain full vision. One of the recognized factors that can delay or prevent full-vision recovery is poor management, and most of this management is being carried out by patients themselves.
Objective: This study aimed to assess the knowledge of diabetes patients on self-management after cataract extraction in two tertiary hospitals in Osun State.
Methods: A cross-sectional descriptive design was conducted among 97 diabetes patients who underwent cataract extraction and were attending clinics and follow-up visits in Osun State. A self-structured questionnaire was used for data collection.
Results: Moderate knowledge was found among the participants on an appropriate diet (56.7%), prevention of injury risk (57.5%), prevention of infection risk (50.9%), and low knowledge on the technique of administration of eye drop (60.8%) after cataract extraction, whereas 74.7% of the total respondents were knowledgeable on the indication for follow-up visit after cataract extraction, these results were found to be below the expected knowledge level.
Conclusion: An intensive and comprehensive educational initiative by nurses should be tailored to meet the specific needs of diabetes patients with cataract surgery. Nurses also need to implement the use of checklist which will enhance learning and improve patient understanding of self-management after cataract extraction.


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Midwives' utilization of nonpharmacological pain relief measures for labor pain management: A descriptive cross-sectional study
Idang Neji OJONG, Alberta David NSEMO, Mathias AGBA
Journal of Integrative Nursing    2022, 4 (2): 76-82.   doi: 10.4103/jin.jin_27_22
Abstract58)      PDF(pc) (528KB)(50)      
Objectives: This study sought to examine midwives' utilization of nonpharmacological pain relief measures in labor pain management and to test the relationship between midwives' knowledge and utilization of nonpharmacological pain relief measures for labor pain management in secondary health facility in Calabar, Cross River State, Nigeria.
Materials and Methods: A descriptive cross-sectional design was used for the study. The study was rooted in Katherine Kolcaba's Comfort theory. Totally, 67 participants were recruited for the study using the purposive sampling technique. A self-made structured questionnaire was used to obtain participants' information on knowledge, utilization, and predictors of nonpharmacological pain relief measures.
Results: Although 41 (61.2%) of the participants had knowledge about nonpharmacological pain relief measures, few did not know some of the cognitive-behavioral and environmental measures in labor pain management. There was 35.8% (24/67) for utilization of cognitive-behavioral measures and 55.2% (37/67) for psychological/emotional measures for labor pain management by respondents, respectively. Fifty (74.6%) of respondents agreed that predictors such as lack of knowledge, lack of updates and training, work experience, best practice guidelines, and equipment were hindrances to utilization. There was statistically significance in relationship between the level of knowledge and utilization of nonpharmacological pain relief measures (r = 0.6, P < 0.05).
Conclusion: The utilization of nonpharmacological measures for labor pain management is low, thus it is recommended that frequent education, training updates on effective labor pain management, provision of clinical guidelines on labor pain management, and enrichment of midwifery training curriculum are imperative to ensure quality labor pain management and positive health outcome.
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Effect of prayer on the self‑care agency and hope in hemodialysis patients
Kevser Sevgi Ünal ASLAN, Funda ÇETİNKAYA
Journal of Integrative Nursing    2022, 4 (2): 68-75.   doi: 10.4103/jin.jin_32_22
Abstract58)      PDF(pc) (577KB)(57)      

Background: The level of selfcare of hemodialysis patients is important in controlling the disease process and symptoms. Nursing care has an important place in the process of resolving existing or developing problems of patients receiving hemodialysis treatment and in adapting to treatment. Prayer is not only a resource that encourages religious/spiritual coping, it is also a spirituality that strengthens hope.

Objective: The objective of this study is to determine whether prayer has an effect on selfcare agency and hope in hemodialysis patients.

Materials and Methods: This is a descriptive and correlational study which was conducted with 180 patients in a private and a public dialysis center. The data of 173 hemodialysis patients who met the inclusion criteria were collected using personal information form, Herth Hope Scale, Selfcare Agency Scale, and Prayer Attitude Scale.

Results: A positive, moderate, and statistically significant correlation was found between the Prayer Attitude Scale and total score (r = 0.144, P = 0.048) and sub-scale future (r = 0.350, P = 0.000) of Herth Hope Scale. And there was positive correlation between the Prayer Attitude Scale and the total score of Self-care Agency Scale (r = 0.599, P = 0.000) and its five sub-dimensions drug use (r = 0.566, P = 0.000), diet (r = 0.619, P = 0.000), self-monitoring (r = 0.522, P = 0.000), hygienic care (r = 0.576, P = 0.000) and mental status (r = 0.328, P = 0.000).

Conclusions: The study found that prayer had a positive effect on selfcare agency and hope in hemodialysis patients.


