Assessment of Nurses’ Knowledge and Competence in Managing Preeclampsia at Maternity Teaching Hospital in Sulaimani city

1.INTRODUCTION

Hypertensive disorders during pregnancy pose a substantial threat to both maternal and fetal health. Among these conditions, preeclampsia is one of the most prevalent and clinically significant, affecting approximately 2–15% of pregnancies globally. Preeclampsia is classified as a hypertensive disorder that develops after 20 weeks of gestation and is typically accompanied by proteinuria or generalized edema. It may also involve hematologic abnormalities such as thrombocytopenia, or signs of end-organ dysfunction including renal impairment, elevated liver enzymes, pulmonary edema, and neurological symptoms such as cerebral or visual disturbances. If left untreated or if it progresses to a severe form, preeclampsia can lead to serious maternal and fetal complications [1]. Multisystem involvement and impaired uteroplacental perfusion can result in adverse outcomes such as intrauterine growth restriction (IUGR), preterm birth, and increased perinatal morbidity and mortality. In severe cases, preeclampsia may become life-threatening for both the mother and fetus [2].

The exact cause of preeclampsia remains unclear, but several risk factors increase its likelihood. Women at higher risk include those pregnant for the 1^st time, aged 35 years or older, those with a pregnancy interval of more than 10 years, or those with a family history of preeclampsia. Other risk factors include multiple pregnancies, a body mass index (BMI) of 35 kg/m² or higher, diabetes, previous hypertensive disorders in pregnancy, vascular disease, and kidney disease [3].

Preeclampsia is often associated with poor placental development or reduced blood flow to the placenta, which can lead to irregular blood pressure regulation in the mother. Nurses play a crucial role in identifying risk factors by taking detailed medical and family histories during a pregnant woman’s first visit. They also educate expectant mothers on the dangers of preeclampsia and the importance of antenatal care. Women who do not receive proper prenatal care are seven times more likely to experience fatal complications from preeclampsia than those who do [4].

The management of preeclampsia involves a multidisciplinary approach aimed at ensuring maternal and fetal safety while minimizing complications. The strategy depends on the severity of the condition, gestational age, and the clinical status of both the mother and fetus. In mild cases, management includes close monitoring of blood pressure, regular assessment of symptoms, and ongoing evaluation of fetal growth and well-being. Lifestyle modifications, rest, and frequent prenatal visits are often recommended. In more severe cases, hospitalization may be required to manage complications, stabilize blood pressure, and conduct continuous fetal monitoring. Pharmacologic interventions such as antihypertensive medications and magnesium sulfate may be used as part of the management plan to reduce the risk of seizures and other severe outcomes. In certain cases, corticosteroids are administered to enhance fetal lung maturity if early delivery is anticipated. The timing of delivery is carefully determined based on clinical findings, with the goal of optimizing outcomes for both mother and child [5].

Nurses play a key role in ensuring timely diagnosis, patient education, and comprehensive maternal care, ultimately improving pregnancy outcomes. Nurses have a critical role in identifying and managing preeclampsia. They monitor blood pressure, assess symptoms (e.g., headaches, vision changes, and swelling), conduct urinalysis for protein, and educate pregnant women on warning signs and preventive measures. Early detection can prevent severe complications, as untreated preeclampsia increases the risk of maternal and fetal mortality. Uninformed nurses may fail to recognize danger signs, delaying treatment and leading to preterm birth, fetal growth restriction, or maternal organ damage [4].

Recent studies have highlighted a global rise in pregnancy-related hypertension, including preeclampsia, due to factors such as advanced maternal age, increasing obesity rates, and lifestyle changes. Although advancements in maternal-fetal medicine have improved outcomes in some regions, many healthcare systems still face challenges related to early detection and management of preeclampsia. In particular, nurses play a crucial role in antenatal care, yet studies suggest gaps in their knowledge and preparedness to manage this condition effectively [6]. Despite the importance of nursing competencies in improving maternal and fetal outcomes, limited research has explored nurses’ knowledge and practices regarding preeclampsia in maternity hospital in Sulaimani city of Iraq. This study aims to fill that gap by assessing the knowledge and competency of nurses in managing preeclampsia, thereby identifying areas for targeted training and improvement.

