ASSESSMENT OF NURSE’S KNOWLEDGE AND PRACTICES REGARDING PEDIATRIC CARDIAC CATHETERIZATION AT SULAIMANI CARDIAC HOSPITAL IN SULAIMANI CITY

Pediatric Cardiac catheterization is considered one of the most diagnostic and interventional procedures available to the cardiologist. Pediatric Cardiac Catheterization has decreased morbidity and mortality for cardiovascular defects, and this invasive process is not free of complications. Aim: To assess the nurse's knowledge and practices regarding pediatric cardiac catheterization Sulaimani City. Methods: A Descriptive -analytical designs are used in the current study. A purposive non-probability sample of ( 30 ) Nurses were recruited who worked in Sulaimani Cardiac Hospital. The present study shows that most participants were males aged between (45-49). years. The study demonstrated that nurses' knowledge in pediatric cardiac catheterization was satisfied, and more than half of them worked with "good practice. Results: the study's result indicates a significant positive statistical correlation between (nurses' knowledge and Nurses' practice at Pre-cardiac, Intra-cardiac, Post-cardiac). Conclusions: The present study shows that most participants were male aged between(45-49). Years. The study demonstrated that nurse's knowledge in pediatric cardiac catheterization was satisfied, and more than half of them worked with "good practice.” Fu rther, the study's result indicates a significant positive statistical correlation between (nurse's knowledge and nurse's practice at Pre-cardiac, Intra-cardiac, Post-cardiac). The study recommends a specific training course for all the nurses working with children undergoing pediatric cardiac catheterization, and also further qualitative studies are also recommended.


INTRODUCTION
Pediatric Cardiac catheterization is considered one of the most diagnostic and interventional procedures available to the cardiologist. It includes inserting a specialized catheter into the systemic circulation (usually through the femoral vein or artery of the puncture site), which is then guided into the heart supported by the x-ray.This procedure is safe when a knowledgeable team achieves it.The complications are usually brief and may consist of minor complications as abnormal heartbeats,reaction to dye or medications,bruising,temporary pain,minor infections,and bleeding (Hasballah et al., 2014 ).
Cardiac catheterization in the pediatric community has similarities with catheterization in adults. However, visible differences in adults, the coronary atherosclerotic disease is more common and extremely rare in pediatrics. The techniques, interventions, and indications performed in pediatrics are different. A variety of therapeutic procedures was done in the pediatric cardiac catheterization lab, including balloon angioplasty of stenotic lesions, embolization and device closure of vessels, device closure of septal defects, and valvuloplasty of stenotic valves stenting vascular stenosis, and even percutaneous pulmonary valve implantation. An entire patient assessment is required and determines the best sedation (Gaze, D. C. (Ed.). 2018).
There is also a probability of more severe but uncommon complications, including hematoma, severe bleeding, blood vessel or nerve damage, irregular heart rhythms and lung or heart failure, stroke, heart attack, blood clots in the lungs or legs (Keshk and Elgazzar, 2018).
Patients undergoing pediatric cardiac catheterization need a knowledgeable nurse who recognizes and spots the complications, Using an appropriate practice of nursing care that will assist the patients to cope successfully with their situation and reduce their vascular complications (Thabet et al., 2019). This invasive process is not free of complications. However, it is safe when a knowledgeable team achieves it. The complications are usually brief and may consist of minor complications as abnormal heartbeats, reaction to dye or medications, bruising, temporary pain, minor infections, and bleeding put (Omer, 2020). There is also a probability of more severe but uncommon complications, including hematoma, severe bleeding, blood vessel or nerve damage, irregular heart rhythms and lung or heart failure, stroke, heart attack, blood clots in the legs or lungs, and renal failure (Keshk and Elgazzar, 2018). Therefore, this study led to assess the socio-demographic data of the nurses who work in the Cardiac center and the quality of the nursing care regarding pediatric cardiac catheterization.
Objectives of the study 1. Identify the level of nurse's knowledge during pre-intra and post nursing care for child undergoing cardiac catheterization 2. Determine the level of nurse's practice regarding child's care following pediatric cardiac catheterization 3. Find the association between nurse's characteristics and each of nurse's level of knowledge and practices 4. The corlation between the level of knowledge and practice during cardiac catheterization procedure

METHOD -Design of the Study
A quantitative design "descriptive" study casecontrol approach was carried out to achieve the objectives of study among participants.

