What do nurses and residents know about childhood asthma ?

Jean-François Lemay MD1, Sean I Moore MD2, Michele Zegray RN MScA4, Francine M Ducharme MD4 Department of Pediatrics, The Montreal Children’s Hospital; Department of Community Health, McGill University Faculty of Medicine; Department of Nursing, The Montreal Children’s Hospital; Departments of Pediatrics and of Epidemiology and Biostatistics, McGill University Faculty of Medicine, Montreal, Quebec


Que connaissent les infirmières et les résidents sur l'asthme infantile?
OBJECTIFS : Évaluer les connaissances de base des résidents et des infirmières en pédiatrie rélativement à l'asthme infantile et cerner les domaines qui pourraient faire l'objet d'une formation complémentaire.MÉTHODE : Enquête menée à l'aide d'un questionnaire, validé, d'auto-évaluation, comptant 25 questions « vrai ou faux » et six courtes questions ouvertes.PARTICIPANTS : Ont participé à l'étude; des résidents en pédiatrie; des résidents en médecine familiale qui ont fait un voir page suivante D espite the prevalence and morbidity of pediatric asthma in Canada, many children with asthma do not receive optimal preventive care (1)(2)(3).Implementation of adequate preventive care requires appropriate diagnosis, adequate knowledge of the changing concepts of asthma management, good physician-patient communication and patient adherence to the treatment plan.Major inadequacies in the knowledge and application of guidelines for diagnosis, and in the management of asthma have recently been recognized among several groups of health care professionals, including physicians (4)(5)(6)(7).Yet, asthma knowledge can be improved by changes in curriculum and continuing medical education (4,(8)(9)(10)(11).It appears crucial to ascertain the level of asthma knowledge among physicians and nurses caring for Canadian children to focus appropriate educational resources and correct, if necessary, this weak link in optimal preventive care.
Three questionnaires have been designed to evaluate basic knowledge of childhood asthma (12)(13)(14).Two questionnaires were intended for parents and patients, and were developed ad hoc, ie, for the purpose of a given study without formal validation (12,13).To our knowledge, only one questionnaire has been designed and validated among health care professionals, namely the Asthma Knowledge Questionnaire designed by Fitzclarence and Henry (14).This questionnaire contains 31 questions covering the following issues pertaining to pediatric asthma: epidemiology, pathophysiology, symptoms, triggering factors, preventive drugs, treatment of acute exacerbations, possible consequences on health and lifestyle, and common misconceptions.This questionnaire discriminated well between parents of children with asthma and those of children without asthma, and displayed high intra-individual reproducibility on repeat testing (r=0.94).Using this questionnaire, various strengths and weaknesses of different groups of health care professionals in Australia and of parents of children with asthma were identified (7,15,16).The importance of tailoring education programs to the specific needs of groups was highlighted in each survey.In North America, no survey of asthma knowledge among health care professionals caring for asthmatic children has yet been published.
Using a validated questionnaire, the objectives of the present study were to assess basic childhood asthma knowledge and to identify areas requiring educational reinforcement among pediatric and family medicine residents, and pediatric nurses working at The Montreal Children's Hospital, a tertiary care pediatric hospital in Montreal, Quebec.

MATERIALS AND METHODS
This survey was carried out at The Montreal Children's Hospital, a tertiary care pediatric hospital with 14,000 emergency department visits and 2000 hospital admissions for asthma annually.Between January and June 1994, pediatric residents and family medicine residents on rotation at this institution were surveyed.In addition, pediatric nurses working day or evening shifts in the emergency department, hospital wards and intensive care unit during the month of June were invited to participate.Fitzclarence and Henry's (14) self-administered questionnaire was distributed to residents during teaching time and to nurses during their shifts.Family medicine residents were surveyed in the middle of their three-month pediatric rotation.The anonymity of respondents was assured.
The questionnaire consists of 25 true/false and six fill-in questions, each worth one point, for maximum score of 31 (Table 1).All portions of each fill-in questions had to be completed to be scored as correct.Correct answers were determined by a consensus of experienced staff members (one respirologist, one allergist, two pediatricians and two nurses) who worked in the hospital's Asthma Centre, which receives 3000 visits annually.The answers provided by the staff members were in keeping with the 1996 Canadian Asthma Consensus Guidelines (17) and corroborated within 98% with those originally proposed by Fitzclarence and Henry in 1990 (14).The only difference from the answers proposed by Fitzclarence and Henry (14)  the c 2 test.The mean questionnaire scores were compared across groups using ANOVA (SPSS for Windows, Chicago, Illinois).P<0.05 was considered statistically significant.