2. MATERIALS AND METHODS

3. RESULTS

Table 1 shows that the age distribution of nurses is fairly balanced nurses, with 24% under 25 years, 36% between 25 and 35 years, and 40% over 35 years. The mean age of the nurses was 35.56 years, with a standard deviation of 12.86, indicating a diverse range of ages. Regarding education, 48% hold a Diploma in Nursing, 24% have a Master’s degree or higher, 16% are midwifery school graduates, and 12% hold a Bachelor’s degree, reflecting diverse qualifications. Marital status data reveal that 64% of nurses are married, 36% are single, and none were widowed in this sample.

TABLE 1: Distribution of study samples according to demographic characteristics

Table 2 shows that 48% of the nurses have over 10 years of experience, reflecting a highly experienced group, while 28% have <5 years, and 24% have between 5 and 10 years. The average professional experience of the nurses was approximately 12.72 years (Mean = 12.72, standard deviation [SD] = 11.39), suggesting a mix of new and experienced nurses. In the obstetric unit, 48% of nurses have <5 years of experience, 24% have 5–10 years, and 28% have over 10 years, with an average of around 9 years (Mean = 9.02, SD = 10.59). This indicates a relatively lower level of experience in this specialized area, indicating less experience in this area. In addition, 56% of nurses reported having attended workshops or training programs related to preeclampsia, while 44% had not participated in such programs.

TABLE 2: Distribution of study samples according to profession background

Table 3 shows that 80% of the nurses correctly identified preeclampsia as hypertension of at least 140/90 mmHg on two separate occasions, along with at least 300 mg of protein in a 24-h urine collection. However, 20% incorrectly defined preeclampsia as hypertension without proteinuria. None of the nurses (0%) mistakenly identified preeclampsia as normal blood pressure with protein in the urine. This demonstrates a high level of accurate knowledge about the definition of preeclampsia among most of the nursing staff.

TABLE 3: Distribution of study samples according to their knowledge in recognizing the correct definition of preeclampsia

Table 4 assesses nurses’ knowledge of preeclampsia care, including risk factors, symptoms, complications, magnesium toxicity signs, and treatments. Each participant was evaluated on a 0–1 scale. Among the 25 nurses, scores below 50% indicated poor knowledge, 50–74% signified fair knowledge, and 75% or higher reflected good knowledge.

TABLE 4: Distribution of study samples according to their knowledge toward preeclamptic women care (Risk factors for preeclampsia)

Table 4 regarding the risk factors for preeclampsia: The majority of nurses (80%) correctly identified chronic hypertension as a risk factor for preeclampsia (“Good”), while awareness was lower for autoimmune diseases (36%”Poor”) and first-time pregnancy (28%”Poor”). Knowledge of diabetes as a risk factor was also limited (44%, “Poor”). In contrast, many recognized blood clotting disorders (60% “Fair”) and previous preeclampsia (72% “Fair”). Awareness was higher for family history (72% “Fair”), multiple pregnancies (64% “Fair”), and high BMI (84% “Good’). Age was well recognized by 88% of participants (“Good”) and preeclampsia before 20 weeks was identified by 56% (“Fair”).

Table 5 assesses nurses’ knowledge of preeclampsia symptoms. Based on the predefined classification (Good: ≥75%, Fair: 50–74%, and Poor: <50%), nurses demonstrated strong knowledge of preeclampsia symptoms, with (84% “Good”) correctly identifying persistent frontal headaches, recognizing sudden swelling (88% “Good”), and identifying seizures (84% “Good”). Blurry vision was recognized by (76% “Fair”) also oliguria (68% “Fair”). However, knowledge of epigastric pain was significantly lower, with only (40% “Poor”) identifying it correctly. This highlights a need for further education on less noticeable but important symptoms.

