Final Year Nursing Students in Nigeria; How Knowledgeable and Prepared are They to Offer Medical Care to Patients with Chronic Kidney Disease?

Abstract

Background:

Nurses play an important role in the management of chronic kidney disease (CKD) patients at primary, secondary, and tertiary levels of care. In other to perform their functions, it is pertinent that they have a good understanding of kidney functions and CKD. We do not know if the current educational curriculum prepares them adequately for this role.

Aim:

To assess the knowledge level of kidney functions and diseases among final year nursing students in Abia State Nigeria.

Materials and Methods:

This was a cross sectional study involving final year diploma and Bachelor of nursing (B. Nursing) students who were randomly chosen. Structured, self-administered questionnaire containing 18 items was the tool for data collection. A score of one was given for each correctly answered question on functions of the kidney, symptoms, signs, causes, and complications of CKD. A score of 50% and above was regarded as good knowledge.

Results:

Two hundred questionnaires were distributed, but 186 were returned (response rate of 93%). Male:female ratio was 1:14.5. One hundred and seventeen (62.9%) knew the correct definition of CKD, but only 69 (37.1%) knew the normal range of glomerular filtration rate. Eighty-one percent had good knowledge of kidney functions while 39 (21%) had good knowledge of CKD. Overall, 42 (22.6%) had good knowledge of kidney functions and CKD. Students who rotated through the dialysis unit during their clinical posting had higher mean knowledge score than others (P = 0.03). There was no significant difference in the mean knowledge scores of the diploma and B. Nursing students (P = 0.76).

Conclusion:

The majority of the final year students had poor knowledge of CKD. There is need to expand the current teaching curriculum so as to increase the knowledge of these future nurses on the basic concepts of CKD to improve outcomes of patient management.

Introduction

Chronic kidney disease (CKD) is a global public health problem.[1] Its incidence and prevalence have increased exponentially in recent years in both developed and developing nations.[2] It is consuming a huge proportion of health care finances in developed countries while contributing significantly to morbidity, mortality, and decreased life expectancy in developing ones.

In Nigeria, the community-based prevalence of CKD has been put at 7.6% in Southeast,[3] 18.8% in Southwest,[4] 27.2% in South-South,[5] 16.5% in North-Central,[6] and 26% in North-West.[7] The cost of renal replacement therapy for end-stage renal disease is enormous and unaffordable by most Nigerians.[8,9] Prevention is of paramount importance and the first step to prevention is awareness of the disease, especially among health-care workers. In Nigeria, the previous studies on awareness of kidney diseases, its detection and referral to the nephrologist had been conducted among the trainee doctors[10] and specialist physicians.[11] In addition, studies on the awareness level of kidney functions and diseases have also been conducted among undergraduates in Benin, Nigeria[12] and the general populace.[13,14] While these studies have various outcomes, they generally depict the poor of awareness of some vital information on some aspects of kidney disease management assessed.

Nurses play an important role in the management of CKD patients at primary, secondary, and tertiary levels of care. In other to perform their functions, it is pertinent that they have a good understanding of kidney functions and CKD. We do not know if the current educational curriculum in Nigeria prepares the future nurses adequately for this role, prompting us to conduct this study. The aim of this study was to assess the awareness level kidney functions and diseases among final year nursing students in Abia State, Southeast Nigeria. The specific objectives were to assess the knowledge of kidney functions and CKD, indicators of kidney damage and reduced kidney function, causes, symptoms and signs of CKD, and treatment options for kidney diseases. The outcome of this study will identify the areas of knowledge deficit. This will assist in expanding the nursing teaching curriculum in other to equip them better for adequate health-care delivery to renal patients. This will result to better outcomes of management of renal patients.

Materials and Methods

This was a cross-sectional study conducted in Abia State. Abia State is one of the 36 states in Nigeria and located in Southeast geopolitical zone.[15] There are four nursing schools in Abia State. Three were selected randomly by balloting. The sample size was calculated using the appropriate formular for estimating sample size for proportions <10,000.[16] A previous study by Okaka and Ojogwu among undergraduate students in a Nigerian university showed that 21% of the students had good knowledge of kidney disease.[12] The sample size for this study was extrapolated from that value at 95% of confidence level and with an error margin of 5%. A minimum sample size of 157 was obtained. This was increased to 200 to make room for nonresponders and increase the scope of the study. There were a total of 409 students in the final year class of all the three nursing schools collectively. These students were in the last week of their final clinical rotation prior to their board certified examinations. The list of these students was made available and formed a table of random numbers from which a sampling interval of 1 out of every 2 students was selected starting from a randomly chosen student. Nonconsenting participants were excluded from the study.

