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EDITOR
Prof. R K Sharma
Dean (R&D), Saraswathi Institute of Medical Sciences, Hapur, UP, India
Formerly at All India Institute of Medical Sciences, New Delhi
E-mail: editor.ijphrd@gmail.com
INTERNATIONAL EDITORIAL ADVISORY BOARD
1. Leodoro Jabien Labrague
(Associate Dean)
Samar State University,College of Nursing and Health
Sciences, Philippines
2. Dr. Arnel Banaga Salgado
(Asst. Professor)
Psychology and Psychiatric Nursing, Center for Educational
Development and Research (CEDAR) member, Coordinator,
RAKCON Student Affairs Committee,RAK Medical and Health
Sciences University, Ras Al Khaimah, United Arab Emirates
3. Elissa Ladd
(Associate Professor)
MGH Institute of Health Professions Boston, USA
4. Roymons H. Simamora
(Vice Dean Academic)
Jember University Nursing School, PSIK Universitas Jember,
Jalan Kalimantan No 37. Jember, Jawa Timur, Indonesia
5. Saleema Allana
(Senior instructor)
AKUSONAM, The Aga Khan University Hospital, School of
Nursing and Midwifery, Stadium Road, Karachi Pakistan
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(Senior lecturer)
RAK Medical & Health Sciences University,Ras Al Khaimah,
UAE
7. Mrs. Olonisakin Bolatito Toyin
(Senior Nurse Tutor)
School of Nursing, University College Hospital, Ibadan, Oyo
State, Nigeria
8. Mr. Fatona Emmanuel Adedayo
(Nurse Tutor)
School of Nursing, Sacred Heart Hospital, Lantoro,Abeokuta,
Ogun State, Nigeria
9. Prof Budi Anna Keliat, Department of Mental Health Nursing
University of Indonesia
10. Dr. Abeer Eswi
(Associate Prof and Head of Maternal and
Newborn)
Health Nursing)
Faculty of Nursing, Cairo University,
Egypt
11. Jayasree. R
(Senior Teacher, Instructor H)
Salalah Nursing Institute, Oman
12. Dr. Khurshid Zulfiqar Ali Khowaja
(Associate Professor)
Aga Khan University School of Nursing, Karachi, Pakistan
13. Mrs. Ashalata Devi
(Assist. Prof.)
MCOMS (Nursing Programme), Pokhara, Nepal
14. Sedigheh Iranmanesh
(PhD)
Razi Faculty of Nursing and Midwifery, Kerman Medical
University, Kerman, Iran
15. Billie M. Severtsen
(PhD, Associate Professor)
Washington State University College of Nursing, USA
International Journal of Nursing Education
NATIONAL EDITORIAL ADVISORY BOARD
1. Dr.G.Radhakrishnan
(PhD, Principal)
PD Bharatesh College of Nursing, Halaga, Belgaum,
karnataka, India-590003
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(Principal, College of Nursing)
AIIMS, New Delhi.
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(Lecturer)
College of Nursing, AIIMS, New Delhi
NATIONAL EDITORIAL ADVISORY BOARD
4. Fatima D'Silva
(Principal)
Nitte Usha Institute of nursing sciences, Karnataka
5. G.Malarvizhi Ravichandran
PSG College of Nursing, Coimbatore, Tamil Nadu
6. S. Baby
(Professor)
(PSG College of Nursing, Coimbatore, Tamil Nadu, Ministry
of Health, New Delhi
7. Dr. Elsa Sanatombi Devi
(Professor and Head)
Meidcal Surgical Nursing, Manipal Collge of nursing, Manipal
8. Dr. Baljit Kaur
(Prof. and Principal)
Kular College of Nursing, Ludhiana, Punjab
9. Mrs. Josephine Jacquline Mary.N.I
(Professor Cum
Principal)
Si-Met College of Nursing, Udma, Kerala
10. Dr. Sukhpal Kaur
(Lecturer)
National Institute of Nursing Education, PGIMER, Chandigarh
11. Dr. L. Eilean Victoria
(Professor)
Dept. of Medical Surgical Nursing at Sri Ramachandra College
of Nursing, Chennai, Tamil Nadu
12. Dr. Mary Mathews N
(Professor and Principal)
Mahatma Gandhi Mission College of Nursing,Kamothe,Navi
Mumbai, PIN-410209,Cell No.: 09821294166
13. Dr. Mala Thayumanavan
(Dean)
Manipal College of Nursing, Bangalore
14. Dr. Ratna Prakash
(Professor)
Himalayan College of Nursing, HIHT University, Dehradun
Uttarakhand
15. Pramilaa R
(Professor and Principal)
Josco College of Nursing, Bangalore
16. Babu D
(Associate Professor/HOD)