TABLE 5: Distribution of study samples according to their knowledge toward preeclamptic women care (Other signs and symptoms of preeclampsia in addition to hypertension and proteinuria are)

Table 6 assesses nurses’ knowledge of preeclampsia complications based on the predefined classification (Good: ≥75%, Fair: 50–74%, and Poor: <50%). Nurses demonstrated strong knowledge of seizures (84% “Good.”), renal failure (84%”Good.”), intracranial hemorrhage (84% “Good.”), intrauterine death (96% “Good.”), and IUGR (92% “Good.”), However, awareness was moderate for other complications, including pulmonary edema (60% “Fair”), placental abruption (68% “Fair”), and HELLP syndrome (52% “Fair”). This suggests that while nurses are highly knowledgeable about the most severe complications, there is an opportunity to enhance their understanding of other risks, particularly pulmonary edema and HELLP syndrome, which require prompt recognition and management to prevent maternal and fetal morbidity.

TABLE 6: Distribution of study samples according to their knowledge toward preeclamptic women care (Complications of preeclampsia include which of the following?)

Table 7 assesses nurses’ knowledge regarding magnesium toxicity symptoms based on the predefined classification (Good: ≥75%, Fair: 50–74%, and Poor: <50%). It shows that nurses demonstrated a good understanding of magnesium toxicity symptoms, with high recognition rates for difficulty speaking or moving (84% “Good”), weakness (76% “Good”), and respiratory compromise (88% “Good.”). Blurry vision (72% “Fair”) and unresponsiveness (72%”Fair”) were classified as moderate awareness. Although (64% “Fair”)of nurses identified loss of deep tendon reflexes as a symptom, highlighting the need for further education on less obvious yet clinically critical symptoms to ensure early detection and prevent severe complications associated with magnesium toxicity.

TABLE 7: Distribution of study samples according to their knowledge toward preeclamptic women care (Which of these are signs and symptoms of magnesium toxicity)

Table 8 assesses nurses’ knowledge regarding treatments for preeclampsia. Based on the predefined classification (Good: ≥75%, Fair: 50–74%, and Poor: <50%), it indicates that nurses demonstrated strong knowledge regarding the treatment of preeclampsia. A high percentage (80% “Good”) recognized bed rest as a main treatment. Moreover, (96% “Good”) understood the importance of a multidisciplinary team. Furthermore, (76% “Fair”) correctly identified delivery of the fetus as the definitive treatment. This is particularly important, as timely delivery remains the only definitive treatment to halt disease progression and reduce maternal and fetal risks.

TABLE 8: Distribution of study samples according to their knowledge toward preeclamptic women care (Treatments for preeclampsia)

Table 9 assesses nurses’ knowledge regarding the immediate measures of magnesium toxicity. It outlines that the majority of nurses (92%) correctly identified stopping the magnesium sulfate infusion as the essential intervention, demonstrating good knowledge. However, only (8%) recognized the need for an indwelling urinary catheter, and none (0%) identified the administration of calcium gluconate. This is concerning, as calcium gluconate is the primary antidote for magnesium toxicity and is essential for reversing life-threatening complications.

TABLE 9: Distribution of study samples according to their knowledge about magnesium toxicity

Table 10 highlights nurses’ knowledge of the drug of choice for managing eclamptic fits. The majority of nurses (88%) incorrectly identified Calcium-likely referring to calcium gluconate-as the drug of choice, which is in fact the antidote for magnesium toxicity, not for treating eclamptic seizures. Magnesium sulfate is the internationally recommended first-line medication for preventing and treating eclamptic seizures. Only 4% correctly selected Magnesium, while another 4% chose potassium, and another 4% selected electrolyte. This suggests a significant misunderstanding among nurses regarding the correct medication for managing eclamptic fits.

TABLE 10: Distribution of study samples according to their knowledge about management of eclamptic fit

Table 11 assesses nurses’ knowledge regarding the immediate nursing actions after a convulsion. It shows that the majority of nurses (80%) correctly identified the importance of ensuring airway patency, administering oxygen, and checking vital signs and fetal heart rate, demonstrating “Good” knowledge. While a portion of the nurses selected “sending blood and urine for testing” (20%) as priority actions, and none (0%) of the participants selected “Document the Event of eclamptic fit.” It is important to note that immediate post-convulsion nursing actions should first focus on maintaining airway patency, administering oxygen, and assessing vital and fetal signs. Failure to document the event or perform laboratory evaluations may hinder follow-up care, but these are secondary to initial stabilization.