-Setting of the Study
The present study was conducted at Sulaimani Cardiac Hospital in Sulaimani City.

-Sample of the Study
A probability and convenience sampling method was used to select a sample from the study. A sample of (30) male and female health care workers who work in Sulaymaniyah Heart Hospital / Catheterization Unit are those who worked before, intra, and after the pediatric cardiac catheterization, -Criteria of the Study Sample 1-Health care workers who agreed to participate in the study. 2-Both genders 3-health care workers in (pre, intra, and post ) pediatric cardiac catheterization

-The study instrument
In order to collect the correct data,questionnaire form was developed by researcher based on related review of literature, and previous studies, to measure the variables underline the present study. It consists of three parts:-Part one: Socio-demographic characteristics of mother consist of (6) items, which include: age, gender, level of education, number of years employed, Have attended Training course about pediatric cardiac catheterization.
Part two: For the nurse's Knowledge in the Pediatric Cardiac Catheterization,A questionnaire was conducted and modified by the researchers, which consists of 48 items to assess level knowledge nurse's abutted the congenital heart defect and management of the defect items have been scaled by three levels of Likert scales by as the following patterns the For items (33) has been positives scaled and items (15) has been negative scaled Part Nurses' practice regarding care of patients undergoing cardiac catheterization consists of three sections Section A Structured (Pre-cardiac catheterization ) consists of (9) items, Section B (Intra-pediatric cardiac catheterization )consists of (12) items and Section C (Post-pediatrics catheterization ) consists of (13) items, the questionnaire Nurses' practice items have been scaled The SPSS (version 24) was used for the data analysis. The demographic characteristics of the samples were reported by using descriptive statistics (frequencies, percentages, and mean) and chi-square test used for associations.
-Validity of the study tools content validity of the questionnaire was analyzed via the panel of 12 experts of different specialties, including (Nursing, Medicine) (. The questionnaire was sent to them by a copy of the questionnaire to each and asked them to investigate the instrument for clarity, relevancy, and adequacy to achieve the purpose of the study. Their comments, suggestions, and amendments were taken into consideration.

Pilot study
A pilot study was conducted on (5) by the nurses who deal with pediatric patients undergoing cardiac catheterization at Sulaimani Cardiac Hospital during the first two weeks of February 2021. The sample of the pilot study was included in the study sample.
The purpose of the pilot study was: • To confirm the clarity of the structure of the instrument throughout the subjects ,understanding and determining required • modification was necessary for the questionnaire. • To estimate the average time consumed for the data collection of each subject. • To enhance the validity and determine the reliability of the instrument.
The result of the pilot study showed that 1. The time required for each observation was approximately 3 hours, range (1-2 hours ) 2. Some items of the questionnaire which were not valid or did not have a significant value have been modified.

-Data Collection
Before interviewing the nurse, an introduction was given, and the purpose of the study was presented personally by the researcher to the subjects and to achieve verbal informed consent, and data was collected from the period 1st of February 2021 to 1st of November 2021.

Statistical analysis
All statistical computation is enhanced using statistical method (SPSS 24). The data had been coded, tabulated, and presented in a descriptive form. In this study the data were analyzed by using the basic statistical methods which include: 1. alpha-cronbach has been used for testing the reliability of the questionnaire. 2.Descriptive statistical data analysis(Frequency, percentage, Mean and stranded deviation) 3. Inferential data analysis: A-Parametric Test (In dependent samples T-Test and One Way ANOVA -F-Test) B-Spearman rank Correlation C. Chi square: using multiple responses package -The significant level of all statistical procedures was determined at (F test), P< 0.000. -There are criteria of the probability level of determining the significance of test:P-value as: High significant (P< 0.001) , Significant (P< 0.05) , Non-significant (P> 0.05)And Very highly significant (P< 0.000) "Average knowledge" were (7.4%) and (25.3%) with "poor knowledge" . . This variable has a mean of 2.42. And a standard deviation of (0.71) .The percentage of people who worked with "good practice" were (65.56%), those with "Average practice" by (11.11%) and (23.33%) of them were in a "poor practice". And a standard deviation of (0.69) .The percentage of people who worked with "good practice" were (77.5%), those who worked in (Average practice) by (6.1%) and who were (poor practice) by (16.4%) And a standard deviation of (0.46) The percentage of people who worked with "good practice" were (61.03%), (18.97%) who were with "Average practice" and (20%) with "poor practice" .   (8) showsThe result of the study shows that, there were statistically significant differences between Nurses' practice at Pre-cardiac catheterization in age (p=0.001), Level of education (p=0.001), Years' employment (p=0.000) and Years of Experience in care of Pediatric Cardiac Catheterization (p=0.000) because (p-value <0.05). But there were no statistically significant differences between Nurses' practice at Pre-cardiac catheterization in gender (p=0.363) because the result of the pvalue was more than the common alpha 0.05.