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A study on the correlation between function motivation and professional identity among nursing volunteers
Juan XU, Wenjun HAO, Hui YANG, Xuanxuan LI
Journal of Integrative Nursing    2021, 3 (4): 165-169.   doi: 10.4103/jin.jin_37_21
Abstract55)      PDF(pc) (499KB)(82)      

Objective: The objective of this study is to understand the status quo of function motivation and professional identity among nursing volunteers and explore the correlation between the two.
Materials and Methods: A total of 3375 nursing volunteers from Nightingale Volunteer Service Group in Shanxi Province were investigated by using Occupational Identity Scale and Volunteer Functional Motivation Scale.
Results: A total of 3375 questionnaires were issued and 3330 were recovered, among which 3324 were valid, with an effective recovery rate of 99.82% (3324/3330). The overall score of professional identity of nurses was 110.31 ± 18.71, and the score of each dimension was 32.17 ± 6.62 for professional cognitive evaluation dimension, 22.77 ± 3.74 for professional social support, 21.31 ± 4.09 for professional social skills, 22.78 ± 3.79 for professional frustration coping, and 11.32 ± 2.03 for professional self-reflection. The total score of function motivation was 157.12 ± 29.92. The above five dimensions of nurse's professional identity scale were positively correlated with the total score of function motivation of nursing volunteers (r = 0.044, 0.035, 0.034, 0.035, and 0.042, respectively, all P < 0.05).
Conclusion: The functional motivation and professional identity of nursing volunteers in Shanxi Province are in the middle level in China. Therefore, it is necessary for the hospital to stimulate nursing staff's enthusiasm about participation by carrying out multi-channel and multi-form volunteer service projects, enhance their professional identity, and make them better give back nursing professional skills to the society.

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Treatment satisfaction and medication adherence among hypertensive patients in a teaching hospital in Ekiti State, Nigeria
Oluwaseyi Abiodun AKPOR, Florence Olutola OLOWOLAJU
Journal of Integrative Nursing    2022, 4 (2): 59-67.   doi: 10.4103/jin.jin_4_22
Abstract53)      PDF(pc) (557KB)(54)      
Objective: This study investigates treatment satisfaction and medication adherence among hypertensive patients attending the medical outpatient clinic of a teaching hospital in Ekiti State, Nigeria.
Materials and Methods: The study design was descriptive and cross-sectional using quantitative research strategy. A systematic sampling technique was used in selecting 270 participants; a structured questionnaire was used for data collection. Medication adherence was assessed using the 8-item Morisky Medication Adherence Scale, and treatment satisfaction was assessed using the 14-item Treatment Satisfaction Questionnaire for Medication.
Results: The study findings revealed that majority (73.7%) of the study participants had good knowledge of hypertension, while 44.4% had a good level of treatment satisfaction. Test of association of participants' sociodemographic characteristics revealed age (χ2 = 23.773, P = 0.003) and occupation (χ2 = 21.251, P = 0.019) to be significantly associated with treatment satisfaction. The level of medication adherence by the participants was observed to be relatively poor (50.4%). The educational status (χ2 = 23.914, P = 0.001) and monthly income (χ2 = 10.406, P = 0.034) of the participants showed significant association with medication adherence.
Conclusion: The study recommends that improving patients' understanding of their disease and treatment with subsidizing hypertensive medications by the government will enhance medication adherence.
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Nursing perspective of expert consensus for diagnosis and treatment of colorectal cancer with integrated traditional Chinese and Western medicine
Shuhong LIU, Ling TANG, Yanan ZHAO, Jingjing HUO, Yan ZHAO, Kang YAN, Baoya ZHAO
Journal of Integrative Nursing    2022, 4 (2): 49-58.   doi: 10.4103/jin.jin_1_22
Abstract50)      PDF(pc) (517KB)(35)      

As one of the most common malignant tumors in the world, colorectal cancer (CRC) is accompanied by a variety of symptoms in the process of disease development and treatment, which seriously affect the functional state and quality of life of patients. In China, comprehensive intervention measures of traditional Chinese medicine (TCM) play an indispensable role in the treatment and rehabilitation of CRC. In order to further standardize and improve the treatment and management of CRC by medical staff, the Chinese Association of Integrative Medicine issued the “Expert Consensus for Diagnosis and Treatment of Colorectal Cancer with Integrated Traditional Chinese and Western Medicine” in August 2021. This paper interprets this consensus in detail from the perspective of nursing, focusing on the common understanding of the pathogenesis of CRC, TCM diagnosis and syndrome differentiation, integrated traditional Chinese and Western medicine nursing, TCM characteristic therapies, etc., with a view to deepening the understanding and practical application of the consensus among clinical doctors and nurses and improving the level of diagnosis, treatment, and nursing of CRC.

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Psychological experience of infected individuals during the pandemic: A qualitative meta-synthesis
Journal of Integrative Nursing    2022, 4 (2): 83-90.   doi: 10.4103/jin.jin_65_21
Abstract42)      PDF(pc) (597KB)(27)      
The purpose of this review is to integrate the psychological experience of infected individuals during the pandemic. The spread of the pandemic has led to psychological and emotional impacts on patients. A qualitative synthesis is needed to identify, appraise, and integrate the available qualitative findings to provide an evidence for the development of interventions. A meta-aggregation approach was used to analyze studies published in English from January 2020 to August 2021. The JBI Qualitative Assessment and Review Instrument was used to assess the methodological quality of included studies. The ConQual system was used to establish the dependability and credibility in the synthesized findings. Six phenomenological studies and one narrative inquiry with an overall quality score of 70%–100% were included. The research findings from 87 participants in eligible studies were aggregated into three categories based on similarity of meaning. Two synthesized findings were generated and rated as moderate based on the ConQual score. The synthesized findings suggested that participants had psychological distress such as fear, anxiety, loneliness, and uncertainty, but they accepted the fact of being infected and tried to adjust themselves using some self-coping strategies, such as diverting attention from disease, seeking help from professional counselors, relying on religious beliefs, and participating in religious activities. They would like to learn more about infections and diseases and needed more informational support from health-care professionals. They were looking forward to recovery from the disease.
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Relationship of demoralization with anxiety, depression, and demographics of Chinese dialysis patients
Cai-Lan ZHUANG, Juan-Lian ZHENG, Lei GAO, Ying-Ling HUANG, Wen-Jing HU
Journal of Integrative Nursing    2021, 3 (4): 155-160.   doi: 10.4103/jin.jin_46_21
Abstract38)      PDF(pc) (530KB)(70)      