TABLE 11: Distribution of study samples according to their knowledge about immediate nursing actions after a convulsion (eclamptic fit) in a preeclamptic patient

Table 12 shows the distribution of study samples according to their knowledge about nursing actions after the administration of magnesium sulfate. The correct nursing action, which includes the assessment of vital signs, patellar reflex, and urinary output, was identified by only 28% of nurses, indicating “poor” knowledge. Meanwhile, 72% of nurses only identified the need to assess vital signs, which is incomplete. None of the nurses identified the need to send blood and urine for testing. Neglecting to monitor patellar reflexes and urinary output increases the risk of missing signs of magnesium toxicity, which can lead to serious complications such as respiratory depression or renal impairment.

TABLE 12: Distribution of study samples according to their knowledge about nursing actions after administration of magnesium sulfate

Table 13 illustrates the result of the study which indicates that, that factors such as age and level of education did not significantly impact nurses’ knowledge of preeclampsia, highlighting a universal need for targeted training.

TABLE 13: The association between knowledge of nurses toward preeclamptic women care and socio-demographic characteristics

Table 14 shows the results of the study. Indicating that, there is no statistically significant association between nurses’ demographic/workshop-related variables and their knowledge and competence in managing preeclampsia, as all P-values were greater than the common alpha 0.05.

TABLE 14: The association between knowledge of nurses toward preeclamptic women care and some information data

Fig. 1 illustrates the distribution of nurses’ knowledge levels concerning the management of preeclampsia, based on predefined classifications (Good: ≥75%, Fair: 50–74%, Poor: <50%). Among the 25 participants, 64% demonstrated fair knowledge, while 36% exhibited good knowledge. Notably, none of the nurses were categorized as having poor knowledge, indicating that all participants possessed at least a basic level of competence in managing preeclampsia.

Fig. 1. Overall knowledge level of nurses regarding the management of preeclampsia.

4. DISCUSSION OF THE RESULTS

Nursing care plays a pivotal role in promoting positive outcomes for both women and fetuses affected by preeclampsia. This study highlights the importance of nurses, as the frontline caregivers responsible for managing preeclamptic patients. The socio-demographic characteristics of the study sample reveal that the majority of nurses were over 35 years old, consistent with findings from [7], which suggests that the experience level of the nurses could influence their approach to care. However, while older nurses may bring more experience, the relationship between age and knowledge was not statistically significant in this study (P > 0.05), suggesting that factors beyond age are important for knowledge acquisition.

Regarding educational attainment, 48% of the nurses in this study held a nursing diploma. This finding aligns with Mohamed et al. [8], who reported a similar trend among nurses working in obstetrics and gynecology departments. In contrast, Khatun et al., [9] found that more than half of the nurses in their study held a bachelor’s degree, reflecting a higher academic qualification among their sample. Although our study did not find a statistically significant association between education level and knowledge (P > 0.05), differences in formal education could influence theoretical understanding, critical thinking, and evidence-based decision-making factors that are crucial in managing preeclampsia. This highlights the need for further research into how education level affects the quality of maternal care.

Experience is another key factor influencing knowledge and care delivery. Over half of the nurses in this study had <5 years of experience, a finding consistent with Abd El Monem et al.[10], who observed similar trends among nurses in Khartoum. While this suggests that newer nurses may lack sufficient clinical exposure, it also offers an opportunity to improve training and mentorship programs, ensuring that less experienced nurses receive targeted support. However, it is also important to consider that variations in knowledge may be influenced by additional factors such as institutional policies, staffing levels, workload, and the availability of resources, all of which could affect nurses’ ability to acquire and apply clinical knowledge effectively.

In terms of training, the majority of nurses (56%) had attended workshops or courses related to preeclampsia. However, this finding contrasts with Mkumbo and Moshi [11], who found that 77.7% of participants had not received any formal training. This discrepancy may be due to differences in the healthcare settings or the availability of professional development opportunities. Regardless, it underscores the need for consistent and continuous education programs for all nurses working with preeclamptic patients, regardless of prior training.

