In vitro assessment of the synergism between extracts of Zanthoxylum zanthoxyloides and Zanthoxylum leprieurii and some standard antibiotics - Juniper Publishers

 

Pharmacy & Pharmaceutical Sciences- Juniper Publishers

Abstract

Purpose: To survive in harsh environments, plants developed functional and metabolic adaptive mechanisms. One of the most relevant defense strategies is the biosynthesis of secondary metabolites, including terpenoids, alkaloids, flavonoids, and phenolics that are accumulated in cellular organelles or secretory structures. Hence, plants are recognized as a valuable source of natural products and for thousands of years very diverse herbal formulations were created to treat several diseases. Zanthoxylum zanthoxyloides and Zanthoxylum leprieurii, two Rutaceae species native to Guinea-Bissau, are well known for their ethnopharmacological relevance.

Methods: In the present study, the in vitro antimicrobial activity of these plants against human pathogens was assessed and the phytochemical profile was screened. The extracts of roots and young leaves were obtained by sequential extraction of increasing polarity (n-hexane, CH2Cl2, EtOAc, MeOH and H2O) and tested against Gram-positive and Gram-negative bacteria. The minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) were determined, as well as the evaluation of the synergic potential of the extracts.

Results: Z. leprieurii leaves extracts, the most apolar ones, had the highest antimicrobial activity, being able to inhibit the growth of Enterococcus hirae and all the Staphylococcus strains assayed, including the resistant ones. A synergic effect between the Zanthoxylum species extracts and standard antibiotics was found, reverting the activity of resistant strains. The phytochemical screening revealed the presence of terpenes, flavonoids, and phenolic compounds, known to have antibacterial properties.

Conclusions: The obtained results point to the validation of their use in tradition medicine and emphasize the worthwhile of additional studies of these species to better understand the compounds and mechanisms that may be valuable to restore antibacterial activity.

Keywords: Zanthoxylum zanthoxyloides; Zanthoxylum leprieurii; Antimicrobial activity; antibiotics; Synergic effect; Bioactivity

Abbreviations: MIC: Minimum Inhibitory Concentration; MBC: Minimum Bactericidal Concentration; LISC: Lisbon University Herbarium

Introduction

The use of plants as a medicine has been reported since the beginning of civilization. Diverse plant parts and extracts led to innumerous formulations created to treat a wide variety of diseases [1-3]. Nowadays, plants are still part of traditional medicine but also play a greater role on the source of new compounds that can be active by themselves or be used as lead molecules to developed new drugs.

The discovery of penicillin in the early 1940s, led to the development of several classes of compounds with antibacterial activity which allowed the reduction of mortality and morbidity caused by infectious diseases. However, the irrational and uncontrolled use of antibiotics by health professionals, animal industry and agriculture resulted in the emergence of resistant microbial populations. As a result of this strong selective pressure and increased volume of intercontinental travel, the development and transmission of multiresistant bacteria is turning into a serious public health problem [4,5].

According to [6], the mechanisms of antibiotic resistance can be summarized in four major classes: I. Modifications of the antibiotic molecule; II. Decreased antibiotic penetration and efflux; III. Changes in target sites; IV. Resistance due to global cell adaptations. The combined effects of these mechanisms associated with rapid growth rates and the ability to exchange genes led to the development of methicillin resistant (MRSA), Vancomycin Intermediate Staphylococcus aureus (VISA) and Vancomycin Resistant Enterococci (VRE). For instance, in 15 European countries more than 10% Staphylococcus aureus infections are caused by methicillin-resistant strains (MRSA), with several countries, namely Portugal presenting resistance rates closer to 50%. Several highly resistant gram-negative pathogens like Acinetobacter species, multidrug-resistant, Pseudomonas aeruginosa, carbapenem-resistant Klebsiella species and Escherichia coli are also emerging as significant pathogens, transforming antibiotic resistance in one of the greatest public health threats of the 21st century [7].

The occurrence of various infectious diseases and the increasing prevalence of antibiotic-resistant pathogens have become a serious threat to human health, and it is necessary to find new antimicrobial agents capable of reversing antibiotic resistance. Pharmaceutical companies, in the past few decades, have shifted their development efforts to chronic diseases and antiviral compounds instead of the development of new antibiotics molecules [8]. Several previous studies proved that there is a huge potential of plant-derived compounds as antibacterial and as a resistance-modifying of other antibiotics through synergistic behavior [9]. Therefore, in vitro antibacterial assessment of plants extracts, their phytochemical profile screening and the evaluation of the synergic affect when combined with antibiotics reversing the bacteria resistance may lead to a new approach on antiinfective therapy [10].

The selected species for the present study are autochthonous plants from Guinea-Bissau, a small African Portuguese speaking country, where there is a wide range of plants used in herbal medicine to treat endemic diseases as result of fragile health services, easily found in local markets and pharmacies [11]. This country is estimated to have a vascular flora with around 1507 species, 1495 of which are native. Since 1997, to protect biodiversity, a network of protected areas was established in Guinea-Bissau, a collaboration between National Institute for Biodiversity and Protected Areas and International Union for the Conservation of Nature [12]. Traditionally used and present in Guinea-Bissau flora, there are two species of Zanthoxylum with medical properties. Zanthoxylum zanthoxyloides is used to treat malaria, sick cell anemia, tuberculosis, ulcers, hemorrhoids, injuries, and syphilitic wounds as well as arthritic pain [13]. Zanthoxylum leprieurii is traditionally used in the treatment of HIV,malaria, urinary infections, rheumatic pain and used as antiseptic [14]. The present work aims to evaluate the in vitro antimicrobial activity of the two Zanthoxylum species, Z. zanthoxyloides and Z. leprieurii, against a selected panel of microorganisms, to better understand their application in traditional medicine. The potential synergistic effect of plant extracts with standard antibiotics was tested as well as screening of the phytochemical profile.

