It is a descriptive study conducted in Bujumbura city the capital of Burundi during the period of one month from 28^th November to 28^th December 2019 in pediatric wards of three HCFs: Van Norman Clinic (VNC), Military Hospital of Kamenge (MHK) and Hospital University Center of Kamenge (HUCK). Burundi has an area of 27,834 km² and is located in central Africa between 2˚45' and 4˚25' latitude south, 28˚C 50' and 30˚53'30" longitude east. It is bordered north by Rwanda, west by democratic republic of Congo and east south by Tanzania. Its population is estimated to 8.05 million in 2008 with 50.8% female and 49.2% male, annual population growth is 2.4% and density is 310 persons per km². Burundi is ranked among the African countries most densely populated which the fertility rate is 6.4 children per woman [8]. The average temperature is 23˚C and annual precipitations are 1274 mm [9].

Bujumbura has primary and secondary health care services with three levels of administration of health care system at national, provincial and district levels [10]. About 22 HCFs (Health Care Facilities) with inpatient services located in Bujumbura, 3 HCFs were selected for this study assess the knowledge of pediatric nurses during the PNC. The chosen HCFs were Van Norman Clinic, Kamenge Hospitalo-University Centre and Military Hospital of kamenge respectively and they are all located in north area of Bujumbura (Figure 1).

Three HCFs selected for this study, two of them are public and one private HCFs, which have different attributes such as clinic, military, and university. All three HCFs are located in the same health district (North district of Bujumbura) (Figure 1). These HCFs share the similar target for teaching mission, where all nursing students and medical students are trained, and more advanced care is delivered. Behind that mission, most small primary HCFs in Bujumbura transfer their patients in these three HCFs and they have high accommodation capacity and treat the largest number of patients.

Population

The total population for these three HCFs was 98 nurses. The specific number for each hospital was 43 nurses, 25 nurses and 30 nurses for VNC, MHK, and HUCK respectively. The sampling was made by convenience and Dillman formula was used for sample calculation [12].

Inclusion Criteria

For making better a study without any difficult about the sample, the following criteria were applied such as: being a worker of the HCFs in the pediatric nursing department, holding a post in the area of study, and accepting to participate in the study. Nurses working all shifts could be included in the study.

Non Inclusion Criteria

The following elements were the basic of determining the non-inclusion criteria such as: Not to be: part of the flying team; nurses from other departments, and nursing trainee.

The questionnaire was developed in French as a language currently used by the majority of nurses, and the kirundi version contained the questions related to the nursing theory was used for helping the nurses to understand better the questionnaire. The data were collected by researcher through the questionnaire that has been distributed to the nurses face to face. At the same time, the nurses proceeded by completing the questionnaire. For conducting better the research, a pilot study was done by 3 nurses at PRCH (Prince Regent Charles Hospital) to pretest the tool. The main components for the questionnaire were the following parameters: demographic data, the study level of nurses, experience at work, nursing diagnosis formulation, barriers related to the best practices and nursing theory implication. The answers given by the nurses were translated in English accordance to the above parameters mentioned.

Sampling

In this study, the sample was calculated using the Dillman formula [12].

N s = N p ( p ) ( 1 − p ) ( N p − 1 ) ( B C ) 2 + ( P ) ( 1 − P )

Where:

N s = completed sample size needed (notation often used is n).

N p = size of population (notation often used is N).

p = proportion expected to answer a certain way (50% or 0.5 is most conservative).

B = acceptable level of sampling error (0.05 = ±5%; 0.03 = ±3%); C = Z statistic associate with confidence interval (1.645 = 90% confidence level; 1.960 = 95% confidence level; 2.576 = 99% confidence level).