RESULTS
The overall participation rate was 80% (28 of 35) for pediatric residents, 89% (33 of 37) for family medicine residents and 50% (81 of 163) for nurses.The characteristics of participants are displayed in Table 2. Surveyed nurses had a mean ± standard deviation (SD) of 8.5±3.4 years of experience in pediatrics.
Table 3   nurses.The mean score obtained by pediatric residents was not influenced by the level of training (year 1 27.0, year 2 28.7, year 3 27.4,years 4 to 5 27.5).Among family medicine residents, a slight trend towards higher scores with the increased training was observed (year 1 23.8±4.7,years 2 to 3 26.9±1.9).Among nurses, no differences in score were observed with years of experience or nursing units.At least 75% of nurses and residents correctly identified bronchospasm and airway inflammation as potential causes in the pathogenesis of asthma (questions 5 and 6), but large group differences were observed for the following questions.Thirty-two per cent of pediatric residents, 12% of family medicine residents and 72% of nurses were unable to name all three main symptoms of asthma (question 26): wheezing, cough and dyspnea with cough, the most frequently omitted symptom.Thirty-nine per cent of residents and 62% of nurses failed to recognize that childhood asthma was predominantly a night-time problem (question 23).More nurses (49%) than pediatric (24%) or family medicine (9%) residents incorrectly believed that chest auscultation was the best way to assess the asthma severity (question 22).
With regards to the management of acute exacerbations, more than 75% of nurses and residents were able to name three appropriate treatments (question 29).All groups recognized that antibiotics were not the cornerstone of asthma treatment (question 8) and that allergy injections would not  With regards to preventive therapy, basic knowledge was deficient in all groups.A notable proportion of family medicine residents and nurses was unable to name two preventive treatments for children with frequent symptoms (question 28).Less than half of individuals within each group were able to name two drugs to prevent exercise-induced asthma (question 31).
Over 80% of nurses and residents acknowledged that most asthmatic children grow normally (question 24) and can lead normal lives with no activity restrictions (question 21); that swimming was not the only suitable sport (question 19); that parental smoking may be detrimental to the child's asthma control (question 20); and that asthma was not infectious (question 13).Regarding common misconceptions, 33% of nurses believed that asthmatic children have an increase in mucus production after drinking cow's milk (question 4).Yet, 83% of them believed these children could continue eating dairy products (question 9).