Materials and Methods

Plant materials

Samples of Z. zanthoxyloides and Z. leprieurii roots and young stems were collected during 2016-2017, in Orango island, Bagos archipelago, Guinea-Bissau and dried at room temperature. Voucher specimens were deposited and identified at the Lisbon University Herbarium (LISC).

Plant extracts

The plant material was powdered, obtaining 6g of leaves and 30g of roots of Z. zanthoxyloides and 13g of leaves and 27g of roots of Z. leprieurii. Each powdered material was subjected to extractions with five ascending polarity solvents: n-hexane (n-hex), dichloromethane (CH2Cl2), ethyl acetate (AcOEt), methanol (MeOH) and water (H2O). Ensuing the usual procedures [15] each solvent extraction took about 24h, at room temperature, with occasional shaking followed by decantation, filtration, drying and storage at -20ºC, until use.

Bacterial strains

To assess the in vitro antimicrobial activity of each plant, extract the model proposed by [16] was considered. The microorganisms include a range of Gram-positive and Gram-negative bacteria, all known to be the cause of several human diseases Table 1.

Antibiotics

The standard antibiotics amoxicillin and oxacillin, purchased from Sigma (Madrid, Spain).

Minimum inhibitory concentration (MIC)

The minimum inhibitory concentration (MIC) values were determined by the microplate broth microdilution method according to CLSI (2019). Briefly, on each well of the microplate, 100 μL of the medium plus 100μL of each extract solution to be tested were added, obtaining concentrations ranging between 500-7.5μg/mL. An inoculum of each microorganism was also added (10μL; final concentration 104cfu/mL). Appropriated antibiotics were used as reference for antibacterial activities. After incubation at 37ºC for 24 h, the optical density at 630nm was measured in a Biotek ELX 808 plate spectrophotometer to assess the bacterial growth and confirmed by macroscopic evaluation. The samples with MIC value ≤ 100μg/mL were determined to have antibacterial activity. All assays were performed in triplicate.

Minimum bactericidal concentration (MBC)

The minimum bactericidal concentration (MBC) was evaluated following the CLSI method [17] with some modifications. 10μL of suspension from each well showing no visible growth was spread out on a Muller-Hinton agar plate. Colony growth was observed after 24h incubation at 37ºC. MBC corresponds to the lowest concentration of extract that reduces almost at 100% the viability of the bacteria.

1ATCC: American Type Culture Collection, Maryland, USA; 2CIP – l’Institut Pasteur Collection, Paris, France; 3MSSA: Methicillin-Sensitive Staphylococcus aureus; 4MRSA: Methicillin-Resistant S. aureus; 5VISA: Vancomycin-Intermediate S. aureus.

Synergic effect of extracts with standard antibiotics

In order to determine the type of interaction between the extracts and the standard antibiotics (amoxicillin and oxacillin), a checkerboard assay was performed against the MRSA strain ATCC 43866 and VISA strain CIP 106760 according to [18]. Two-fold serial dilutions of antibiotic was prepared on the horizontal rows of microtiter plate and then cross- diluted vertically by two-fold serial dilutions of the extracts. The concentration of each antibiotic ranged from 1 to 1/2048 of the MIC and the concentration of the compounds from 1/2 to 1/64 of the MIC.

The synergic effect was determined based on the fractional inhibitory concentration index (FICI), calculated according to the formula

FICI= FIC(A)+FIC(B)

where, FIC(A)= MIC (A in the presence of B)/MIC (A alone) and FIC(B)= MIC (B in the presence of A)/MIC (B alone) [18]. When FICI ≤ 0.5 a synergic effect is considered. FICI ranging 0.5-4 are classified as indifference and FICI values > 4 an antagonistic effect is pondered [18].

Phytochemical screening

A semi-quantitative phytochemical analysis to detect the major chemical groups found in each extract was carried out through thin layer chromatography (TLC) on silica gel plates [19]. Proper mixtures of eluents were used to develop and the spots were revealed with appropriated spray-reagents made according to [20]. being: anisaldehyde-sulfuric acid reagent for terpenoids,Dragendorff reagent for alkaloids, natural products–polyethylene glycol (NEU) reagent for flavonoids and Fast Blue salt reagent for phenolic compounds. Results were displayed between absent (-) and a strong intensity (+++).

Results

Minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC)

A total of 20 extracts of two Zanthoxylum species were prepared where the bactericidal and bacteriostatic activity (MBC and MIC) were evaluated against an enlarged panel of Gram positive and Gram negative sensitive and resistant bacteria strains. The results are presented in Table 2.