Objective: The purpose of this study is to investigate the demoralization level of dialysis patients in China and analyze the influencing factors.
Materials and Methods: A convenience sample of 278 dialysis patients from a tertiary hospital participated in a cross-sectional descriptive study using a structured questionnaire including assessments of demographic data, Demoralization Scale-II (DS-II), and Hospital Anxiety and Depression Scale. The main analysis consisted of descriptive statistics, correlation coefficients, and multiple linear regression.
Results: The mean standard deviation DS-II score was 11.87 (7.72). Dialysis patients had a high level of demoralization. Findings from multiple linear regression indicated that demoralization was positively correlated with marital status (β = 0.141; P = 0.001), employment status (β = 0.113; P = 0.006), anxiety (β = 0.393; P < 0.001), and depression (β = 0.224; P < 0.001). These variables explained 57.1% of the variance in patient demoralization.
Conclusions: Demoralization is common in dialysis patients and is associated with marital status, employment status, anxiety, and depression. Health-care providers might regularly assess demoralization in dialysis patients, and develop related interventions to improve the quality of life.

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Knowledge, attitude, and practice of techniques of breastfeeding among new mothers: A survey across Delhi Region
Himanshu VERMA, Sirshti SINGH, Nitika BAHUGUNA, Mukul DAHIYA, Jyoti SHAH
Journal of Integrative Nursing    2022, 4 (1): 26-29.   doi: 10.4103/jin.jin_51_21
Abstract37)      PDF(pc) (485KB)(8)      
Objective: The present study aims to evaluate aims to assess the knowledge, attitude, and practice of primiparous mothers in the immediate postpartum period regarding breastfeeding techniques which will be helpful in forming awareness and training programs.
Materials and Methods: A cross-sectional survey was used. A total of 120 primiparous mothers with a mean age of 24.92 years participated in the survey and filled the questionnaire related to the knowledge, attitude, and practice of techniques of breastfeeding.
Results: Results revealed that 48.3% of new mothers were not aware of the correct techniques to initiate breastfeeding, whereas 68.3% of subjects reported that during latching, the baby's upper and lower lip should be everted. The majority of new mothers were aware of breastfeeding techniques with some misconceptions as in our culture, most of the breastfeeding information passed from generation to generation.
Conclusion: The level of awareness about feeding skills among primiparous mothers can be further improved by antenatal counseling or training from health-care workers during the gestational period. This will further help new mothers to educate and will provide adequate information which will decrease the myths.
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I must eat what I want: A roadblock to type 2 diabetes management
Oluwaseyi Abiodun AKPOR, Samuel Segun ABEGUNDE, Olaolorunpo OLORUNFEMI, Oluwaseun Oluwafunmilayo ABIODUN
Journal of Integrative Nursing    2022, 4 (2): 91-96.   doi: 10.4103/jin.jin_58_21
Abstract34)      PDF(pc) (459KB)(35)      
Globally, type 2 diabetes mellitus (T2DM) is considered as one of the most common diseases, which is associated with irreversible risk factors such as age, gene, race, ethnicity, and reversible factors such as diet, physical activity, and smoking. Noncompliance to dietary regimen is the major factors for rapidly rising incidence of T2DM among developing countries. Recently, elevated HbA1c level has also been considered as one of the leading risk factors for developing microvascular and macrovascular complications. Improvement in the elevated HbA1c level can be achieved through diet management; thus, this study found that improvement in patients' dietary knowledge, attitude toward, and compliance to diet regimen will promote a better control of the disease. In conclusion, the stakeholders (health-care providers, health facilities, agencies involved in T2DM care) should educate the patients on the importance of dietary modification in the disease management. Similarly, there is a need for nurses and other health care professionals to advocate and promote a better holistic management that will encourage patients participation and family involvement in the care.
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Operational procedures of auricular point sticking technology
Hong CHEN, Shanshan LIU, Kexin LIU, Suna LI, Ling TANG
Journal of Integrative Nursing    2022, 4 (2): 97-102.   doi: 10.4103/jin.jin_11_22
Abstract33)      PDF(pc) (480KB)(26)      
As an external treatment technique of traditional Chinese medicine (TCM), auricular point sticking, which is rooted in holographic biology theory and TCM viscera and meridian theory, is a safe and effective treatment method. This article introduces the technology overview and development process. The auricular point sticking technique for constipation is taken as an example to specify the basic requirements, assessment, operational points, acupoint selection and matters needing attention during the implementation of the auricular acupressure technique, providing a reference for the operating procedures of this technique in the clinical treatment of other diseases such as insomnia, diarrhea, colds, hypertension, headache, and dysmenorrhea.
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Skin damage due to personal protective equipment among nursing staff in a dedicated coronavirus disease‑2019 hospital of tribal India
Avatarkishan JAISINGHANI, Vikas GUPTA, Amanjot Kaur CHAUHAN
Journal of Integrative Nursing    2022, 4 (1): 8-14.   doi: 10.4103/jin.jin_42_21
Abstract31)      PDF(pc) (563KB)(11)      
Background: Nursing staff are at much greater risk of infection (Ebola virus diseases and severe acute respiratory syndrome) due to their exposure to highly infectious bodily fluids and droplet nuclei and the need for personal protective equipment (PPE) to reduce the transmission risk.
Aim: The present study was conducted to estimate the prevalence of skin injuries and their types due to PPE usage among nursing staff in tribal India.
Materials and Methods: This descriptive cross-sectional study was conducted in the dedicated coronavirus disease-2019 (COVID-19) hospital for a period of 4 months among 144 nursing staff wearing Grade 2 and 3 PPE kits. Study subjects were approached through social networking websites and survey questionnaires (Google forms) according to relevant guides, and research literature was used to collect the details regarding baseline, duty, and skin injury characterization. Chi-square test was used to find the association between skin injury and baseline or duty characteristics, and the association was significant at a P < 0.05.
Results: It was observed that 54.7% of nursing staff were working for 6 or more hours and 16.5% of subjects were wearing the PPE kit for 5 or more hours per day. Skin injury was reported by 86.3% of the subjects after using PPE. Skin injuries among nurses were statistically significant with their current place of stay and daily duty hours (P < 0.05).