Yenepoya Nursing College, Yenepoya University, Mangalore
17. Dr. Theresa Leonilda Mendonca
(Professor and Vice Principal)
Laxmi Memorial college of Nursing, A. J. Towers, Balmatta,
Mangalore, Karnataka
18. Madhavi Verma
(Professor)
Amity College of Nursing, Amity University Haryana
19. LathaSrikanth
(Vice Principal)
Indirani College of Nursing,Ariyur,Puducherry
20. Rupa Verma
(Principal)
MKSSS college of nursing for women, Nagpur
21. Sangeeta N. Kharde
(Professor)
Dept. of OBG Nursing KLES's Institute of Nursing Sciences,
Belgaum
22. Dr. Suresh K. Sharma
(Professor)
(Nursing) College of Nursing, All India Institute of Medical
Sciences, Rishikesh (UK) 249201
23. Sudha Annasaheb Raddi
(Principal & Professor)
Dept of
OBG Nursing, KLEU's Institute of Nursing Sciences, Belgaum
IFC PAGE FINAL.pmd 8/13/2013, 8:31 PM2
International Journal of Nursing Education
NATIONAL EDITORIAL ADVISORY BOARD
24. Rentala Sreevani
(Professor & HOD)
Dept. of Psychiatric Nursing,Sri.Devaraj Urs College of
Nursing, Kolar, Karnataka
25. Accamma Oommen
(Associate Professor and Head)
Department, Child Health Nursing, Sree Gokulam Nursing
College, Trivandrum, Kerala, India
26. Shinde Mahadeo Bhimrao
(Professor)
Krishna Institute Of Nursing Sciences Karad Tal-Karad Dist
Satara Mahashtra State
27. Dr. Judith A Noronha
(Professor and HOD)
Department of Obstetrics and Gynaecological Nursing,Manipal
University
28. Prof.Balasubramanian N
(Head)
Psychiatric Nursing, Shree Devi College of Nursing,Mangalore
29. Mrs. Harmeet Kaur
(Principal)
Chitkara School of Health Sciences, Chitkara University,
Punjab.
30. Mrs. Chinnadevi M
(Principal)
Kamakshi Institute of Nursing, Bassa wazira, Bhugnara Post,
The Nurpur, Dist Kangra, HP,
31. Dr.Linu Sara George
(Professor and Head)
Department of Fundamentals of Nursing, Manipal College of
Nursing Manipal
32. Juliet Sylvia
(Professor and H.O.D)
Community Health Nursing, Sacred Heart Nursing College,
Madurai
33. Dr. (Prof). Raja A
(Professor & HOD)
Department of Medical Surgical Nursing,Sahyadri College of
Nursing,Mangalore-575007
34. Beena Chako
(Professor)
PSG College of Nursing, Coimbatore. Tamil Nadu 35. Anitha
C Rao, Professor and Principal, Canara College of Nursing,
Kundapur, Karnataka
35. Dr.N.Gayathripriya
(Professor)
Obstetrics and Gynaecological Nursing, Sri Ramachandra
University, Chennai
SCIENTIFIC COMMITTEE
1. Padmavathi Nagarajan
(Lecturer)
College of nursing, JIPMER, Pudhucherry
2. Mrs. Rosamma Tomy
(Associate Professor)
MGM College of Nursing, Kamothe, Navi Mumbai
3. T. Sivabalan
(Associate Professor)
Pravara Institute of Medical Sciences (DU), College of Nursing,
Loni, Maharashtra
4. Ms Daisy J Lobo
(Associate Professor)
MCON, Manipal, Karnataka
5. Sanjay Gupta
(Assistant Professor)
M.M. College of Nursing, Mullana (Haryana)
6. Prashanth PV
(Nursing Supervisor)
M.O.S.C Medical College
Hospital, Kerala
7. V. Sathish
(Academic Officer)
Allied Health Sciences, National Institute of Open Schooling
Ministry of Human Resource Development,Government of India
8. Dr. Suman Bala Sharma
(Senior Clinical Instructor)
National Institute of Nursing Education, PGIMER, Chandigarh.
9. Smriti Arora
(Assistant Professor)
Rufaida College of Nursing, Faculty of Nursing, Hamdard
University,New Delhi-110062
10. Rajesh Kumar
(Asst. Professor)
SGRD CON(SGRDISMR),Vallah Amritsar Punjab
11. Baskaran. M
(Assistant Professor)
PSG College of Nursing, Coimbatore, Tamil Nadu,
12. Mr. Kishanth
(Olive.Sister Tutor)
Department of psychiatric Nursing,College of Nursing,
JIPMER, Pondicherry - 06
13. Mr. Mahendra Kumar
(Associate Professor)
Savitribai phule college of nursing, Kolhapur
14. Bivin Jose
(Lecturer)
Psychiatric Nursing, Mar Baselios college of Nursing,
Kothamangalam, Kerala
15. Poonam Sharma
(Assistant Professor)
INE, Guru Teg Bahadur Sahib (C) Hospital, Ludhiana,Punjab.