The MSSA growth was inhibited by Z. zanthoxyloides n-hex root extract (MIC 60µg/mL) and by both Z. leprieurii leaves and roots AcOEt extracts (MIC 60µg/mL). Z. zanthoxyloides AcOEt leaves extract and Z. leprieurii n-hex and CH2Cl2 leaves extracts inhibit the development of the MRSA strains (MIC 60 µg/mL). The VISA strain was inhibited by Z. leprieurii CH2Cl2 leaves extract (MIC 60µg/mL). Z. leprieurii CH2Cl2 and AcOEt leaves extracts also presented activity against S. epidermidis (MIC respectively 15 and 60µg/mL). Z. zanthoxyloides leaves n- hex extract, Z. leprieurii leaves CH2Cl2 and AcOEt extracts and Z. leprieurii roots AcOEt extract exhibited inhibitory activity against E. hirae (MIC 60μg/mL). The most active plant part was the Z. leprieurii leaves and the extract presenting major activity was the CH2Cl2 extract which displayed activity against MRSA, VISA, S. epidermidis and E. hirae strains.

Synergic effect of extracts with standard antibiotics

In order to evaluate the interactions between the extracts and two reference antibiotics used to treat S. aureus infections (amoxicillin and oxacillin), the checkerboard assay was performed with two S. aureus strains one methicillin-resistant (MRSA, ATCC 43866) and vancomycin-resistant (VISA, CIP 106760). The results for extracts with fractional inhibitory concentration index (FICI) 1 or lower are displayed in Table 4 and Table 5. FICI values under 0.5 are considered to show a synergic interaction between the antibiotic and the plant extracts [18].

Phytochemical screening

Results are displayed in Table 3.

MSSA: Methicillin-Sensitive Staphylococcus aureus; MRSA: Methicillin-Resistant Staphylococcus aureus; VISA: Vancomycin- Intermediate Staphylococcus aureus; VRE: Vancomycin-Resistant Enterococcus; Nd: Non-Defined; (-) not tested.

Discussion

Analyzing the results displayed in (Table 2), the bioactive extracts are the non-polar ones, mainly CH2Cl2 and AcOEt extracts which are rich in terpenes and flavonoids (Table 3). Terpenoids have antibacterial properties in nature, acting by an unclear mechanism. They seem to disrupt the membrane of bacteria cell [8]. Flavonoid’s bioactivity is markedly related with the antioxidant action. Nevertheless, several properties have been reported as anti- inflammatory, antimicrobial, antiviral, antiallergic and antitumor [21-23].

No antibacterial activity was found for Gram-negative bacteria and B. subtilis. The presence of a highly hydrophobic outer membrane that works as a permeability barrier in this group, can explain those results [24]. Comparing the MIC / MBC values (Table 2), it is possible to deduce that the extracts that presented antibacterial activity will act as bacteriostatic agents [25]. MIC is considered the standard parameter to determine the susceptibility of bacteria to an external agent like a compound or extract and corresponds to the lowest concentration of compound/extract that inhibits the bacterial grow. MBC is considered a relevant index of the bactericidal activity of antimicrobial agents. MBC corresponds to the lowest concentration of extract that reduces almost at 100% the viability of the bacteria. If the MIC and MBC are in the same range, the extract will probably kill the bacteria.

The antimicrobial activity of Z. zanthoxyloides polar extracts (ethanol and water extracts) against resistant isolates of S. aureus was previously reported by [16]. Similarly, the antibacterial activity of Z. leprieurii and Z. zanthoxyloides essential oils against a MSSA strain was reported by [26,27] published the results of the antibacterial activity of steam bark MeOH/H2O extract of Z. leprieurii against a MSSA strain. Those results sustained the ethnopharmacological properties described for these Zanthoxylum species, once they are mostly used for intestinal disorders and wound care.

Staphylococcus aureus strains are one of the major pathogens worldwide related with a large range of clinic manifestations with different levels of severity, triggering lethal infections, by synthesizing a large variety of toxins and enzymes. S. aureus strains developed an increasing antibiotic resistance such as a methicillin resistance (MRSA) and a vancomycin-intermediate resistance (VISA) [28]. The emergence of multidrug resistant bacteria strains and the increase of the pathogenicity of the strains are intimately related [29]. One approach to overcoming bacterial resistance mechanisms and restoring antibiotic efficacy is the use of inactive plant extracts when administered individually, in combination with antibiotics. This combinatory strategy may play an important role on the management of challenging infectious diseases [18].

In order to establish the potential interaction between the plants extracts and references antibiotics the checkerboard assay was performed as previously described. The extract that stood out was the Z. zanthoxyloides roots MeOH extract, which by itself presents no relevant antibacterial activity against resistant VISA strain (MIC= 500μg/mL) but was able to restore synergistically the antibacterial activity of the two antibiotics tested, amoxicillin from 60 to 4 μg/mL, (FICI = 0.18) and oxacillin from 125 to 7.5μg/mL (FICI = 0.31), corresponding in both cases to a 16- fold reduction. Z. leprieurii leaves AcOEt was also able to interact synergistically with oxacillin against the VISA strain, lowering the antibiotic MIC from 125 mg/mL to 7.5μg/mL (FICI = 0.31), corresponding to a 16-fold reduction.

For the MRSA strain (ATCC 43866) Z. leprieurii CH2Cl2 extract was able to revert synergistically the antibacterial activity of amoxicillin decreasing the MIC value from 60 to 4μg/mL (FICI= 0.46) corresponding to a 16-fold reduction. Z. leprieurii roots MeOH extract also displayed some synergistic interaction with amoxicillin against this strain, lowering the antibiotic MIC from 60 to 30μg/mL (FICI =0.5). The water extract of Z. zanthoxyloides roots when combined with oxacillin, decreased the antibiotic MIC value from 125μg/mL to 15μg/mL against MRSA strain (FICI=0.37).