Conclusion: In this study, it was found that 86.3% of subjects had suffered from skin injuries by using PPE while caring for COVID-19 patients during duty hours, so an effective preventive measure should be adopted.
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Smartphone dependency and its impact on academics among medical and nursing students: A cross‑sectional study
Rakesh SHARMA, Vibhuti VAIDYA, Rincy RAJAN, Anumol Thottiyil ELDHOSE, Hemkala RATRE, Hemant Lata RAI
Journal of Integrative Nursing    2022, 4 (1): 30-35.   doi: 10.4103/jin.jin_44_21
Abstract28)      PDF(pc) (651KB)(6)      
Objective: This study aimed to assess smartphone dependency and its impact on academics among medical and nursing students.
Materials and Methods: A cross-sectional study was carried out on Bachelor of Medicine and Bachelor of Surgery (MBBS) and Bachelor of Science in Nursing (BScN) students in a medical teaching institute. The Smartphone Dependency Scale and self-structured questionnaire on impact of smartphone on academics were used to assess smartphone dependency and its impact on academics. A total of 436 students were selected using the total enumerative sampling technique. Data were analyzed using the descriptive (frequency, percentage, mean, and standard deviation) and inferential (t-test, Chi-square test) statistics.
Results: The mean age of students was 20.6 ± 1.29 years, 81% were females, and the mean body mass index score was 21.59 ± 3.41 kg/m2. The mean impact on academics and smartphone dependency scores was 19.92 ± 7.01 and 48.58 ± 11.46, respectively. The impact on academics had a significant association with student category (P < 0.001) and gender (P < 0.001). A significant association was found between the impact on academics (P = 0.003) and smartphone dependency (P = 0.05) with studying class.
Conclusion: The use of smartphones is more among medical students. Students studying in the first and second years are found to be more dependent on smartphone, which caused a serious impact on their academics. Smart appliances have become mandatory in this era of technology, and it is not possible to stop its usage but negative impact of smartphones on students' academic performance needs to be addressed. Therefore, it is mandatory to organize educational seminars and workshops to promote the appropriate use of smartphones.
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Nursing perspective of the expert consensus on diagnosis and treatment of integrated Chinese and Western medicine in lung cancer
Jing ZHANG, Tao MA, Shuhong LIU, Yan ZHAO, Ling TANG
Journal of Integrative Nursing    2022, 4 (1): 1-7.   doi: 10.4103/jin.jin_61_21
Abstract27)      PDF(pc) (511KB)(12)      
Lung cancer is a malignant tumor with the highest incidence and mortality in China, which seriously affects the quality of life of patients. Traditional Chinese medicine (TCM) plays a unique advantage in the treatment and rehabilitation of lung cancer. In order to standardize TCM diagnosis and treatment and disease management of clinical medical workers, the Chinese Association of Integrative Medicine issued the “Expert Consensus on the Diagnosis and Treatment of Lung Cancer by Integrated Traditional Chinese and Western Medicine” in August 2021. Experts' recommendations were made on the clinical staging and syndrome differentiation and classification of lung cancer, characteristic TCM therapies, and nursing care of integrated traditional Chinese and Western medicine. This article interpreted the Consensus on the above aspects from a nursing perspective, hoping to provide references for clinical medical workers in the treatment and nursing care of lung cancer.
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Exploring the impact of coronavirus disease-2019 pandemic on malaria and identifying the strategies for the containment of twin infections
Saurabh Rambiharilal SHRIVASTAVA, Prateek Saurabh SHRIVASTAVA
Journal of Integrative Nursing    2022, 4 (2): 103-103.   doi: 10.4103/jin.jin_59_21
Abstract25)      PDF(pc) (381KB)(24)      
The emergence of the coronavirus disease-2019 (COVID-19) outbreak and its rapid transmission in different parts of the world has become a major public health challenge. Considering the consequences of malaria in the past, it is the need of the hour that in the process of containing COVID-19, we should not ignore the strategies aimed toward the prevention and control of malaria infection. There is no point in complaining about the developments that have already happened, the best strategy will be to consider the different facets of COVID-19 infection containment as opportunities and then act accordingly. In the process of fighting against the COVID-19 infection, we have ignored the delivery of essential services pertaining to malaria. This calls for the need to revisit the planned and implemented services for COVID-19 infection and use the existing mechanism for implementing the strategies required for malaria elimination.
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The role of nursing in enhanced recovery after surgery programs in accordance with spine surgery: A mini review
Qing‑Qing HOU, Xue LUO, Hong‑Mian LI, Ying HOU, Zhi ZHANG
Journal of Integrative Nursing    2022, 4 (1): 42-47.   doi: 10.4103/jin.jin_08_20
Abstract23)      PDF(pc) (891KB)(9)      
Spine surgery is typically having a relationship to high degrees of pain and immobility. It is a known fact that the implementation of an enhanced recovery after surgery (ERAS) approach has led to a paradigm shift in various surgical specialties. These protocols require doctors, nurses, anesthesiologists, patients, and their families to agree to strengthen communication with each other, and involve a long timeline and teamwork from start to finish. To our knowledge, the role of nursing in the ERAS of spine surgery has not been reported before. The purpose of this study is to summarize the role of nursing in ERAS programs in accordance with surgical periods. The methods applied for this review include literature review of the world's acknowledged databases such as Springer Link, PubMed, Embase, and Wanfang, especially in the period of 2000–2015. A total of 9 studies fulfilled the eligibility criteria and were included in the review. The findings confirm that the nursing work continued throughout the perioperative procedure, which plays a key role in the successful ERAS pathway. According to different nursing measures, ERAS nursing can effectively promote the postoperative recovery of spine surgical patients, with fewer postoperative complications and increased patient satisfaction.
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Research capacity and training needs of nurses’ in Shanghai, China: A multicenter, cross-sectional survey
Huajiao XU, Ying SHEN, Lingling WU, Weihong SHEN
Journal of Integrative Nursing    2022, 4 (3): 120-126.   doi: 10.4103/jin.jin_34_22
Accepted: 30 September 2022