1) By using the formula the sample at HUCK was obtained as follow:

N s = ( 43 ) ( 0.5 ) ( 1 − 0.5 ) ( 43 ) ( 0.05 1.96 ) 2 + ( 0.5 ) ( 1 − 0.5 ) = 39

2) By using the formula the sample at VNC was obtained as follow:

N s = ( 25 ) ( 0.5 ) ( 1 − 0.5 ) ( 25 ) ( 0.05 1.96 ) 2 + ( 0.5 ) ( 1 − 0.5 ) = 24

3) By using the formula the sample at MHK was obtained as follow:

N s = ( 30 ) ( 0.5 ) ( 1 − 0.5 ) ( 30 ) ( 0.05 1.96 ) 2 + ( 0.5 ) ( 1 − 0.5 ) = 27.8 = 28

The total sample size for three HCFs (HUCK, VNC, and MHK) was 91 nurses during this study.

Sample technique

The randomization process was applied in all HCFs where the nurses were divided into the groups referring to their level study, and then the number was written in the shift paper from one to 100. The nurses who picked the impair number was accounted to be taken in the sample during the study. For avoiding the bias in all HCFs, the extra numbers were added in the shift papers for replacing whose could be absent during the survey.

The questionnaires were checked for completeness of the data based on the developing questionnaires as mentioned at the end of each day and were then given serial numbers and coded before entering into the computer. A statistical Package for Social Scientists version 16.0 software (SPSS) was used to analyze the data which were presented as frequency table, bar graphs.

During the assessment, the diagnostic assessment type was chosen among the forms of assessments (diagnostic, formative and summative) referring on the elements shown in the table below and basing on the parameter of the survey [13]. Each criteria was quoted out 10.

After that the research committee of hope Africa University approved the research protocol (N/Ref: DP/132/2019). The permission of data collection obtained from the authorities of the same school who gave us the letter asking the access to the investigation in the 3 HCFs (N. Ref: CVN/071/2019 and N/2019/DGCHUK.3026/M.5). Before the collection data process, we ensured to the nurses that the information collected from them won’t be anytime used in order to affect them negatively. Verbal informed consent was obtained individually from nurses who were concerned by the study. The study was voluntary, and the confidentiality was assured during all process of data collection considering the ethical consideration.

The demographic data of participants are represented in Table 2. The range of years varied from 20 to 60 years old at the average of 33.33%. Among all participants females were found at high level (65%) against male participants (34%).

The study levels of nurses in three HCFs were represented in Figure 2. The levels A₃ (nurse who had done 2 years of high school), A₂ (nurses who had done paramedical high school), A₁ (nurses who had done 3 years of university in ancient system), A₀ (nurses who did a school of nursing 3 years at university in new system of BMD) were reported with at 15.6%, 64.1%, 10.9% and 8.4% respectively.

The experience at work for the nurses was represented in Figure 3. 15.6% (14) of nurses were accounted to have an experience between a month to one year, one year to three years and four years to seven years found in the same range of 20.3% (19). Another side 17.2%(16) was obtained for both 8 years to 11 years and 12 years to 15 years and 9.4% (9) has an experience of 15 years and more.

The steps of IBP during the nursing diagnosis process in three HCFs are represented in Figure 4. All steps were not recognized by the majority of nurses with 84.6% (33), 87.5% (21), and 89.3% (25), respectively for CHUK, VNC, and MHK.

Barriers which affect the best practice in pediatric unit were represented in Figure 5. 20% (18) of concerned nurses don’t have freedom in decision making, 30% (27) complain the lack of good communication, and 20% (18) of nurses don’t have adequate time to do well the practice. The specification was obtained at 4% (4); bad care management at 30% (27). Only 6% (6) can discover a problem of children. Other characters like relation between nurse and patient and gap in professional judgment were not recognized with 85% (77) and 65% (59) respectively.

Figure 6 shows the knowledge level of nurses about the using of NT in

nursing practices. 92% (94) don’t implicate a holistic approach during their practice, and 93% (85) do not know the importance of holistic theory. The orientation based on theory was found at 5% (5), compared to the evaluation of PNC that comes with 4% (4). In the same orientation, the use of research in pediatric inpatient was quoted with 5% (5) of nurses only. In other sides, the evidence based practice (EBP) was recognized by 5% (5).