Conclusion

Due to the growing problematic of drug-resistant bacteria it is urging to discover new compounds and new pathways to control and revert antibiotic resistance, to regulate the increasing bacterial derived diseases worldwide. The use of natural products as plant extracts reveal to have a multi target mechanism of action leading to a reduced prevalence of bacterial resistance. Therefore, the study of plant compounds and their synergistic interaction is a fundamental step in overcoming community health problems arising from current bacterial infections.

Some of the studied extracts were active against Gram positive strains but the results that stood out were the synergistic activity that some of the extracts presented, being able to restore the activity of the tested antibiotics. Overall, these results emphasize the worthwhile of additional studies of these species to better understand their efficacy and safety in traditional medicine and the mechanisms behind the restore of the antibacterial activity.

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Impact of Training on Nurses Performance and Productivity at Neonatal Intensive Care Unit (NICU)- Juniper Publishers

 

Nursing & Health Care - Juniper Publishers

Abstract

Introduction:Neonatal Nursing is Sub-Specialty of Nursing that works with Newborns born with variety of problems. It generally encompasses care for those neonates who experiences problems shortly after the first initial hours of birth till 28 days of life. So, it is essentially important for caregivers to undergo training that not only enhance knowledge but bring change in behavior by holding accountability to care neonates and to meet general to specific needs.

Objective and Purpose:Objective of the study was to assess the impact of training on Nurses Knowledge and Skills working at Neonatal Intensive Care Unit.

Methodology:An Experimental Study was made and Basic Neonatology Course in collaboration with Department of Pediatrics, Nursing Education Services and Research Development and Skill Center of Liaquat National Hospital. The Program was initiated to train nurses and doctors dealing with neonates. Course evaluation was based on Pre and Post Test on ICU infection module, Mid-Quiz and Final Quiz based on different Sections. For skills development clinical Simulators were used at Skills Development Centre (RSDC) and rotations were done Neonatal Intensive care (NICU), Pleads OPD and Well Baby Centre were selected. Paired T-Test and ANOVAs was applied.

Results: Total 25 participants were enrolled. We found significant differences in mean scores 26.82±6.16 and 31.9±10.45 of mid quiz and final quiz respectively (p=0.005).

Conclusions:Study showed the impact of training on all participation and validated the significance of continuous nursing education and contributed to make nurses valuable and safe by enduring high quality care to neonates and helped nurses to have sound proficiency at NI

Introduction

The Care of Newborn and premature babies have undergone major development in recent years. Premature holds high rate of morbidity than full term babies. Nurses working with this specialty need to be clinically sound to provide quality care to sick neonates with general to specific medicine and surgical needs. Newborns are born with variety of problems and first 28 days of life are essential for them to survive. An article by Haydeh Heidari [1] was one of the sources of inspiration with Title “Stress management among parents of Neonates hospitalized in NICU”. Where authors had talked on the bonding of neonates to their parents as there is interruption and delays in paternal and neonate bonding and attachments. From same it was articulated that research on maternal - infant bonding has revealed that contact with infants is fundamentally important for the development of maternal self-confidence, security, sentimental emotional stability and preparation for learning about infant’s growth and development. Maintaining calm among parents of sick neonate is challenging for health professionals working in NICU. This research had highlighted the most significant aspect of care where parents collectively shared that supportive staffs had a positive effect on their ability to maintain calm. “We feel calm when we see how nurses are working hardly and it gives us hope that their hard work and God’s will are going to help our baby get better”. Although the impact of developmental care on premature infants has been investigated at length, often the issue of professional development and training related to this type of care has not been examined Milette [2].

The daily Rounds at NICU and need expressed by nurses we planned a training program especially for Neonatal Nurses. Many nurses expressed when they undergo professional qualification diploma or degree program, they are trained in general nursing aspects and when transition phase is encountered, and Units are assigned to enter in world of many sub-specialty which College of Nursing presently don’t have in their curriculum Sheri Price [3] wrote in one of the Article Administrative Sciences: The Importance of Continuous Professional Development to Career Satisfaction…. Nurses throughout their Career Span” that data collection showed Nurses wrote “We have a great general education that gives great head Start, but Now I’m Looking for Education. I’m looking for more specialized training and I’m Finding it’s really hard to find”. Based on the fact Neonate Post Basic Course Training was to see its impact on performance and productivity of Nurses and Midwifes working in NICU.

Purpose

The aim of the study was to educate nurses to gain the necessary knowledge and skills to be able to provide specialized care to neonates. The impact of training was seen in cardiorespiratory support, care of neonate going under surgical procedure and disease processes and work as team in promotion of recovery for sick neonate from serious illness and meet patient satisfaction standards.

Study Design, Material and Method

An Experimental Study was made, and Basic Neonatology Course conducted in collaboration with Department of Peads and Nursing Education Services along with Research Development and Skill Center of Liaquat National Hospital. It was combining effort taken to Train Nurses and doctors dealing with Neonates. Pre and Post Test on ICU infection module was taken followed with Mid-Quiz based on different Sections (Section A: MCQs, Section B: Case Study, fill in the blanks, true and false, Section C: was of small essay questions and Section D: Bonus question). Final Quiz was subjective Based with Short essay Questions, while for Clinical Simulators at RSDC were used, NICU, Peads OPD and Well Baby. Paired T-Test and ANOVAs was applied.