Abstract21)      PDF(pc) (648KB)(4)      
Aims: The aim of this study is to investigate nurses' research capacity and related training needs in Shanghai to provide evidence to further nursing research training.
Materials and Methods: A cross-sectional design with a convenience sample of 1226 clinical registered nurses, including the Nursing Research Capacity of Self-Evaluation Questionnaire and Research Training Needs Form, was recruited from 14 public hospitals in Shanghai, China. And the influencing factors of nurses' research capacity were analyzed.
Results: The mean score of nurses' research capacity was (46.25 ± 22.90) in Shanghai, that was at a low-to-medium level. The influencing factors of nurses' research capacity including age (F = 15.983, P < 0.001), education (F = 20.738, P < 0.001), professional title (F = 6.993,
P = 0.001), working years (F = 7.803, P < 0.001), department (F = 8.545, P < 0.001), and position (F = ?3.354, P = 0.001). The most critical factor is the time to participate a study (P < 0.001). And what the nurses demanded were writing skills, special lectures, and participating in colleagues' projects mostly.
Conclusion: Nurse's scientific research capacity still needs to be improved in Shanghai. The key to improving this situation is the individualized scientific research training and education for nurses and the practice of more participation in scientific research projects.
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Omicron: Egyptian nurses’ knowledge and attitudes
Mostafa SHABAN, Marwa Mamdouh SHABAN, Osama RAMADAN, Huda Hamdy MOHAMMED
Journal of Integrative Nursing    2022, 4 (1): 15-19.   doi: 10.4103/jin.jin_63_21
Abstract20)      PDF(pc) (518KB)(10)      
Objective: The current study aimed to assess the knowledge and attitudes of nurses toward the current COVID-19 pandemic and Omicron variant.
Materials and Methods: A cross-sectional online survey was used. Totally 277 Egyptian nurses completed an electronic questionnaire comprising demographics with 5 items, nurses' knowledge on Omicron with 18 questions, and nurses' attitudes on Omicron with 5 questions. The data collected were expressed using numbers, percentages, and mean and standard deviation.
Results: The mean age of nurses was 27 ± 5 years, nearly 50% of the nurses were bachelor degrees. The total score of correct answers related to knowledge was 75%, showing the different degrees of knowledge about Omicron. The majority of nurses showed positive attitudes toward controlling and managing the COVID-19 pandemic.
Conclusions: Egyptian nurses have average knowledge about Omicron and a positive attitude toward controlling the COVID-19 pandemic. There should be scope for further assessment to enhance understanding about COVID-19. Moreover, health education programs should be developed for nursing staff to improve information, beliefs, behaviors, and attitudes towards the Omicron variant in particular and the COVID-19 pandemic in general.
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Research progress in core body temperature measurement during target temperature management
Guiying LIU, Yanyan ZHANG, Ling TANG
Journal of Integrative Nursing    2022, 4 (1): 36-41.   doi: 10.4103/jin.jin_40_21
Abstract19)      PDF(pc) (512KB)(6)      
Core body temperature (CBT) is increasingly attracting attention as crucial data during target temperature management (TTM). Accurate and continuous measurement of human CBT can effectively identify and monitor central high fever, and provide a basis for the effective implementation during TTM, which is therefore of great significance for human health care and disease monitoring. The reliable core measurement sites are nasopharynx, esophagus, bladder, rectum, pulmonary artery, etc., but the measurement methods in these sites are all invasive. At present, the medical field is more inclined to noninvasive data collection methods through monitoring an appropriate site (such as forehead, mouth, or axilla) depending on clinical circumstances, so as to ensure the comfort and security of patients to the greatest extent. This review will provide reference choosing more safe and accurate temperature measurement methods for patients during TTM by reviewing the sites and accuracy of invasive and noninvasive CBT measurements.
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Nursing perspective of expert consensus on the diagnosis and treatment of cerebral infarction with integrated traditional Chinese and Western medicine
Guiying LIU, Ling TANG, Shirong HU, Haiyan E, Yanyan ZHANG, Yu YANG, Jing ZHANG
Journal of Integrative Nursing    2022, 4 (3): 107-113.   doi: 10.4103/jin.jin_8_22
Abstract17)      PDF(pc) (509KB)(4)      
Cerebral infarction (CI) is also known as ischemic stroke. It is one of the most common cerebrovascular diseases, with high mortality and disability rate, which has seriously threatened human health. To better apply the diagnosis and treatment plan of integrated traditional Chinese and Western medicine to the treatment of patients with CI, the Chinese Association of Integrative Medicine issued the Expert Consensus on the Diagnosis and Treatment of Cerebral Infarction with the Integrated Traditional Chinese and Western Medicine in 2021. It involves etiology and pathogenesis of CI, diagnosis and treatment standards of Traditional Chinese Medicine (TCM) and Western Medicine, syndrome elements of TCM, as well as rehabilitation nursing of CI with integrated traditional Chinese and Western medicine during acute period and recovery period. This study interprets the consensus from routine nursing, dietary nursing, emotional nursing, complication nursing, rehabilitation nursing, and continuous nursing, aiming to provide evidence-based support for clinical TCM nursing practice.
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In‑vial exhaust method versus conventional exhaust for injection of COVID‑19 vaccine: Correspondence
Journal of Integrative Nursing    2022, 4 (1): 48-.   doi: 10.4103/jin.jin_57_21
Abstract15)      PDF(pc) (405KB)(9)      
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Bibliometrics and visual analysis for clinical research on intervention of traditional Chinese medicine nursing technology on rheumatoid arthritis
Ling TANG, Jianni QU, Hong GUO, Mei WANG, Nini XU, Xiaoyan BAI, Xueyan FAN, Zhixuan XU, Yihui TIAN, Fen ZHOU
Journal of Integrative Nursing    2022, 4 (1): 20-25.   doi: 10.4103/jin.jin_53_21
Abstract14)      PDF(pc) (1573KB)(15)      
Objective: The objective of this study is to explore the current situation, clinical research hot spots, and trends of traditional Chinese medicine (TCM) nursing technology in rheumatoid arthritis (RA), to draw a panorama of clinical research, to provide the basis and clues for subsequent high-level evidence integration and further in-depth research.
Materials and Methods: Seven databases including China National Knowledge Infrastructure, Chinese Scientific Journal Database (VIP), Wanfang Database, Chinese Biomedical Literature Database (Sino-Med), PubMed, Embase, and the Cochrane Library were searched. The bibliometric method and visualization software CiteSpace were used to conduct a multi-dimensional analysis of the included literature.
Results: A total of 805 pieces of literature were included (of them, one was written in German and four in English), and the number of published literature showed an increasing trend year by year. There were only 30 (3.73%) pieces of literature published in nursing journals. The hot spots of the co-occurrence map were concentrated in: (1) the nursing of fumigation in RA; (2) the efficacy evaluation of TCM nursing technology on pain, joint malformation, and joint dysfunction caused by RA. The included literature themes focused on five TCM technologies: fumigation, moxibustion, acupoint patching, acupoint injection, and Chinese herbal soaking. The beginning year and strength in TCM fumigation were 2012 and 5.2, and those in moxibustion were 2011 and 3.38.