16. Kapil Sharma
(Associate Professor)
INE,G.T.B.S.(C) Hospital, Ludhiana (Punjab)
International Journal of Nursing Education ” is an international peer reviewed journal. It publishes articles related to nursing and
midwifery. The purpose of the journal is to bring advancement in nursing education. The journal publishes articles related to specialities of
nursing education, care and practice. The journal has been assigned international standard serial numbers 0974-9349 (print) and
0974-9357 (electronic). The journal is covered by Index Copernicus, Poland and is included in many international databases. We have
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Print-ISSN: 0974-9349, Electronic - ISSN: 0974-9357, Frequency: Half yearly (Two issues per volume).
www.ijone.org
Editor
Dr. R.K. Sharma
Institute of Medico-legal Publications
4th Floor, Statesman House Building, Barakhamba Road,
Connaught Place, New Delhi-110 001
Design & Printed at
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4th Floor, Statesman House Building, Barakhamba Road,
Connaught Place, New Delhi-110 001
IFC PAGE FINAL.pmd 8/13/2013, 8:31 PM3
I
International Journal of Nursing Education
www.ijone.org
Volume 06 Number 01 January-June 2014
1. Perceptions and Experiences of Written Feedback of Nursing Students .............................................................................. 01
Amina Aijaz Khowaja, Raisa B Gul, Amina Aijaz Khowaja
2. Administration of Insulin to Type 1 Diabetes-Current Nursing Practice............................................................................. 06
Anjuladevi Kamaraj, M Gandhimathi, C Rameshc
3. Lived Experiences of Failure on the National Council Licensure Examination - Registered ............................................ 10
Nurse (NCLEX-RN): Perceptions of Registered Nurses
Mc Farquhar Claudette
4. The effect of Problem Solving Training on Decision Making Skill in Nursing Students ................................................... 15
Heidari M, Shahbazi S
5. Registered Nurses Perception of Medication Errors: A Cross Sectional Study in Southeast of Iran ................................ 19
Zahra Esmaeli Abdar, Haleh Tajaddini, Azam Bazrafshan, Hadi Khoshab, Asghar Tavan, Giti Afsharpoor,
RN Masoud Amiri, Hossein Rafiei, Mohammad Esmaeili Abdar
6. Registered Nurses Perception of Medication Errors: A Cross Sectional Study in Southeast of Iran ................................ 24
Abdul Jaleel, R Jeyadeepa
7. Two Teaching Strategies In Subcutaneous Injection: A Comparative Study ........................................................................ 30
Khadijah C Bautista, Nazik M A Zakari
8. Effectiveness of Behavioral Modification Therapy in Coping with Adjustmental Problems........................................ 36
among Juvenile Delinquents
Kishanth Olive, Sheeba
9. Objective Structured Clinical Examination - Emerging Trend In Nursing Profession ....................................................... 43
G Muthamilselvi, P Vadivukkarasi Ramanadin
10. Empowering Children and Adolescents on Prevention of Coronary Artery Disease......................................................... 48
Ramya K R, Kiran Batra R
11. Pediatric Baccalaureate Nursing Curriculum in Pakistan: Strengths, Limitations and Recommendations ................... 54
Shela Akbar Ali Hirani, Jacqueline Maria Dias
12. Knowledge, Attitude And Practices Of Adolescents Related To HIV/AIDS in Selected Schools of Delhi .................... 59
Smriti Arora, Jyoti Sarin
13. Mothers Knowledge on Domains of Child Development ........................................................................................................ 65
Miby Baby, Sangeetha Priyadarshini, Sheela Sheety
14. Effectiveness of Information Education Communication (IEC) Package on Life Style ...................................................... 69
Practices of Adolescents - A Pilot Study
L Mendonca
15. An Exploratory Study to Identify Factors Associated with Noncompliance of Medications and ................................... 73
Recommended Lifestyle Behavior After Renal Transplantation- A Pilot Study
Uma Rani Adhikari, Abhijit Taraphder, Tapas Das, Avijit Hazra
16. Intimate Partner Violence an Evil of Society with Integration of Ecological Model a New Perspectiv .......................... 79
Yasmin Mithani RM, Zahra Shaheen Premani, Zohra Kurji
17. Are Health Care Resources Allocated Equitably in Pakistan?................................................................................................. 83
Zahra Shaheen, Zohra Kurji, Yasmin Mithani
18. Effectiveness of an Empowering Programme on Student Nurses' Understanding and .................................................... 89
Beliefs about HIV/AIDS
Smriti Arora, Sarin Jyoti, Sujana Chakravarty
Contents
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II
19. A Study to assess the Knowledge and Involvement in Child Rearing Practices among .................................................... 94
Fathers of Hospitalised Children of 1-6 Years of Age, in Kasturba Hospital, Manipal
Sreeram A, D' Souza A, Margaret B E