Training was done over period of 9 days, total of 45 hours. Total Theory Hours were of 32.5 and clinical hours 12.5 hours. There were 25 Participants. Clinical Location was as Research and Skills Center, Well Baby Nursery, NICU and Pediatric OPD at Liaquat National Hospital. For the first time it happened that Team of Pediatric Faculties and Surgeons from Medicine and Surgery, Residents from Medicine and Surgery, Nursing Managers departmental and Nursing Education Services, Research and Skills development Center Team, Infection Control and Head Nurses joined hands and came forward to train nurses. Altogether there were (28 Trainers). This was the set example of team approach which in actual reflected on purpose of the training. The nurses and independent raters found scenario-based simulation training more effective than traditional communication course. Introduction of simulation-based training to in-service nursing education could enhance nurses’ communication performance in clinical practice HSU LL [4].

Participants were from different Hospitals Liaquat National Hospital and Medical College (LNHMC), Hamdard University and Hospital (HUH) and Memon Medical Institute and Hospital (MMIH) - As Shown in Figure 1. Unit Based participation was seen where neonates are been cared; Labour Room, Neonatal high dependency Unit, Neonate intensive care unit, Pediatric (Combine Specialty of Medicine and surgical), Peads Intensive Care Unit and High Dependency Unit. Inclusion Criteria was Inclusion Criteria: Nurses and Doctors working in NICU and those dealing mainly neonates and Exclusion Criteria: Nurses and Doctors not working in NICU and neither deal patient’s category (neonates) - Figure 2.

Learning is one of the necessary conditions to transfer what was taught to a daily working practice and it is processed as soon as the person appropriates a certain knowledge as articulate by Mira VL [5] Interactive session through Presentations, were made by team of trainers on different topics which includes neonatal medicine, neonatal surgery, neonatal infectious disease and other general to specific are of newborns. Evaluation was done by conducting Mid Quiz to assess knowledge of disease process along with Nursing Care and Responsibilities. Mid Quiz consists of MCQs, Case Study, Fill in the blanks and true and false. This was significant markup that benefitted us not only to understand Knowledge level of the nurses but also their ability to comprehend with variety of questions style. Participants who had put a word with exact Responses in Case Scenario rated full as per section marks. Interestingly, responses in Quiz were checked by team and it was also found that People were comfortable more on responding Short essay questions. So, one of the learning limitations was noted and planned accordingly in promoting and enhancing concept building and critical thinking. Group Presentation was made to develop good group dynamics. Reflective Writings were part of every day. Cases were discussed, and thought-provoking question were given, and queries related were discussed and cleared. Final Quiz was conducted based on Short essay questions. Recommendations and conclusions were done with participants and trainers on one platform.

Statistical Analysis

Statistical Package for the Social Sciences Software (SPSS, version 21) was used for analysis. Quantitative variables such as scores of midterm, final term, pretest and posttest were presented in terms of Mean ± SD. Qualitative variables as gender, institutes, hospital units and designation were presented in terms of frequency and percentages. Student t-test and ANOVA was applied for finding mean differences between quantitative variables. P-value ≤ 0.05 was considered as significant.

Results

In our study, 25 participants were enrolled. 11(44%) were males and 14(56%) were females. They all were from different institutes in which 19(76%) from LNH, 4(16%) from HUH, 2(8%) from MMH. Out of all, 4(16%) from labor room, 1(4%) from neonatal HDU, 4(16%) from NICU, 6(24%) from paeds, 1(4%) from paeds medicine, 3(12%) from paeds surgery, 4(16%) from PICU, well baby nursery 2(8%). According to designation, only 1(4%) was senior resident, 2(8%) were resident, 15(60%) were RN, 4(16%) were RM and 3(12%) were RN/RM. We found significant differences in mean scores 26.82±6.16 and 31.9±10.45 of midterm and final term respectively (p=0.005). The mean score of pretests based on MCQ’s criteria was 10.76±2.11 and mean score of posttests based on subjective question was 12.10±1.8, which shows the significant differences in mean scores of pre and posttest criteria (p=0.002). It also indicates that the mean score of posttest increases as compared to pretest (Figures 1 & 2).

The mean score of male and female in midterm was reported as 26.45±5.59 and 27.10±6.77 which shows insignificant differences between mean scores of both gender (p=0.799). In final term, the mean score was reported as 33.72±8.12 in males and 30.46±12.14 in females. Another finding of the study narrated that female had higher score while assessing training program while male had higher varied score while assessing organizational effectiveness. Zulfiqar Ali [6] in pre-test, the mean score was reported as 10.90±2.02 in males and 10.50±1.99 in females. In post-test, the mean score was reported as 12.25±2.43 in males and 12±1.41 in females. We found insignificant differences in mean scores of final terms (p=0.456), pre-test (p=0.617) and posttest (p=0.768) with respect to gender. The detailed frequency distribution according to gender is presented in Table 1. According to different institute participants, the differences in mean scores obtained from different institutes participants were also found significant in midterm (p=0.025) and final term (p=0.031). There is no significant difference was found in mean scores of pretests (p=0.888) and posttest (p=0.371). The detailed frequency distribution of different institute participants is presented in Table 2.