RESULTS
Table (9) shows the result of the study shows that, there were statistically significant differences between Nurses' practice at intra-cardiac catheterization in age (p=0.033), Level of education (p=0.000), Years' employment (p=0.017) and Years of Experience in care of Pediatric Cardiac Catheterization (p=0.001) because the result of the p-value was less than the common alpha 0.05.But there were no statistically significant differences between Nurses' practice at Intra-cardiac catheterization in gender (p=0.817) because (p-value >0.05).
Table (10) shows the result of the study shows that, there were statistically significant differences between Nurses' practice at postcardiac catheterization in age (p=0.009), Level of education (p=0.000), Years' employment (p=0.031) and Years of Experience in care of Pediatric Cardiac Catheterization (p=0.002) because (p-value <0.05). But there were no statistically significant differences between Nurses' practice at post-cardiac catheterization in gender (p=0.265) because the result of the pvalue was more than the common alpha 0.05. Table(11) The result of the study indicates that that there is a significant positive statistical correlation between (nurses' knowledge and Nurses' practice at Pre-cardiac, Intra-cardiac, Post-cardiac,) which was (0.683, 0.762, 0.527) and that the significance value was (0.000, 0.000, 0.003) by respectively and were less than 0.05.  (100)    The nurse sterilize the side of the puncture The nurse puts pressure and observes the site of the puncture for any (bleeding, hematoma)