Conclusion: The related studies are on the rise. It has entered the field of international readers with clear research hot spots. However, there are still shortcomings such as little literature published in Chinese nursing core journals, few non-Chinese-related documents, and a lack of international exchanges and cooperation. The current research hot spots in this field are TCM fumigation, and the cutting-edge trend of future research may be fumigation and moxibustion technology. It is suggested that further research can focus on evidence integration and original research on the self-optimization of these two techniques.
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Technology-based psychosocial support for adolescent survivors of leukemia: An example intervention for nurse specialists
Journal of Integrative Nursing    2022, 4 (3): 157-165.   doi: 10.4103/jin.jin_46_22
Abstract13)      PDF(pc) (571KB)(2)      
Technology-based interventions are thought to be one of the innovative alternatives for improving the psychosocial health of adolescent survivors. This article outlines an example of technology-based psychosocial intervention for adolescent survivors of leukemia. This technology-based psychosocial support intervention consists of five separate modules related to personal development, coping skills, and a healthy lifestyle. intervention can be applied to adolescents (aged 12–18 years) who have completed leukemia treatment at least 2 years ago and are disease free. Psychosocial interventions are crucial to improving adolescent survivors' psychosocial well-being in long-term follow-up. It is thought that psychosocial interventions can be effective on survivors' self-efficacy, coping skills, and quality of life, and survivors will be satisfied with the program. Regarding the model of childhood cancer survivorship care, this intervention can be integrated into the follow-up program and guide pediatric oncology nurses in preparing support programs for adolescent survivors.
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Practice and patronage of traditional bonesetting in Ondo State, Nigeria
Nafiu Fatihudeen OKORO, Adeleke Araoye OJO, Oluwaseyi Abiodun AKPOR, Oghenerobor Benjamin AKPOR
Journal of Integrative Nursing    2022, 4 (3): 145-150.   doi: 10.4103/jin.jin_6_22
Abstract12)      PDF(pc) (555KB)(4)      
Objective: This study was carried out to investigate the determinants of the practice and patronage of traditional bonesetting (TBS) in a Local Government Area of Ondo State, Nigeria.
Materials and Methods: A descriptive research design approach with purposive sampling technique was used. Data collection was through the use of two set of self-developed structured questionnaire (for bonesetters and clients). The study obtained data from eight traditional bonesetters and fifty-six inpatients receiving treatments in the bonesetters' homes across the study location.
Results: Findings from the study showed that the major cause of fractures were road traffic accidents while low cost of treatment was the major influence for patronizing traditional bonesetters. The study also revealed that majority of the traditional bonesetters had little or no formal education. Among the sociodemographic characteristics of the participants, only occupation showed signification relationship with reasons for patronage of TBS homes (χ2 = 28.164, P = 0.036).
Conclusion: The patronage of traditional bonesetters may be impossible to eradicate; thus, the study recommends the need for collaboration among traditional bonesetters and modern orthopedic practitioners through recognition and continuous training of the traditional bonesetters on appropriate management and referrals.
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Role of community health nurse in the prevention of elderly dehydration: A mini‑review
Mostafa SHABAN, Huda Hamdy MOHAMMED, Sahar HASSAN
Journal of Integrative Nursing    2022, 4 (3): 166-171.   doi: 10.4103/jin.jin_36_22
Abstract11)      PDF(pc) (624KB)(2)      
As dehydration is related to negative health outcomes in the elderly, including an increased risk of disability and death, prevention may help improve health, functional status, and quality of life. Dehydration diagnosis can be challenging in the elderly as the traditional physical indications of dehydration may be absent or ambiguous. Numerous etiologies place the elderly at an increased risk. The role of the community health nurse (CHN) derives from the responsibilities attached to her, and the Betty Neuman's Systems Model of health care with three levels of protection is usually applied to the CHN. In this mini-review, we try to integrate the Betty Neuman's Systems Model with the results of identified articles. This study includes a literature search of reputable international databases such as SpringerLink, PubMed, Embase, and Wanfang, particularly for the period 2005 to the present. Ten articles that met the qualifying criteria were included in this study. The findings of this study draw a picture of the role of CHN in preventing dehydration across the three levels of prevention as mentioned by Betty Neuman.
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Faculty of health sciences students’ knowledge and attitudes toward coronavirus disease 2019 during the first wave of the pandemic: A cross‑sectional survey
Melek Ertürk YAVUZ, Bahar Candaş ALTINBAŞ, Didem SARIMEHMET, Ayla GÜRSOY, Cansel ÖZEL
Journal of Integrative Nursing    2022, 4 (3): 151-156.   doi: 10.4103/jin.jin_30_22
Abstract10)      PDF(pc) (597KB)(4)      
Objective: The study aimed to determine the faculty of the health sciences students' knowledge and attitudes regarding the coronavirus disease 2019 (COVID-19) pandemic.
Materials and Methods: This cross-sectional survey was completed with 317 undergraduate students of one health sciences faculty in Turkey. The data were collected between March 1, 2020, and March 15, 2020, by face-to-face interviews using a questionnaire created by the researchers. Number, percentage, mean, standard deviation, and Pearson Chi-square test were used to evaluate the data.
Results: In this study, a high proportion of students answered questions about COVID-19 correctly. About 55.8% of the students took partial precautions against COVID-19 to protect themselves against COVID-19 and “frequent washing of hands” was the most common precaution. We determined that the main reasons for not taking any precautions against COVID-19 were “low number of cases in Turkey” and “getting irritated by the mask.” About 98.4% of the participants were entirely/partially following the news on COVID-19, with social media being the most commonly used medium. Female students took more protective measures than male students. The 1st-year students had more positive thoughts about vaccination compared to those in the other classes.
Conclusions: Although the knowledge of the students about COVID-19 was good in the first wave of the pandemic, more than half of the students stated that they partially complied with the protective measures.
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Nurses and nursing students' knowledge regarding blood transfusion: A comparative cross-sectional study
Rakhi GAUR, Shiv Kumar MUDGAL, Neha SUYAL, Suresh Kumar SHARMA, Rajat AGARWAL, Ritu RAJ, Chaturvedi JITENDER
Journal of Integrative Nursing    2022, 4 (3): 137-144.   doi: 10.4103/jin.jin_39_22
Accepted: 30 September 2022
Online available: 30 September 2022