Female nurses were represented with high number at 65% of the participant against male participants at 35% (Table 1). Even if the number of women looks high, it could not cause high risk to the practice. This high number could be caused by culture where men used to say that the nursing role concerns females only contrary to eelier centuries where it is said that even the first nurse was a man [14]. Ersilia continued to confirm that the best practice has no relation gender.

Age, the results reveal that the range of ages was reported in intervals between 20 years to 60 years. This is caused by the fact that some of the HCFs of the study dated many years ago. This could cause problems if nurses could keep working with experience at work without enough knowledge about the best practice in PNC. It is also a matter for young workers because even if they still have enough force to work but they did not study all processes of nursing cares based on EBP due to the poor curriculum developed by schools of nursing. The similar study conducted by David on the place of the patient and his family in the process of nursing care in hospital area has found the same contribution [15].

The A₂ level was represented with a high percentage (65%) in all three HCFs compared with other levels. Burundi since 1945 to 1997, the nursing skills were taught only at high school, and the majority of nurses were accounted to having A₃ and A₂ levels, but among them the A₂ nurses were working in the HCFs with a big package. However, the A₃ level was considered as a help professional in the nursing practices system and are located in the small HCFs et health district hospitals [10]. This was explained by the fact that there was no other level with high competencies compare A₂. For these three HCFs, the CHUK and MHK are accounted among the HCFs do have several years for delivering nursing cares than CVN. The same reason can be applied for these two HCFs that were accounted with the majority of A₂ and A₃ level 60% (55). In other side, the CVN is new clinical affiliated to the private university and its activities do have a total of 9 years, therefore, the majority of A₀ and A₁ were assessed in this clinic with 15% (14) out of 18 nurses. This explains the reason related to the existing of new levels (A₁ and A₀) in the health system of Burundi from 1997. In the case of the PNC could depend on the levels, all three HCFs could fail by taking care the patients, however, the previous comparison doesn’t explain that the four levels have the same capacity to develop skills and competencies in pediatric unit because their curriculum is totally different, adding also the experience especially for A₂ and A₃ levels.

Currently, the three HCFs concerned by this study are the reference hospitals do not allow the A₃ and A₂ levels, because their competencies are low than nursing care outcomes. The findings in this study, however, show the contrary as well as the majority of nurses are the A₃ et A₂. In the case of the PNC could depend on the level, these three HCFs could be assessed without PNC competencies.

The economic crisis in the country could be one among the weaknesses that can contribute by limiting the access of nurses with high level in the HCFs services regarding to their salaries [16]. This could cause the inadequate number of highly qualified nurses in the pediatric unit of the two hospitals.

Considering the previous situation as above mentioned, all three HCFs should give a chance of a job for the A₀ In addition the universities in collaboration with the government should put in place the masters program and A₀ for increasing the number of nurses who have a high degree in nursing skills for the PNC and help the nurses to develop their maturity during the nursing skills in the HCFs [17]

In this study, a lot of years of experience were assessed to be held by 17% and 17%, respectively with 8 to 11 years, and 12 to 15 years, but it was accounted with average of 16.7 years for all nurses in the three HCFs. This could be a chance for the three HCFs for being the excellent during the PNC even the nurses do not have the background required for developing better the nursing cares inpatients pediatric wards (Figure 2). The same explanation as above mentioned based on the years of existing HCFs could be related with this current situation. In the case of the practices of PNC could be based on the experience, one among the two hospitals (VCN) could meet some difficulties for ensuring the quality of nursing cares. However, the studies conducted in other countries like Australia and Canada about a systematic approach to maximizing nursing scopes of practice, show that the experience at work can play a major role in making good practice in terms of making a good nursing care plan based on EBP [18]. The lack of this study (limitation) is that it doesn’t focus on the comparison of experience at work and practices for making the correlation between these two aspects. For improving more this study in the perspectives, it is important to assess the practice conducted by the nurses if the quality is based on the experience. Based on the contribution developed by other authors [12], it is important for these three HCFs to consider the experience during the PNC. In spite of other studies, which was conducted has found different propositions: the best practice is successful when qualities like trust, diversity, mindfulness, interrelated, respect and effective communication are recognized during the accomplishment of the work [19].