20. Identify Risk Factors For Postnatal Depression Among Antenatal Mothers - A Hospital Based Study ....................... 101
Alma Juliet Lakra, Salomi Thomas
21. Accessing Community Through A Nursing Course: Evidence Based Practice.................................................................. 105
Amina Aijaz Khowaja, Lubna Ghazal, Fatima Jawad, Naveeda Haq
22. The Threat of Domestic Violence: an Analysis through 'ology' Perspectives ..................................................................... 109
Zahra Shaheen, Yasmin Mithani, Zohra Kurji
23. Comparison of Maternal Comfort between two Breastfeeding Positions ........................................................................... 113
Bency G, Maria P, Anusuya V P
24. Patterns of Auditory Verbal Hallucination among Patients Diagnosed with Chronic Schizophrenia .......................... 118
Bivin J B, Sailaxmi Gandhi, John P John
25. Health Risk Behaviour and Depression among Adolescents ................................................................................................ 123
Dayananda B C, Meera K Pillai
26. An Experimental Study to assess the effectiveness of the Structured Teaching Programme on .................................. 128
Knowledge of Traffic Safety among School Children at Selected Urban Schools in Ludhiana, Punjab
Gaurav Kohli
27. A Study to Determine the effectiveness of Therapeutic Back Massage on Quality of ...................................................... 132
Sleep among Elderly in Selected old Age Homes at Mangalore
Gayathri J Nair, Swapna Dennis, Babu Dharmarajan
28. Malnutrition among Underfive Children and Factors Influencing it .................................................................................. 135
Anumod S, Aparna S V, Ggayathri Devi A S, Julie I S, Lydia Ferry, Shilpa Santhan, Hepsibai J
29. A Study to Compare the Nutritional Status Assessed by CAN Score and Ponderal ........................................................ 140
Index Against WHO Intrauterine Growth Curves among Newborns at Birth in
Selected Hospital of Ambala, Haryana
Herbaksh Kaur, Yogesh Kumar, Jyoti Sarin
30. Randomized Control Trial to Evaluate the effectiveness of Helping Babies Breathe ........................................................ 146
Programme on Knowledge and Skills Regarding Neonatal Resuscitation among
Auxiliary Nurse Midwives Students
Jagadeesh G Hubballi, Sumitra L A, Sudha A Raddi
31. A Study to assess the effectiveness of Laughter Therapy on Depression among Elderly................................................ 152
People in Selected Old Age Homes at Mangalor
Jaya Rani George, Vineetha Jacob
32. Knowledge and Practice of Housewives on Domestic Plastic Waste Management.......................................................... 155
Jince V John, Sarita T Fernandes, Sujith Kuriakose
33. Effectiveness of SIM Versus PIM on Neonatal Developmental Supportive Care in Terms of......................................... 161
Knowledge among Nursing Students
Kuldeep Kaur, Jyoti Sarin, Gurneet Kaur
34. Impact of Students-Teacher Relationship on Student's Learning: A Review of Literature .............................................. 167
Yusra Sulaiman Al Nasseri, Lakshmi Renganathan, Fadhila Al Nasseri, Ahmed Al Balushi
35. Lessons from the Field: Using the Work of a Department Research Committee to Facilitate......................................... 173
Nursing Faculty Research and Scholarship
Lori S Lauver
36. Awareness of Mothers of Under Five Year Children Regarding Round Worm Infestation, its ...................................... 179
Prevention and Management: A Descriptive Analysis
Mamatha G, Munirathnamma K
37. A Comparative Study on Level of Job Satisfaction among Nurses in Government and .................................................. 183
Private Hospitals of Andhra Pradesh, India
Gupta M K, Reddy S, Prabha C, Chandna M
38. Engaging Millennial Nursing Students To Bring Theory Into Practice ............................................................................... 189
Margarett S Alexandre
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III
39. Effectiveness of Occupational Therapy on Symptoms of Schizophrenia ............................................................................ 195
Minnu Prasad, Nalini M
40. A Comparative Study to assess the Effectiveness of Video Recorded Instruction and Pamphlet .................................. 201
Regarding Prevention of Swine FLU among High School Children, in Selected Schools of Belgaum City
Moreshwar S A, YumnamM, Shivaswamy M S
41. Nurses' Compliance at Reporting Patient's Pain: Shift Handover Observations from a.................................................. 206
Tertiary Care Hospital in Karachi, Pakistan
Nazbano Ahmedali, Fauziya Ali, Nasreen Sulaiman, Rozina Roshan, Zohra S Lassi
42. Assessment of effectiveness of a Structured Teaching Programme on Knowledge of ................................................... 211
Staff Nurses Regarding Risk Factors and Prevention of Deep Vein Thrombosis in a
Selected Hospital, Ludhiana, Punjab
Nidhi Kumar