Structured, self-administered questionnaire containing 18 items was the tool for data collection. The questions were organized into three sections. The first section contained the relevant basic demographic characteristics. The second section was designed to elicit knowledge of kidney functions while the third section tested the knowledge of CKD among the students. The knowledge of dialysis and transplantation were excluded as these domains were regarded as postbasic qualification knowledge. The questionnaire was pilot-tested with 20 students in the school not selected for the study. The aim of the pilot study was to determine the reliability of the questionnaire, reveal difficulties in understanding the meaning of the questions, estimates the amount of time for completion of the questionnaire, and to assess the students’ willingness to be involved in the study. The face and content validity of the questionnaire were assessed by two nursing educators, one renal nurse, and one nephrologist. On the basis of the feedback obtained, some questions were modified, the clarity of some questions was improved, and the option “I do not know” was added to a few questions.

Statistical analysis

The Statistical Package for Social Sciences version 21 was used to analyze the data. A score of one was given for each correctly answered question on functions of the kidney, symptoms, signs, causes, and complications of CKD. Continuous variables were expressed as mean (standard deviation) while categorical variables were expressed as proportions. A total score of 50% and above was regarded as good knowledge. P < 0.05 was considered statistically significant. Charts and table were used for display of data where necessary.

Results

Two hundred questionnaires were distributed, but 186 were returned (response rate of 93%). There were 174 females and 12 males giving a female:male ratio of 14.5:1. Students undergoing a degree program in nursing sciences were 110 while those involved in a diploma program were 76. The mean age of the students was 23.5 ± 2.8 years. Table 1 shows the knowledge of functions of the kidney among the students.

Table 1.

Knowledge of kidney functions among the students

Functions	Correct responses (%)
Production of urine	186 (100)
Removal of waste products of metabolism	117 (62.9)
Assists in production of blood	48 (25.8)
Maintenance of blood pressure	84 (45.2)
Maintenance of healthy bones	3 (1.2)
All of the above	45 (25.2)

Adequate knowledge of functions of the kidney was found in 81% of the students. Up to 98.4% knew the correct meaning of glomerular filtration rate (GFR) while only 37.1% knew the correct normal range of GFR.

CKD was correctly defined by 62.9% while 59.7% correctly identified more than 3 months as the period of persistent of markers of kidney damage or reduced kidney function in the definition of CKD. Proteinuria was identified as a marker of kidney damage by 45.2% while only 14.5% identified hematuria as a possible marker of kidney damage. Causes of CKD identified by the students were as illustrated in Figure 1.

Figure 1.

Knowledge of causes of chronic kidney disease among the students. GN: Glomerulonephritis

Symptoms of CKD correctly identified by the participants included general body weakness in 37.1%, vomiting in 9.7%, swelling of the face in 40.3%, and loss of appetite in 22.6%. The complications of CKD correctly identified by the participants included cardiovascular diseases in 72.6%, bone diseases in 6.5%, anemia in 25.8%, and restless leg syndrome in 6.5%. Treatment options for CKD were identified as drugs, dialysis, kidney transplantation, and complementary and alternative medicines in 46.8%, 95%, 100%, and 23.5%, respectively. Alternative medicines suggested by the participants included nutritional supplement (46.8%), herbal medications (21%), and water therapy (24.2%).

Overall, good knowledge was found in 22.6% of the students. Students who had clinical experience in the dialysis unit had higher mean knowledge score than those students who did not have such clinical experience (59.5 ± 5.6 vs. 48.6 ± 5.1 respectively, P = 0.03). There was no statistically significant difference between the mean knowledge scores of the B. Nursing students compared to their counterparts in diploma nursing (11.9 ± 4.5 vs. 12.2 ± 5.1, P = 0.76). The distribution of knowledge scores between these two categories of students is shown in Figure 2.

Figure 2.