DISCUSSION
Pediatric and family medicine residents, and pediatric nurses had remarkably better knowledge of acute asthma treatment than of chronic management.Residents generally scored higher than pediatric nurses on the Asthma Knowledge Questionnaire.No significant differences in scores were observed among residents according to level of training and among nurses according to clinical units and years of pediatric experience.
These observations are in keeping with the traditional training of medical residents and nurses, which is centred around the treatment of exacerbations.While it is expected that future pediatricians, allergists and respirologists would have better understanding of pediatric asthma care than nonspecialists, the majority of Canadian children are cared for by nonspecialists.Consequently, family medicine trainees should develop excellent skills to recognize asthma symptoms, and to implement basic preventive management and the routine treatment of acute exacerbations.Pediatric residents who will serve as consultants for children unresponsive to regular management need to acquire even broader knowledge of preventive and chronic management of childhood asthma.Pediatric nurses are expected to reenforce and teach day to day management of asthma while dispelling the frequent misconceptions that may interfere with compliance.Thus, important deficiencies in basic pediatric asthma knowledge among trainees and nurses should be recognized and corrected to ensure that health professionals can fulfil their expected role in the Canadian health care system.
A large number of the residents surveyed did not realize that pediatric asthma was more of a problem at night than during the day and that cough was a key asthma symptom.If this deficiency is not corrected, a substantial proportion of children with cough-variant asthma will continue to be misdiagnosed and inadequately managed with antibiotics, decongestants or anti-tussive preparations (18).
Major inadequacies were also observed among residents and nurses on the subject of preventive and maintenance therapy.These observations are in keeping with Henry et al (7), and Fitzclarence and Henry (15) reports of significant discomfort with preventive therapy and home management of childhood asthma among medical students and pediatric nurses in Australia.Insufficient knowledge of this area can tremendously affect a patient's asthma control.Children with repeated emergency visits or hospital admissions usually need maintenance therapy (17,(19)(20)(21).Health professional trainees caring for these children, particularly in a tertiary care setting, need to learn and incorporate this information in management plans.Although recommended in all consensus statements, maintenance therapy is still universally underused in children with recurrent and/or chronic asthma (22,23).Unfortunately, Canada is no exception to this observation (24).Underuse of maintenance preventive therapies has clearly been associated with higher morbidity (25,26).Although guidelines and consensus statements are believed to be efficient means of summarizing current knowledge, this knowledge has not adequately reached our pediatric and family medicine trainees, and pediatric nurses (27).
Outdated beliefs continue to be perpetuated.For instance, the impression that chest auscultation is the best means of assessing asthma severity possibly results from the fact that this manoeuvre is commonly observed during an acute exacerbation.It is still widely believed that the ingestion of dairy products increases mucus production and, hence, can aggravate asthma, but little convincing data exist in the literature to substantiate this belief (28)(29)(30).The misconception concerning milk and mucus may lead to confusion among parents, and can be dispelled by nurses who are frequently the providers of nutritional advice to families.
The results of the survey must be interpreted in light of the following limitations.While the participation rate was high for all residents, only half of targeted nurses completed the questionnaire.With no demographic information available for the nurses who declined participation, it is impossible to examine whether the surveyed nurses were truly representative of all those working at our institution.The modest participation rate (50%) of nurses may be due, in part, to the timing of the survey (June), which corresponds to the beginning of the summer holidays, and to the difficulty in reaching part-time nurses.This may have resulted in a greater representation of the most knowledgeable nurses in the survey either because of their full-time position or because of self-selection.Such a selection bias, if present, would likely overestimate the asthma knowledge among nurses.Yet the similar findings among Australian nurses suggest that our observations may reflect strengths and weaknesses among nurses practising in tertiary care hospital settings (7).Whether our findings can be generalized to other settings is not known.
No apparent increase in knowledge with years of training was observed among pediatric residents.First year pediatric residents, tested after a minimum of six months of training, scored very high (27 of 31).First year family medicine residents, tested after four to six weeks of pediatric training, scored slightly lower than first year pediatric residents (24 of 31).In contrast, a recent survey of medical students documented a steady increase in basic asthma knowledge from mean score of 11 of 31 among first year students to 23 of 31 among fifth year students (31).The Asthma Knowledge Questionnaire contains relatively few questions specific to preventive and management issues (eight questions) but includes several questions addressing common misconceptions, clearly identified as such by most residents early in their training.Our findings suggest that this questionnaire as-sesses basic knowledge, which is rapidly mastered by any resident after a few months of pediatric training.Thus, we believe that the similar performance of our pediatric residents, irrespective of their level of training, reflects the rapid acquisition of basic asthma knowledge and the inability of the questionnaire to assess advanced knowledge.More focused questionnaires have been used to assess knowledge after specific educational programs (9)(10)(11)(32)(33)(34).However, the knowledge tested in these questionnaires often is too focused.The Asthma Knowledge Questionnaire, thus, remains a valuable screening tool for assessing basic, not advanced, knowledge of childhood asthma among various groups of health care professionals and caregivers.

CONCLUSIONS
Residents and nurses at The Montreal Children's Hospital generally have adequate basic knowledge of acute childhood asthma management, yet they need reinforcement in the interpretation and management of chronic and/or recurrent symptoms.Educational interventions should be tailored to the specific needs of each health care professional group.
describes the performance of the participants on the 31-point childhood Asthma Knowledge Questionnaire.The 28 pediatric residents obtained a mean SD score of 27.7±1.8,the 33 family medicine residents averaged 25.5±3.6 while the 81 pediatric nurses scored 22.3±3.8(P<0.001).Pairwise comparisons of overall performance revealed statistical differences only between residents and Can Respir J Vol 6 No 5 September/October 1999 419Nurses, residents and childhood asthma