43. A Comparative Study To Assess The Perception of Doctors, Nurses, Faculty of Nursing .............................................. 214
and Nursing Students on Ideal Clinical Learning Environment
Preethy J, Erna J R, Mariamma V G
44. Study to assess the Depression and Ideation of Suicide among Terminally Ill Patients, ................................................. 219
in Selected Hospitals, Ludhiana, Punjab
Ramanpreet Kaur
45. A Cross-Cultural Comparison of a Clinical Nurse Competency Path Model .................................................................... 222
Susan B Sportsman, Patti Hamilton, Randall E Schumacker
46. Identify the Impact of Tuberculosis on Health Status and Coping Strategies.................................................................... 228
Adopted by Tuberculosis Patients
Rashmi, Shobha Prasad, Sulakshna Chand
47. Effectiveness of Music Therapy vs Foot Reflexology on Pain among Postoperative Patients ........................................ 232
in Selected Hospitals at Mangalore
Reena Baby, Babu D
48. Nurses' Practice Related to Prevention of Pressure Ulcer among Patients and Factors ................................................... 235
Inhibiting and Promoting These Practices
Rishu Anand, Vinay kumari, Rathish Nair
49. Effectiveness of Planned Teaching Programme on Prevention of Anaemia among ......................................................... 240
School Going Adolescent Girls
Moreshwar S A, Naik VA, Chrostina B C
50. Perception and Experience of Teachers and Postgraduate Nursing Students on .............................................................. 244
Microteaching as an effective Teaching Strategy
Shanthi Ramasubramaniam, Lakshmi Renganathan
51. A study to assess the Stressors of the Intensive Care Unit Patients' and to Compare these............................................ 250
with the Nurses' Perception in Selected Hospitals of Karnataka State
Tsering Paldon, Elsa Sanatombi Devi, Flavia Castelino
52. The Lived Experience of Associate Degree Nursing Students Intending to Pursue the RN-BSN .................................. 255
Unn Hidle
53. Mixed Methods Research: A New Approach ............................................................................................................................ 260
Vathsala Sadan
54. Nursing Industry: Where Rescuers Become The Victims....................................................................................................... 267
Vijayta Doshi
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INTRODUCTION
The term feedback is frequently used in the field of
education. In education, feedback is referred to the role
of assessment as a stimulus for further learning.
Moreover, feedback is considered as an interactive
process between the teacher and student that helps to
bridge the gap between the students current and
expected level of performance. [1] Several studies
emphasize its usefulness, if it is given as feed forward.
[2, 3] Feed- forward is proactive direction that enables
students to move forward by working on the
suggestions during the progress of the work or written
assignment. [4] Feedback may not be found helpful by
the students if, it is written in negative tone; the
comments are in illegible handwriting, and its quantity
is too little or too much. Moreover, lack of
Perceptions and Experiences of Written Feedback of
Nursing Students
Amina Aijaz Khowaja1, Raisa B Gul2, Amina Aijaz Khowaja1
1Senior Instructor, 2Associate Professor, School of Nursing and Midwifery, Aga Khan University, Stadium Road,
P.O. Box 3500, Karachi-74800, Pakistan
ABSTRACT
Background: Written feedback is known to enhance students' learning. However, the effectiveness
of feedback is determined by the quality of feedback and the students' receptivity towards written
feedback. This study aimed to explore students' experiences of written feedback in the nursing degree
programmes in Karachi.
Method: A descriptive exploratory design was used in the study. The study comprised of 379 nursing
students from nine nursing institutions. Students filled out the questionnaire that had open ended
questions regarding the current practices of written feedback. They also provided suggestions for
improving these practices in their institutions. Nearly 93% of the students responded to the open
ended questions. The information was than manually analyzed for categories and subcategories.
Findings: Student shared numerous experiences and suggestions regarding written feedback. Five
categories were extracted from students' narratives. These included: merit of verbal and written
feedback; quantity and quality of the feedback including need for personalized feed-forward; care
for students' self- esteem; teachers' competence for written feedback; and consistency in feedback
practices.
Conclusion: The findings of this study have implications for teachers, students and institutions similar
to the context of this study. Teachers need to be aware of the role and impact of written feedback on
students' learning and develop competence for giving effective feedback. Polices need to be developed
to enhance the effectiveness of written feedback practices.