ANOVA test is applied

*Significant at <0.05

**Insignificant at >0.05

Study not only showed substantial and positive impact of training on nurses. With p=0.005 and p=0.002 that validates scope of continuous nursing education. Training motivated Nurses endure high quality care to neonates and to have sound proficiency at NICU. Analyzing the Results of Mid Quiz Sectional Review was taken below mean score in Mid Quiz. Mean Score seen high in Section C based on small essay questions. So final was prepared on analysis made on participants understanding to comprehend thing well in short essay questions since it was first time such training was done so at all levels comforts were taken in account for better understanding of NICU concepts

Discussion

Pediatric and Neonatology (2015) [7] by Rocio. M. Pena had coherent discussion under critique “impact of a developmental care training course on knowledge …. In neonatal Unit” that nurses working in NICU received no training in developmental care. Given continuous advances and changes in Medical Era has caused health professionals to enroll in Continuous education to acquire and maintain skills. A lucid discussion was made in terms of training NICU nurses that after long time field of Neonatology realized to take and initiate training among such group of nurses who in actual working for population who cannot speak for themselves. Training based on six major categories that completed circle of neonatal care; Peads Surgery, Peads Medicine, Peads Infectious Disease, Neurological, Bio-Ethics and Basic neonatal Care. A systematic approach to care was given by group of trainers that helped nurses to understand disease process and to monitor and be acquainted with danger signs in neonates. It focused on ethical decision making, care of dying neonates, bereavement, and cultural communication Murakami [8].

Concept of early warning signs was especially been put in course as real and most underlying threatening emergencies are detected through this. This section as covered mainly through case studies that promoted critical thinking of Nurses. It gave acknowledgement to them to figure out and execute type of intercession demanded by condition or an event encountered by neonates. The ideal time frame for frequency of resuscitation skills training has yet to be determined. Results obtained from this performance improvement project using hands-on practice sessions [9]. Moreover, team approach is expected in all decisions made for the patients in and during CPR, Carrying out invasive procedure like intubation and administration of surfactant therapy, Blood Exchange Transfusion and its monitoring during Cycles of In-and Out, Peritoneal Dialysis etc. Training gave an opportunity to retain knowledge of nurses and to be more efficient in using and implementing care plans that resulted in positive outcomes.

Peads Surgery had the most flexible approach in making participants to learn about special surgical series. Case presentation was made on diseases like NEC; Hirsch sprung Disease, bowel obstructions or atresia, TEF, Congenital Diaphragmatic hernia. There were five groups each group headed by a surgery resident as facilitator. Peads Surgeon foster discussion on cases those significantly were useful. Apart from this at end of each case presented discharge teaching and care instructions for parents in most easy and simple language was demonstrated by peads surgery residents. There is a strong gap between theory and practice in nursing field and the nurses pay more attention to scientific and skill aspects than science and art of nursing. During the last two decades, almost all countries have been confronted with increasing demands for health services Borzadady Farahani [10]. Data collection was made by taking Pre and Post Test of Infection Control Module, Mid and Final Quiz based on Assessing Knowledge about Disease Process and Nursing Responsibilities. Reflective writings were found to be the most significant contrivance to evaluate over all courses. It gives us prospect to learn about participants need and expectations as it received after a one complete session cycle. Few Examples of reflective writing were as follows:

“We felt fortunate to be part of training and team together thought to train us, this was the moment awaited to retain my knowledge”. (Mid Age Nurses of NICU). “Handling Neonates had always been risky and difficult mainly for activities like positioning them with tubes and invasive lines, bathing and weighing them daily, measuring length, FOC & Plotting it to growth graph, abdominal girth measuring, feeding babies through NG/OG, Cup and Spoon, Routine Care: Eye Care, Skin Care, mouth Care, Perineal Care, invasive line care. We were doing because we were taught but this training gave rational to all are actions and now we are aware to bring change in practices to promote more of the neonate safety. (Nurse Midwife - NICU) “It was very hard to engulf these big concepts of tiny world (neonates). We never thought Neonatology basics will be a giant step to learn as academics do not have these in their curricula”. (Newly Hired Novice Nurse).

Revista Latino-Americana de Erfermagem [11] affirmed that another factor associated with the appropriateness of continuous education is the role of management. The reality of academic training for nursing professionals has changed radically in recent decades in terms of maintaining the rhythm of current clinical practice. The study has created a platform for Senior Management, faculties, nursing leaders to plan such comprehensive training programs and to carry on learning wheel to empower and retain nurses. This act ultimately will improve patient safety and satisfaction level. Clinical decision participation is promoted to improve recovery level. Limitation of study was, only knowledge was assessed in summative while clinical evaluation was not assessed collectively. In addition, it was small scale study. Despite for it been small scale to its limitation it showed participants eagerness, interest and thirst to learn and grow in this specialty. It postulated to influence nurses to bring change in behavior and attitude while caring for neonate with dissimilar diseases processes. Research on developmental care (2005) by Isabelle, Lucie and Marie Confirm that small scale is ambitious and help to convince nurses, planners, decision makers for the potentials of training offers for health and development of premature infants.