The nursing practices need the competencies and advanced nursing skills. However, when the nurses do not have an orientation based on nursing evidences (IBP and EBP) [20]. The results in this study, however, they showed the contrary situation because the majority (97.5%) of nurses were not able to know the nursing plan, the involvement of parents, the diagnosis formulation, the nursing theory application and the importance of nursing monitoring and assessment that constitute the nursing practices process. It is explained by the lack of involvement of all stakeholders especially the head of HCFs and the responsible of services in the HFCs investigated in this study. The gap of nursing theory application and the poorest curriculum developed at universities could be also the main obstacles for ensuring to nurses in these to realize the nursing practices in the pediatric services of these HCFs, in the case of all nurses were not able to know the process of nursing theory into practices. The consequences could raise up in the pediatric services of these HCFs, as well as the improvement of nursing practices can be stopped according to the lack of nurses facing on the practices. The main consequences could be the increasing of incidence of patients in these HCFs, even the mortality could be assessed in that situation. The same consequences were assessed in different countries, where the lack of best nursing practices in pediatric services was analyzed to be the main causes [21]. High school level in nursing (A₂ and A₃) in the three HCFs where higher than other levels (A₁ and A₀). The process of nursing diagnosis was not recognized with the average of 97.6% of nurses in all HCFs referring to the experience at work. This overall pattern did not vary by HCF, but differed depending on the type of level. The experience behind the level of study could be the parameters that can help to orient the HCFs by making decision for the promotion of the PNC in these HCFs. Therefore, for getting the best results during the PNC, it is important to consider nurses based on their curriculum and competencies at work. It is also important to take account on nurses who are able to orient the nursing skills during practices referring to the holistic nursing; working environment, the best educational system and the fact of encouraging nurses with different motivational factors play a big role in the implementation of holistic care dispensation [22]. For that it is an emergency situation for the government to revise the process in which the nursing care is offered into HCFs. In addition, a specific committee in the pediatric unit should be set in these two hospitals regarding to the training system.

The studies that may help to orient the information above mentioned related to the lack of nursing schedule into the services of HCFs were developed by Hamilton of state for the science review about the primary care where it was found that nurses are considered as the backbone of pediatric care that administer the vaccines, manage the ventilators in the PICU (Pediatric Intensive Care Unit), educate parents on how to care their own children. In addition, they provide the continuity of care across the specialists, therapists and techs of modern medicine [23]. This was also considered as the obstacles during the PNC in these three HCFs investigated. To resolve this problem it is important to consider all nurses who work in pediatric unit as the managers of PNC and to allow them to be able for becoming empowered and make good and best practices by considering children and their families in all process of nursing care in the hospitalization [24].

During the implementation of PNC some barriers can be assessed as the obstacles that can block the progress of nurses for taking carefully the patients. In this context, the consequences can be assessed immediately for the patients and the families of these later. In this study, the barriers which affect the best nursing practices in pediatric ward were assessed. For all nurses in the three HCFs, the absence of freedom in decision making, the lack of communication, the inadequate time and the specification of roles were recognized by the majority of nurses as the barriers for the first step of nursing practices in their service with 80%; 70%; 80% and 96% respectively.