Keywords: Written Feedback, Teachers Accountability, Students' Assessment, Students' Perceptions
DOI Number: 10.5958/j.0974-9357.5.2.054
opportunities to clarify the teachers’ comments can
make it difficult for the students to understand and
utilize the feedback. [5]
Existing literature regarding the usefulness of
written feedback from students’ perspectives provided
stimulus to explore the phenomenon in Pakistani
context. Although the phenomenon of written
feedback such as its provision, quality, usefulness and
its benefits has been widely explored by several
researchers in the developed countries; this topic is
limitedly explored in the developing countries such
as Pakistan. Moreover, no studies were found in this
topic in nursing education in Pakistan .Therefore, this
study was undertaken to identify students’ experiences
on written feedback in the nursing degree programmes
in Karachi. This article describes a section of qualitative
1. amandeep kaur-1-5.pmd 1/6/2014, 9:30 AM1
2International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
study from a larger study which involved 379 nursing
students from nine public and private nursing
institutions in Karachi.
MATERIAL AND METHOD
A descriptive exploratory study was undertaken
to gain an in-depth understanding of students’
experiences on the written feedback and their
recommendation to improve practices of written
feedback in their nursing institutions in Karachi. These
institutions were offering BScN or MScN degree
programmes, were recognized by Pakistan Nursing
Council, and had the policy to return written
assignments to their students and provided access to
their students were included in the study. Students
from second year were selected to ensure that they
would have received written feedback in their
assignments. The data was collected via an open-ended
questionnaire, was typed in a word document and then
was manually analyzed for patterns of similarities and
differences in the practices of written feedback.
FINDINGS
Demographics of the Participants. Out of 379
students, nearly 56% of the participants were females
and 44% were males between the ages of 21-25. With
regard to the participants’ educational background,
majority of them (75%) had academic qualification of
intermediate. Although, 41.2% of the students shared
that they spoke Urdu, rest of the (58.8%) students spoke
local languages such as Pushto, Sindhi, and Punjabi,
in their homes. With regard to the medium of
instruction during their schooling (before nursing),
approximately, 53% of the students had studied in
English medium schools. Nearly 47 % students had
mixed instructions i.e. they were mostly taught in Urdu
or in their local language with one English course.
However, in their nursing schools, all the students
(100%) were expected to write their assignments in the
English language.
Students’ Views and Recommendations for
Improving the Practices of Written Feedback
Of the 379 students, 353 students responded to the
open ended questions and many of them offered
multiple comments (612 comments in total). The
comments included students’ views as well as
suggestions to improve the practices of written
feedback at their institutions. All the comments were
organized into five categories and associated sub
categories (see Table 1). The categories include merit
of verbal and written feedback; quantity and quality
of feedback; care for students’ self-esteem; teachers’
competence for written feedback; and consistency in
feedback practices.
Table 1: Students’ Views and Recommendations
Themes from the Number of (%)
open ended questions comments = 612
1. Merit of verbal and written feedback
1.1 Significance of written feedback 144 -23.5
1.2 Opportunities to discuss feedback 76 68
2. Quantity and Quality of the feedback
2.1 Attention to promptness, clarity, thoroughness 221 -36
2.2 Need for personalized Feed-forward 110 30
3 Care for students’ self- esteem 76 -12.4
4 Teachers’ competence for written feedback
4.1 Teachers’ abilities and skills 101 -16.5
4.2 Teachers’ values and attitudes 45 56
5 Consistency in feedback practices 70 -11.4
5.1 Provision of assignment guidelines 52
5.2 Format of feedback
5.3 Institutional policies on written feedback 6 12
Total 612 -100
1. amandeep kaur-1-5.pmd 1/6/2014, 9:30 AM2
International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 3
Merit of Verbal and Written Feedback
Out of 612 comments, about 144 (23.5 %) comments
were on the merit of verbal and written feedback.
Students highlighted that both verbal and written
feedback were helpful. However, some of them
received only written feedback and some received only
verbal feedback.
Significance of written feedback. Students
highlighted several advantages of written feedback.
They stated that written feedback improved the
quality of their assignments by engaging them in the
learning process. Some students verbalized that due
to academic stress, they could not often remember
verbal comments; with written feedback they could
refer to the teachers’ comments before submitting the
next assignment. A few students mentioned that
written feedback was helpful to see their progress in
acquiring academic writing skills. Students
commented that teacher written comments; whether
positive or negative, leave a long-lasting learning
experience for students. They proposed that the
written feedback practices should be encouraged in
academic settings, which is rare phenomenon in their
nursing institutions.
Opportunities to discuss feedback. Besides
acknowledging the several benefits of written
feedback, students expressed that there should be an
opportunity to discuss the feedback with the teacher.
They thought that verbal feedback is complementary
to written feedback as it was easier in understanding
their problems and solutions in academic writing
compared to the teachers’ written comments alone.
Quantity, Timing and Quality of Feedback
Out of 612 comments, about 221 (36%)
comments were on the quantity and quality of
feedback. Two sub-categories emerged which include
the promptness, clarity, and thoroughness of the
feedback and provision of formative and personalized
feedback.