Conclusion

Frequent sittings were done in different phases of training with trainers: Pre-Phase, Mid-Phase and Post-Phase helped us to modified things. Debriefing was done for all process of trainings: Skills Sign Off, Quizzes and Presentations. We hope that upon completion of training there would be a significant change in nursing practices an. It was efforts of team which resulted in constructive outcomes. Adequate training and orientation when starting their career, and continuing education throughout their career, were of significant importance to student nurses. Continuing education was seen as a career-long component of a nursing career. Student nurses believed that their formal education only provided them with a starting point, with an understanding that additional training, learning and education would take place throughout their career Price S [12]. Study showed the impact of training on all participation and validated the significance of continuous nursing education and contributed to make nurses valuable and safe by enduring high quality care to neonates and helped nurses to have sound proficiency at NICU. A study also indicated that trained healthcare working force is crucial in tertiary care hospitals of Pakistan [6].

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Parking Demand for Elementary & Secondary Schools in Jordan- Juniper Publishers

 

Civil Engineering- Juniper Publishers

Abstract

This study aimed at investigating parking demand at elementary and secondary schools in Irbid city; the second largest city in Jordan, to identify the main influencing factors, and develop models to predict future demand based on local conditions. The major considered factors included school area, number of students, number of teachers, number of classrooms, gender of students, education level (elementary, secondary), and school ownership (public, private). A total of 118 different types of schools were surveyed from different areas in Irbid City. The required field data were collected on regular weekdays by field surveys and manual counting for the total number of parked vehicles and the variation during the schools working hours, while schools descriptive information’s were obtained from the directorate of education in Irbid city. Peak demand models for different types of schools were developed using multiple linear regression analysis by SPSS software. The results of the study showed that the main affecting factors on school parking demand include the total number of students, classrooms, and teachers. However, more focus was given to the number of students due to collinearity among these main independent variables and to be consistent with the international practice.

Keywords: Parking demand, Elementary school, Secondary school, Irbid, Jordan

Term Campus

Concerns are raised about traffic congestion and parking problems in Jordan as one of the developing countries with high population growth, immigration from neighbouring countries, increasing vehicle ownership and weak public transportation system, that require expansion of road networks and affect traffic operations and parking demand (both on street and off-street). Parking is an important element in the transportation system, since each driver needs to park somewhere before and after each trip. Parking has a significant effect on traffic problems like traffic congestion, traffic safety and environment. It must be effectively organized whether at on- or off-street to meet the land uses parking demand, reduce traffic problems and keep the desired levels of service for the street network.

Parking studies are main part of transportation studies used to assess the impact of new proposed developments. Findings and results represent the input needed to understand the existing parking conditions and requirements, to guide and enhance parking planning, management, and implementation of related projects. Parking studies may also help to set possible improvements required for handling existing traffic conditions and accommodating future changes to create balance between parking supply and demand especially in cities where the cost of land is expensive. It is necessary to estimate parking demand requirements at existing and proposed developments to assess parking adequacy and their impact on the transportation network. Parking demand models are necessary tools to guide engineers, planners, and decision makers in transportation planning and parking management.

It is not accurate to use international parking demand models in Jordan to estimate or predict the required parking demand without validation for local conditions since there are different socioeconomic and traffic characteristics between different countries, especially between developed and undeveloped ones. So it is essential to develop parking demand models based on local traffic and socioeconomic conditions in order to provide more accurate estimates. This study aims at investigating the required parking demand at elementary and secondary schools in Irbid city, identify affecting factors, and develop models to predict future parking demand as a function of the main influencing factors such as the school area, number of class rooms, number of students, number of teachers, gender of students, school ownership (public, private), etc. Parking demand models are used to provide prediction for future parking demand at developments for planning and management and creating balance between demand and supply.

Literature Review

The Institute of Transportation Engineers [1] has defined parking generation as “an educational tool for planners, transportation professionals, zoning boards and others who are interested in estimating parking demand of proposed development”. It has also defined parking supply as “the total number of parking spaces that are built or available at the study site, regardless of whether or not are utilized” and parking demand as “the total number of parking spaces required at a given site during the peak period”. It has been found by different international studies that the total number of students is the main variable that is positively related and significantly affect the number of parking spaces needed at school’s land use. Other variables that may affect schools parking demand include number of teachers, number of classrooms and school area. ITE [1] predicts parking demand rates for different types of schools (elementary, middle, high, private, and schools for blind) at different location types based on the number of students and presents linear relationships between school peak parking demand and the number of students.

Dubai Municipality [2] has a parking generation manual which estimates the required parking rates for different school levels based on the number of students. Different factors are presented based on school level (kindergarten, elementary and intermediate, and secondary), ownership (private, government), period (school morning peak, school afternoon peak, traffic peak hour), and gender (male, female). Riyadh Municipality [3] has a Parking Generation Manual which estimates parking rates for elementary governmental schools in Riyadh city based on the total area of the school, number of classes, number of students, and number of employees. Different studies were conducted in Jordan at different land uses to investigate parking demand and develop models for parking demand prediction based on local conditions. Al-Masaeid et al. [4] have conducted a study in Jordan to estimate parking generation rates at different land uses including apartment buildings, restaurants, shopping centers, office buildings, hospitals, and hotels and found lower parking demand rates as compared with developing countries. Ghuzlan et al. [5] have investigated the parking demand for multistory apartment buildings in Jordan, and identified their significant influencing factors which included building age (years), number of floors, apartment gross floor area (m²), average apartment income (JD), average apartment car ownership, and location of the building.