DISCUSSION
Nursing care is one of the most crucial factors, preventing cardiac catheterization complications experienced by patients. In Kurdistan Region, a particular hospital, which focuses on Pediatric Cardiac Catherization does not exist as there are no specialized nurses who are certified in this specific field. Thus, nurses' knowledge and practices are competent in pre,intra, and post pediatric cardiac catheterization at Sulaimani cardiac hospital. It is essential to study. The Nurse plays an essential role in providing nursing care to the patient who undergoes cardiac catheterization. According to socio-demographic factors, the distribution of the sample discovered that 33.3% of the participants were aged between 45-49 years, and 26.7% were between 40-44 years, and only 16.7% were Less than 40 years old. The majority of participants, 63.3%, were male. This result is supported by the descriptive crosse sectional study done in Mosul Hospitals (Mahmood et al., 2021). as their sample were primarily male; however, they differ in sample age groups as most of them were aged between 25-29 years old.
Regarding the educational level, the current study showed that most participants hold a technical institute degree in nursing, estimated as 66.7%, and 23.3% have preliminary nursing graduates. This conclusion supported a study conducted in Eygpt by (Ali et al., 2015).Further (Feroze et al., 2017), (Keshk & Elgazzar,2018), Which were agreed, reported that more than half of nurses had a general nursing diploma according to their qualification. The experience in nursing and the duration of work for nurses in this center revealed that most of the nurses were 4 -8 Years experienced in pediatric cardiac catheterization, and the minority had more than nine years of experience in the care of Pediatric Cardiac Catheterization. These findings confirm the study done in Baghdad (Zaki,2010),which indicated that the maximum percentage of job experience was ranged between (1-10) years. However, (Omer,2020). the study conducted in the capital of Kurdistan Region to assess the Quality of Pre-Cardiac Catheterization Nursing Care at the Surgical Specialty Hospital -Cardiac Center in Erbil City supports the present study that no training sessions are given regarding pediatric cardiac catheterization for most of the study samples (55.5%) in Kurdistan region or abroad.
The study demonstrated that nurses' knowledge in pediatric cardiac catheterization was satisfied, as the percentage of nurses who responded with "good Knowledge were (67.3%), whose with "Average knowledge" were (7.4%) and (25.3%) with "poor knowledge." This finding agreed with another study done in Al-Najaf All-Ashraf City, which shows nurses' knowledge regarding cardiac patient care was good (Al-Ftlawy,2014). This finding has come along with a cross-sectional analysis done in Pakistan indicating that registered nurses have the proper level of knowledge regarding cardiac catheter care patients (Feroze et al., 2017). However, this finding contradicts the study results done in Mosul Hospital, which indicated that nurses working in medical and surgical ward nurses' Knowledge of Patient Safety After Cardiac Catheterization were unacceptable (Mahmood et al., 2021). Thwassults showed that most nurses had good knowledge about post-cardiac catheterization complications. A similar study done in Egypt to determine the Nurse's knowledge found that nurses had good knowledge about cardiac patient care (Ali et al., 2015). Nurses' knowledge was excellent and sufficient about cardiac catheterization procedures. Inconsistent with the present study, a study conducted in the cardiac unit in Palestine to determine the Nurse's knowledge about DOI: 10.33899/mjn.2022.171435 pacemaker implantation showed similar results (Alkaiyat et al., 2019).
Regarding the Nurse's practices, the percentage of people who worked with "good practice" was (65.56%), those with "Average practice" by (11.11%) and (23.33%) of them were in a "poor practice" the result of the study done in Erbil found that overall quality of pre cardiac catheterization nursing care, 81.8% of the nurses were at an acceptable level compared to 18.2% were at a reasonable level. At the same time, the mean score of overall quality of care was 2.18, indicating an acceptable level of patient care. This contrasts with the cross-sectional analytical study in Pakistan (Yaqoob et al., 2019). that most nurses were observed with unsatisfactory practices. The outcome of the study indicates that there were statistically significant differences between Nurse's knowledge in Level of education (p=0.000), Years' employment (p=0.012), and Years of Experience in care of Pediatric Cardiac Catheterization (p=0.005). This conclusion is supported by the study done in Rania city, Kirkuk, and Khartoum city by (Sharif, et al., 2018) (Sameen, 2018 ) (Aziz & Lafi, 2011).
In contrast, (Hasballah, et al., 2019). stated that no significant correlation existed between gender, age, job experience, and marital status; negative correlations were also found between practice and years of experience.
The mean of knowledge was found suitable compared to the mean of practice, which was poor. The outcome of the study indicates that there were statistically significant differences between Nurses' practice at Pre-cardiac catheterization in age (p=0.001), Level of education (p=0.001), Years' employment (p=0.000), and Years of Experience in care of Pediatric Cardiac Catheterization (p=0.000) because (p-value <0.05). Nevertheless, no statistically significant differences have been found between Nurses' practice at Pre-cardiac catheterization in gender (p=0.363).
The outcome of the study shows that there were statistically significant differences between Nurses' practice at intra-cardiac catheterization in age (p=0.033), Level of education (p=0.000), Years' employment (p=0.017), and Years of Experience in care of Pediatric Cardiac Catheterization (p=0.001). This finding is supported by the study (Mahmood et al., 2021). which stated that the Level of Nurse's knowledge and practice of cardiac catheterization regarding patient safety increase with experience of the job.
The study's result shows that there were statistically significant differences between Nurses' practice at post-cardiac catheterization in age (p=0.009), level of education (p=0.000), Years' employment (p=0.031), and Years of Experience in care of Pediatric Cardiac Catheterization (p=0.002) because (p-value <0.05) This showed that nurses have good knowledge about post-cardiac catheterization complications. It was found that the significant value of P < 0.0001 by applying a correlation which showed there was a good association between practice and knowledge (P < 0.05).

CONCLUSIONS
The present study shows that most participants were male aged between(45-49). Years.The study demonstrated that nurse's knowledge in pediatric cardiac catheterization was satisfied, and more than half of them worked with "good practice." Further, the study's result indicates a significant positive statistical correlation between (nurse's knowledge and nurse's practice at Pre-cardiac, Intra-cardiac, Post-cardiac). The study recommends a specific training course for all the nurses working with children undergoing pediatric cardiac catheterization, and also further qualitative studies are also recommended.

ETHICAL CONSIDERATIONS COMPLIANCE WITH ETHICAL GUIDELINES
The study's protocol was accepted by the council of the College of Nursing and approved by the ethical committee of the College of the University / Medicine of Sulaimani. An official letter has been presented from the College of Nursing to the Sulaimani General Directorate of Health to obtain facilitation and cooperation; consequently, an agreement letter has been submitted from the Sulaimani General Directorate of Health Sulaimani Cardiac Hospital.

FUNDING
The researcher did not receive any grant from funding agencies in the public, non-profit sectors, or commercial for this research.

AUTHOR'S CONTRIBUTIONS
Study concept; Writing the original draft;Data collection; Data analysis and Reviewing the final edition by all authors.