Attention to promptness, clarity, and
thoroughness. Many students identified that delayed
feedback was a major reason for not incorporating it
into their next assignment. Many students also felt that
the number of assessments per term or semester was
high and students often had to work on multiple
assessments such as exams, presentations, and
assignments of other courses, thus, they miss the
opportunities of learning from the feedback. They
thought with fewer assignments, faculty will also have
more time to provide effective feedback and also enable
the students to incorporate the feedback in an effective
manner.
Several students reported the issue of lack of clarity
in teachers’ written feedback. They suggested that
feedback should be written clearly using simple
language that matches the level of the students’
understanding. Moreover, they suggested that
feedback should be written in legible handwriting or
should be typed for the clarity. One student wrote,
“Feedback should focus on few issues and provide
suggestions on those. Moreover, teachers should be
watchful of number of issues she wants to address to
students at a time. Once those issues are resolved, other
can be addressed later. In this way, a teacher can help a
student understand and absorb feedback”.
Need for formative and personalized feed-
forward. Many students commented on the provision
of formative feedback on outlines and drafts before the
final submission and grading on their final
assignments. One student wrote “feedback on drafts
makes “graded work a reward and not a punishment”.
Moreover, students felt that formative feedback helped
decrease students’ anxiety of failing in the assignments
and also improved their writing skills. Some students
expressed that they are given feedback on their
assignments at the end of their courses or semester,
which is useless. Besides the importance of formative
feedback, a few students commented on the
importance of personalized feedback. They verbalized
that general feedback in the class by teachers on written
assignment does not meet the students individual
learning needs.
Care for Students’ Self-Esteem
Out of 612, around 76 (12.4 %) comments were
about the effects of feedback on the students’ self-
esteem. Several students’ expressed that negative
feedback and offensive remarks in the comments given
by teachers were discouraging for students. They
emphasized that positive feedback should be given to
increase students’ interest and motivation. One student
wrote, “Feedback should not be given, if it does not
have the element of encouragement”. They also added
that teachers should be flexible, patient, and open to
students’ learning, as improvement in the writing skills
will take time, with constructive feedback.
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4International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Teachers’ Competence for Written Feedback
Out of 612 comments, approximately 101 (16.5%)
students commented on the teachers’ abilities, skills,
values and attitudes in providing written feedback.
Students’ comments are further divided in two
subcategories; i.e. is teachers’ abilities and skills and
teachers values, and attitudes. Both sub-categories
highlight that because of teachers’ lack of appropriate
training in providing feedback, they received unfair
feedback.
Teachers’ abilities and skills. Several students
highlighted that the quality of feedback greatly differed
from faculty to faculty. Many students expressed that
there was no congruency between written feedback,
marks, and assignment criteria. As one student said
“teachers do praise in the comments but it is not shown
in the marks” and complained that when teachers are
asked to elaborate on the allocated marks, they do not
have a clear justification for marks deduction. A few
students thought that most teachers tended to check
assignments superficially, which is in their view shows
that the faculty members lacked training in feedback
provision.
Teachers’ value and attitude. Many students
expressed that teachers gave marks on the basis of
personal relations or students’ personality or ethnicity,
but not on the students’ quality of assignments. They
expressed that feedback and marks given by teachers
also reflected their personal grudges, discrimination
and prejudice with specific students. Some students
suggested using code numbers on students’
assignments instead of names to avoid teachers’
biasness in marking. A few students recommended
that if there are two faculty members teaching the same
course, and both are involved in students’ assessment,
all students should be equally exposed to their
marking. In other words, they should divide the
assignment checking in such a way that one
assignment of all students is marked by the same
teacher.
Consistency in Feedback Practices
Out of 612, seventy comments were on the needs
for consistency in feedback practices. Three
subcategories emerged in this category, which include:
provision of clear guidelines on assignments, format
of feedback; and the importance of institutional
policies with respect to written feedback.
Provision of clear guidelines Students verbalized
that in the absence of clear guidelines, they faced
ambiguity in attempting the assignments, and as a
result, they could not meet the teachers’ expectations.
Furthermore, due to lack of clear guidelines, teachers
were inconsistent in marking the assignment. They
proposed that the assignment guidelines should be
provided in written.
Format of Feedback Some students suggested
having set criteria for marking the assignments
[Rubric]. They suggested that they should receive
anecdotes throughout the entire paper and not a
generalized summery or only mark at the end of the
paper. They added that feedback should consist of
strengths and area of improvement. Some students
added that advanced computerized feedback methods
(email, track changes) can be used as these are quick
and efficient method of feedback.
Institutional policies on the written feedback.