A study at the University of Washington [6] has conducted parking field surveys at a high school located at Seattle metropolitan area and collected data about location, site area, building area, time of regular classes, total number of students, teachers, and administrators and developed models for parking rate as a function of the number of students. Wong et al. [7] conducted a parking demand study in Hong Kong at different land uses to investigate parking demand for both private cars and goods vehicles. Linear parking demand models were developed for different land uses including schools. A study at the Arizona state university [8] has surveyed parking demand at three elementary schools in Maricopa county region in Arizona with data on the number of students, number of employees, and school size. Parking demand rate was calculated as a function of the number of students, resulting in a rate of 25 vehicle/student as compared to 14 vehicle/student in the national ITE parking generation manual.

Data Collecion and Reduction

The study data were collected from Irbid city which is the second largest city in Jordan after the capital (Amman), with a population of 929,224 [9]. The city is in the northern part of Jordan with most of its total area classified as residential. The directorate of education in Irbid was contacted to obtain the available information about schools including school area, education type, education level, students’ gender, number of students, number of classrooms, and number of teachers. Field surveys and manual counting was performed for collecting parking data during schoolworking hours. The study included 118 elementary and secondary schools from Irbid city to investigate their parking demand and the main influeing factos [10]. different types of schools were considered and surveyed in the study including public and private schools for male, female, and mixed students, in elementary and secondary levels. (Table 1) presents a list of abbreviations for the main dependent and independent variables as they are used in this study.

Parking demand data were collected through field surveys to obtain accurate information about existing parking supply and the peak number of parked vehicles at each school site with parking demand variation along the schoolworking hours. Vehicle counts at schools were conducted as follows:

a. The total number of parked vehicles were continuously counted by visual observation and recorded manually on a regular weekday.

b. Vehicles that were considered in the schools parking demand surveys included personal automobiles for teachers and administrative staff, school buses, commercial vehicles for school needs, and vehicles for school visitors such as students’ parents and education supervisors, and for special related activities.

c. To get the accurate data for real peak demand, all access points (gates) to the schools were considered in this study.

d. Some teachers, and administrative staff preferred to park a little far from the schools buildings or at adjacent streets to avoid congestion in front of the schools gates and these vehicles were also considered.

e. During field surveys, the counting was only for the parked vehicles for school purposes and not for any other developments activities.

Some descriptive independent variables were coded as (0, 1) or (0, 1, 2) for regression analysis and model development as shown in (Table 2). (Table 3) shows a sample of the collected data that were surveyed which includes descriptive information and peak parking demand for secondary private schools (all are mixed and morning schools). Similar data were collected for all school types.

Analysis and Modeling

Correlation matrices were developed for each school type to investigate correlation between different variables and parking demand before model development. (Table 4) presents a sample correlation matrix for male elementary public schools.

It can be seen from the above table, that parking demand is highly correlated with the number of students, number of classrooms, and number of teachers which are also highly correlated with each other’s. The same trend was also noticed for other types of schools. The statistical analysis linear regression method was performed on the collected data using the statistical package for social sciences (SPSS) software in order to develop models for predicting school peak parking demand as a function of its influencing variables. The highest number of parked vehicles during observation period was the value considered in regression analysis and model development. (Table 5) through 11 present the developed models for parking rate as functions of the main affecting variables. All equations and parameters are significant at 95% confidence level, where: Since NT, NC, and NS have high collinearity with each other and to be consistent with the international practice, it has been decided to focus on the total number of students (NS) in the developed parking demand models. (Tables 6-11) (Table 12) presents a summary of the developed models for the school peak parking demand as a function of the number of students for different school types. (Figure 1) shows the relationship between parking demand and the number of students at all school types combined. The model R2 is weak (0.40), so it is not recommended to use a combined model and it is preferred to use separate models (rates) for different school types.

Comparison with Other Models

(Figure 2) shows an example of a comparison for parking demand based on the observed data and developed models with the corresponding predicted values from ITE and Dubai manuals for male elementary public schools. As can be seen from the above figure, the developed rates provide closer estimates for parking demand while international models provide high overestimates as compared to the field observations.

Conclusion & Recommendations

Empirical models were developed for predicting peak parking demand at each type of school as a function of the main influencing variables. Key conclusions are summarized as follows:

I. Depending on data collection and analysis it was found that the main affecting factors on school parking demand include the total number of students, classrooms, and teachers. However, more focus was given to the number of students due to high collinearity between the three factors and to be consistent with the international practice.

II. The relationships between the dependent variable (peak school parking demand) and the affecting factors have liner forms.

III. A weak relationship was found between average peak parked vehicles and the total number of students for all school types combined, so it is not recommended to use a combined model and it is preferred to use separate models/rates for different school types.

IV. The developed school parking demand rates provide closer estimates than commonly used international models as compared to field observations.

Based on the data collection, analysis, and model developments in this research, it is recommended to:

1. Conduct similar studies at different land uses to establish a comprehensive parking demand manual based on local conditions instead of using foreign manuals with different socioeconomic and traffic characteristics.

2. Utilize the results of this study in planning, design, construction, and study of school parking in Jordan.

3. Validate the study results for other cities in the country.

Conduct similar studies every few years to find out the effects of changes over time in socioeconomic characteristics, population, vehicle ownership, to propose possible updates if required.

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