Abstract10)      PDF(pc) (565KB)(9)      
Objective: The objective of this study is to measure and compare the knowledge of nursing students and nurses on blood transfusion in an Indian context.
Materials and Methods: The present comparative, cross-sectional study enrolled 296 nurses and 177 nursing students through a purposive sampling from a medical university hospital and different nursing institutions. The data were collected in the month of June and July of year 2021, using a self-structured questionnaire. The questionnaire had two sections: Section-I contained demographic data (8 items for nurses and 5 for students) and section-II included 26 items that assessed nurses' and nursing students' knowledge on blood transfusion.
Results: Findings indicated that nurses and nursing students had insufficient knowledge about blood transfusion. Nurses, however, had significantly greater total blood transfusion knowledge scores than nursing students (16.51 ± 3.85 vs. 12.10 ± 3.28; P < 0.001). The marital status (adjusted odds ratio [AOR] =0.456, 95% confidence interval [CI] 0.244, 0.853; P = 0.037), educational level (AOR = 5.072, 95% CI 1.982, 9.634 (P = 0.003); AOR = 6.540, 95% CI 2.54, 16.871; P = 0.001) and work experience (AOR = 0.216, 95% CI 0.067, 0.702 [P = 0.037]; AOR = 0.331, 95% CI 0.135, 0.811; P = 0.013) were the significant predictors of the level of knowledge among nurses. The attendance in any educational programme on blood transfusion (AOR = 0.225, 95% CI: 0.062, 0.818; P = 0.041) was a significant predictor of the level of knowledge among nursing students.
Conclusion: Nurses and nursing students have unsatisfactory knowledge on blood transfusion; emphasizing the critical need for immediate and successful teaching activities in this area.
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Does educational intervention change knowledge, attitude, and practice regarding pharmacovigilance among nursing officers in Central India? An interventional study
Chaitali Ashish CHINDHALORE, Ganesh Natthuji DAKHALE, Ashish Vijay GUPTA
Journal of Integrative Nursing    2022, 4 (3): 114-119.   doi: 10.4103/jin.jin_45_22
Abstract9)      PDF(pc) (643KB)(5)      
Objectives: To evaluate the impact of educational intervention on knowledge, attitude, and practice (KAP) regarding pharmacovigilance (PV) and adverse drug reaction (ADR) reporting among nursing officers.
Materials and Methods: A pre- and post-single-arm interventional study was conducted at All India Institute of Medical Sciences (AIIMS), Nagpur from May 2021 to October 2021 among 48 nursing officers. Data related to KAP were obtained through validated questionnaires before and after 3 months of educational intervention.
Results: The mean knowledge score among nursing officers significantly improved from 11.05 ± 3.09 to 16.77 ± 2.07 after training session (P < 0.001). The mean score regarding attitude was significantly upgraded from 21.16 ± 5.6 to 23.79 ± 2.97 (P < 0.001). At baseline, the mean practice score was poor (2.41 ± 2.89), which was improved after training session, but the difference is not significant.
Conclusion: Educational intervention had a significant impact on knowledge and attitude toward ADR reporting. The practice of detecting and reporting an ADR to the treating consultant is improved, but it is not transformed into reporting an ADR to the PV center to a significant extent. Hence, it is recommended to streamline ADR reporting process by implementing such training modules more frequently.
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Nursing perspective of Guidelines for Diagnosis and Treatment of Gout with Integrated Traditional Chinese and Western Medicine
Suqian LI, Chun WANG, Lin LU, Ling TANG, Huaxin WANG
Journal of Integrative Nursing    2022, 4 (3): 172-176.   doi: 10.4103/jin.jin_7_22
Abstract9)      PDF(pc) (532KB)(5)      
Gout is a common rheumatism and its long-term recurrent attacks can cause joint destruction and deformity, even disability, which seriously affects the quality of life of patients. Chinese medicine plays a unique advantage in the treatment and rehabilitation of gout. To further standardize the diagnosis and treatment of gout with integrated traditional Chinese and Western medicine, the Chinese Association of Integrative Medicine issued the Guidelines for Diagnosis and Treatment of Gout with Integrated Traditional Chinese and Western Medicine in August 2021. Expert recommendations were made on the etiology and pathogenesis; diagnosis and classification standards; patient health management; and integrated traditional Chinese and Western medicine treatment, prevention, and nursing of gout. This article interprets the guidelines from the nursing point of view, focusing on the detailed explanation of diet care, functional exercise, and appropriate techniques of traditional Chinese medicine for gout, in order to provide better clinical reference for high-quality nursing services for gout patients.
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Referral and counter-referral practices in obstetric emergencies among health-care providers in selected health facilities in Plateau state, Nigeria
Alberta David NSEMO, Samuel Mahan Zakka MALAU, Idang Neji OJONG
Journal of Integrative Nursing    2022, 4 (3): 127-136.   doi: 10.4103/jin.jin_29_22
Accepted: 30 September 2022