It is due by the fact that the nurses do not have job description. This may cause some problems during the nursing implementation in pediatric ward, because there is no any orientation for providing the nursing care of quality The monitoring and assessment of nursing care conducting in the services could not be carried as well as each nurse has its specific orientation. This could affect directly the patients through the lack nursing cares based on poor investigation referring to the inadequate evidence nursing tasks. Because the nurses do not enough time for using nursing theories during the nursing cares in pediatric service adding also the little time recorded for nurses during the practices by staying together with the patients and their families; the worst care management, the incapability in problem discovery, bad relation nurse-patient and the gap in professional judgment were assessed by the nurses also as the main barrier in nursing pediatric practices with 70%, 94%, 85% and 80% respectively. The same situation with similar explanation were developed by other authors in different studies, where the lack of organization into the service, the lack of leadership management were assessed as the fact that influencing negatively the orientation of nursing practices in the pediatric unit [22]. For avoiding these current issues in the pediatric service, it is important for the leaders of HCFs to establish the job description for each nurse based on its specific level.

The same studies were conducted in America, heavy workload of hospital in pediatric service, nurses experience, inadequate supply of nurses, reduced staffing and increased overtime, and reduction inpatient length of stay was assessed in the study carried out as the main causes of lack PNC in the HCFs [25].

For increasing the quality of PNC in three HCFs of Bujumbura, the tracking system of patients from their entrancing in the hospitalization (pediatric ward), their evolution during the nursing care administration, they exist from the service, and their returning at home could be planned in the PNC steps or process for ensuring the outcomes of each patients during the period determined.

Poor communication between nurses and other health care providers was assessed by some authors as the causes that can influence negatively on the quality of PNC especially for the patient safety, quality of care, patient outcomes, and staff satisfaction [25]. The communication could be also, one of mechanisms that could help the leaders and nurses to conduct well the PNC, through the mode of communication by developing some strategies like the assessment report cares for each patient into the hospitalization, and the communication on time between nurses, leaders, and the patient’s families.

The EBP is the final stage of nursing care inpatients service, where the nurses are supposed to take care a patient based on the deepest investigation (IBP) that may occur the nursing diagnosis. In addition, the EBP phase helps the nurses to do the plan where all nursing care approaches should be realized referring to the EBP process [26]. The results in this study, however showed that the holism implementation, the importance of holistic theory, the knowledge-based on theory were not recognized by 92%, 93% and 94% respectively. In addition the practices oriented on nursing theory, the PNC evaluated by using nursing theory, the application research in NPC and the evidence-based practices knowledge were not recognized by the nurses average of 96% (87), 95% (86), and 95% (86), respectively. It is explained that the nurses do not recognize the nursing theory. In addition, the health public system of Burundi do not have the national guidelines related to the nursing practices and the regulation order of nurses committee that could help the nurses to ensure the monitoring and assessment of nursing care in the pediatric services in the HCFs [25]. Considering this mismanagement, the consequences could raise for the nursing care implementation in the pediatric ward as well as the nurses follow the wrong diagnosis and wrong EBP. The same information was developed by Cooke in his study carried out in US

[4]. To avoid this, it is important to the government to establish the guidelines related to nursing practices in HCFs, and to put on place a national order regulation for nurses in Burundi. It is also required for the HCFs to establish the norms for helping the nurses during practices and to put on placing the committee that could help for ensuring the PNC in HCFs. For that the impact will be recorded directly to the patient by the worst assistance during the inpatient process.

After that the nurses have been evaluated, it was found that their level of knowledge was too low at 32%. this could be the major impact for implementing best nursing care in PNC which could result the delay in hospitalization, high risk of mortality and or morbidity which affects the families economic status of sick children. This could be also caused the lack of assistances by professional mentors; education not based theories of nursing, low income of health care facilities which do not supply the needed materials in services. The solution of this problem could be successful if HCFs leaders recruit experienced nurses and give the needed requirements for the best practice. It is better to prepare the workshops about PNC for the purpose of updating the knowledge level of nurses. The study conducted by Fraser mentioned that diagnostic assessment is more applied in education to assess student knowledge when learning; this could mean a lot about nurses that they could be assessed day by day as continued training in order to help nurses stay updated [27].