Parallel box plot comparing knowledge scores of students according to academic award in view

Discussion

The main findings of this study were that the students had a good knowledge of functions of the kidney. However, there was poor knowledge of markers of kidney damage, causes, symptoms, and complications of CKD. Also, students who had clinical experience at the nephrology/dialysis unit had a significantly higher mean knowledge score when compared to their counterparts who did not. Furthermore, there was no significant difference between the mean knowledge scores of the B. Nursing students compared to their counterparts in diploma nursing.

The good knowledge of kidney functions obtained in this study is similar to the findings by Okaka and Ojogwu among undergraduate nonmedical students in Benin City, Nigeria, where 95% of the students had good knowledge of kidney functions.[12] A possible explanation to this similarity in finding is that both groups of students were undergraduates with current or past knowledge of biology and easy access to internet facilities. They were thus expected to have higher knowledge of kidney function when compared with the general populace. This assertion was corroborated in the finding of poor knowledge of kidney functions obtained in an earlier study among the general populace in South-East Nigeria[13] and by Alebiosu among a similar population in South-West Nigeria.[14]

Proteinuria is a marker of possible kidney damage and its persistence for 3 months can define CKD. Less than half of the students correctly identified proteinuria as a marker of CKD. This calls for concern, especially considering the fact that these future health workers would be playing a crucial role in the detection of CKD and its management after their basic training.

More than half of the students were not aware that diabetes mellitus, chronic glomerulonephritis, obstructive uropathy, and consumption of excessive analgesics can cause CKD. Similarly, the majority of the students were not aware that kidney diseases could be inherited. This is quite alarming considering the fact that diabetes mellitus is prevalent in our environment and has been implicated as one of the most common causes of CKD among Nigerian patients. In addition, diseases such as polycystic kidney disease, Alport syndrome, and some forms of glomerular diseases are genetic in nature and could be inherited. The majority of the students did not know this.

In general, symptoms and signs are poorly predictive of CKD; hence, the need to detect CKD using laboratory assessment. Despite this, some clinical features such as hiccups, vomiting, general body weakness, edema, and pallor, can indicate the loss of excretory and synthetic function of the kidneys. These clinical features were poorly identified by these students. This is similar to the finding by Okaka and Ojogwu among undergraduate students of a Nigerian University where <50% of the students identified general body weakness and <20% of identified vomiting and poor appetite and as possible symptoms of kidney disease.[12] While the study participants in the latter study were nonmedical students, the participants in this index study were medically inclined in their chosen career, and hence, expected to demonstrate a higher degree of knowledge. This poor knowledge is not peculiar to these students. A previous survey among the general population in South-East Nigeria showed that <20% identified vomiting and poor appetite as possible symptoms of kidney disease.[13] Another study among the general populace in Southwest Nigeria by Dada et al. showed that 78.4% of the participants had no idea of common symptoms associated with CKD.[17] Furthermore, a recent survey by Akpan and Ekrikpo among urban dwellers in extreme South-South Nigeria showed that <50% of the populace were aware that vomiting and hiccups are possible symptoms of kidney failure.[18]

While the majority of the students correctly identified cardiovascular diseases as a complication of CKD, their knowledge of anemia, bone disease, and restless leg syndrome was abysmally poor. This knowledge deficit has implication for the management of CKD and calls for concern in addressing the preparedness of this future nurses in playing a role in identification and prereferral care of patients with CKD. It is quite revealing to know that a good number of these students believe in the use of alternative medicines in treating CKD; with 21% of them suggesting herbal medications as an alternative treatment regimen.

Conclusion

There is an urgent need to revisit the teaching curriculum of nursing students in Nigeria who are involved in both the diploma and B. Nursing program with a view to expand its content. Emphasis needs to be placed on definition, screening, identification of possible causes, symptoms, and complications of CKD. In addition, it will be helpful to allow these future nurses to have clinical experience in nephrology/dialysis units of the hospitals during their training. This need is based on the findings from this study that the mean knowledge score of the students who had clinical rotation through the nephrology/dialysis unit during their training had better knowledge of kidney functions and chronic kidney disease than their colleagues who did not have such a clinical exposure during their training.

Limitation

This study was conducted among nursing students in one state of Nigeria only. However, the same teaching curriculum is used nationally; hence, the knowledge of these students may arguably be a reflection of what the curriculum imparts. In addition, this study is the first study in Nigeria that assessed the knowledge and preparedness of final year nursing students in Nigeria to offer renal care to patients; hence, the strength of the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.