The study also found that 80% of nurses demonstrated good knowledge in identifying preeclampsia, aligning with ElazimElmenshewy et al. [12], who noted a similar level of awareness in their study. In terms of magnesium toxicity, 92% of nurses knew the correct immediate action to take, which indicates a strong understanding of this critical area of preeclampsia management. These findings are encouraging, as they reflect a solid foundation of knowledge in key aspects of care. However, statistical analysis indicated no significant correlation between knowledge levels and factors such as education level or years of experience (P > 0.05), suggesting that knowledge gaps may be influenced by other variables. Therefore, there is still room for improvement, particularly in broader care practices beyond immediate recognition and response.

Overall, 64% of nurses in this study had a fair knowledge of preeclampsia care, with the remaining 36% demonstrating good knowledge. This result contrasts with the study by Faris and Faris [13], which reported poor knowledge in their sample. This variation suggests that there is no uniform level of understanding across different settings and highlights the need for targeted interventions to address these knowledge gaps. Fair knowledge may indicate that while nurses possess a basic or moderate understanding, there are gaps in critical areas such as early warning signs, complication management, or medication monitoring that could compromise patient safety and hinder timely interventions.

To improve nurses’ knowledge and care for preeclamptic women, several targeted solutions can be implemented based on the study’s findings. Given that 64% of nurses demonstrated only fair knowledge of preeclampsia care, standardized training programs are essential to reduce knowledge gaps and address inconsistencies in educational opportunities. Developing evidence-based educational programs focused on the clinical management of preeclampsia will ensure nurses remain up to date with current research and best practices [8]. Furthermore, since over half of the participants had <5 years of experience in obstetric care, mentorship and on-the-job training should be prioritized. Pairing experienced nurses with less experienced ones can provide hands-on guidance, build clinical confidence, and support effective knowledge transfer from senior staff [14]. These strategies are crucial for strengthening the competence of nursing staff and ultimately improving maternal and fetal outcomes.

Another key solution is the implementation of regular assessments and feedback, such as quizzes, simulations, and case-based evaluations, to measure nurses’ knowledge and clinical judgment. Given that the majority of nurses in this study demonstrated only fair knowledge, such assessments are vital for identifying specific gaps and guiding targeted follow-up training sessions [15]. For example, if a significant number of nurses show limited understanding of magnesium sulfate toxicity management, focused retraining on that topic should be provided.

Moreover, promoting multidisciplinary collaboration – among nurses, obstetricians, midwives, and other healthcare providers – is essential for delivering holistic care to preeclamptic patients. This approach not only improves communication and decision-making but also reduces the risk of delayed interventions or mismanagement [13]. Given the absence of a significant association between knowledge levels and demographic factors in this study, it is evident that system-level strategies such as team-based care and institutional protocols may play a more influential role in ensuring safe outcomes. By implementing these strategies in response to the identified knowledge patterns, healthcare institutions can build stronger nursing competencies and enhance maternal and fetal outcomes in cases of preeclampsia.

5. CONCLUSION

This study shows that nurses’ knowledge about managing preeclampsia needs improvement to ensure better outcomes for both mothers and babies. While some nurses demonstrated a good understanding of key areas such as the definition of preeclampsia and responding to magnesium toxicity, many showed only a fair knowledge overall. Notably, gaps were observed in broader aspects of care, including monitoring complications, interpreting clinical signs, and applying standardized care protocols. Factors such as age, education level, and years of experience appeared to influence knowledge, though not always significantly. To address these issues, it is essential to implement comprehensive training programs, provide mentorship opportunities, conduct regular knowledge assessments, and promote teamwork between nurses and other healthcare professionals. Strengthening these areas will help reduce complications and improve the quality of care provided to women with preeclampsia.

6. ACKNOWLEDGMENT

We express our sincere gratitude to all participants for their participation.

7. ETHICAL CONSIDERATIONS

The ethical committees of the College of Nursing and the College of Medicine at the University of Sulaimani approved the study. Formal authorization was then obtained from the Director of Health in Sulaimani and the administration of the Maternity Teaching Hospital. Before data collection, nurses were informed about the study’s purpose, their right to confidentiality, and the voluntary nature of their participation. Verbal consent was obtained with assurances that their responses would remain anonymous and confidential. Participation was voluntary, and nurses had the right to withdraw at any time during the data collection period.

8. CONFLICTS OF INTEREST

The author affirms that they have no conflicts of interest.

9. FUNDING

The study was financially supported through author fees