Abstract8)      PDF(pc) (596KB)(2)      
Objective: This study aimed to examine the referral and counter-referral practices in obstetric emergencies among health-care providers in selected health facilities in Plateau state of Nigeria.
Materials and Methods: A concurrent embedded descriptive mixed method consisting of both quantitative and qualitative methods was adopted for the study. Participants (104) were recruited using multistage sampling and 8 participants using purposive sampling techniques for quantitative and qualitative aspects of the study, respectively. The three-phase delay model directed the study. A self-developed structured questionnaire and an in-depth interview guide were used to elicit quantitative and qualitative responses from the participants. Quantitative instrument was tested for reliability, while the qualitative instrument went through the rigors of qualitative data.
Results: Findings revealed low level of referral and counter-referral practices as only 19 (18.27%) and 30 (28.85%), respectively, of care providers referred patients above 10 times in a year. The study also revealed inadequate human and material resources for referrals and counter-referrals. The mean on barriers to referral was 2.90, which was above the cutoff of mean of 2.50, which indicates that the barriers are militating against referral and counter-referral in obstetric emergencies.
Conclusions: Low levels of referral and counter-referral practices are identified with inadequate resources among others posing as barriers. Therefore, provision of standard operational procedures/protocols in every health-care facility as well as provision of adequate material and skilled human resources among others is recommended to enhance referral and counter-referral network in obstetric emergencies. There is also a need for teamwork and synergy among all stakeholders in the referral chain.
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