Few students expressed that it was unfortunate that
their institution did not have the system of either verbal
or written feedback on written assignments. Policies
of not sharing assessment marks with students or not
returning their assignments resulted in frustration, as
then students have no way of knowing where they
stand and where they need to work hard. As one
students wrote “if the school policy does not require
teachers to provide feedback, it leads to biased results
and favoritisms”. They also said that it should be made
mandatory for the teachers to provide feedback. They
added that if students are not satisfied with the
feedback, there must be a policy for reviewing their
assignments again. Two students verbalized that only
English language teachers provide them with feedback
and felt that feedback should be provided by all
teachers in all the courses.
DISCUSSION
Findings of this study indicated that majority of
the students wished best written feedback practices
in their nursing institutions. Most students expressed
that they received insufficient feedback or no feedback
on their written assignments. Individual discussion
with teachers also confirmed that there were no
policies regarding assignments feedback in any of the
nursing schools enrolled in this study.
The study findings revealed that many students
wished to receive personalized feed- forward on drafts
1. amandeep kaur-1-5.pmd 1/6/2014, 9:30 AM4
International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 5
or outlines before the final submission. The usefulness
of written formative feedback or feed-forward is well
established in the literature. [6, 7] However, to the
researchers’ knowledge, formative feed-forward on
graded assignments is not a common practice in
nursing institutions in Pakistan. Knowing the
advantages of formative feedback, the faculty may
restructure their assessment practices and make more
use of the formative feedback. Consistent with the
literature [2, 3, 5] this study highlighted the importance
of provision of clear guidelines for assignments as it
facilitates the educators in making professional
judgments about the quality of students’ work and
learning outcomes against set standards.
Students raised the concern that their teachers
lacked accountability in providing feedback. Wormeli
[8] emphasizes that accountability is not only implies
to students, teachers also are accountable to students
and they should practice professional ethics and
adherence to sound pedagogies while dealing with
student including assignment checking, giving
appropriate written and verbal feedback and grading
them. Several issues highlighted by the students in this
study such as, timely provision of feedback, feedback
written with legible handwriting, impact of negative
feedback on students’ self-esteem, and balancing
feedback with criticism and suggestions are also
consistent with existing literature. [2, 3, 7, 9]
CONCLUSION
The findings of this study have implications for
teachers, students and institutions similar to the
context of this study. Teachers need to be aware of the
role and impact of written feedback on students’
learning and develop competence for giving effective
feedback. For better utilization of the feedback,
teachers and students should have shared
understanding about the goal, and processes of written
feedback. Moreover, there should be institutional
commitment to introduce polices to promote practices
of effective written feedback.
ACKNOWLEDGEMENTS
We acknowledge the thesis committee members,
heads of all the nursing institutions for providing
access to their students, and the students of all the
nursing institutions who participated in this study.
Conflict of Interest : We do not have any conflict of
interest
Source of Support: Funding of this project was
supported by Aga Khan University School of Nursing
and Midwifery
Ethical Clearance: The study had an approval from
the University Ethical Review Committee (ERC).
REFERENCES
1. Clynes MP, Raftery SE. Feedback: An essential
element of student learning in clinical
practice. Nurse Education in Practice 2008; 8:
405-411.
2. Carless D. Differing perceptions in the feedback
process. Studies in Higher Education
2006; 31(2): 219-233.
3. Gibbs G, Simpson C. Does your assessment
support your students’ learning? Learning and
Teaching in Higher Education 2004-2005; 1(1):
3-31.
4. Conaghan P. Lockey A. Feedback to feed forward:
A positive approach to improving candidate
success. Leitthemia. Springer Suppl 2. 2009; 12:
45- 48.
5. Weaver MR. ‘Do students value feedback?
Student perceptions of tutors’ written
responses. Assessment & Evaluation in Higher
Education 2006; 3(3):379- 394.
6. Murtagh L, Baker N. Feedback to Feed Forward:
student response to tutors’ written comments
on assignments Practitioner Research in Higher
Education 2009; 3(1): 20- 28.
7. Koen M, Bitzer EM, Beets PAD. Feedback or Feed-
forward? A case in one higher education
classroom. Journal of social sciences 2012; 20(1):
68-87.
8. Wormeli, R (2006), Accountability: Teaching
through Assessment and feedback, not
grading. American secondary education 34(3),
14-27.
9. Young P. ‘I Might as Well Give Up’: Self-esteem
and mature students’ feelings about
feedback on assignments. Journal of Further and
Higher Education 2000; 24(3):409-418.
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6International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
Diabetes is very much a universal and growing
problem with serious health related and socio-
economic impacts on individuals and society4. Hence,
the enhancement of knowledge on management of
diabetes could help in reducing these impacts
enormously. Insulin is a protein hormone secreted
from the â cells of islets of langerhans of pancreas. Type
1 diabetes children depend on external insulin for their
survival since their hormone is no longer produced
internally by â cells of islets of langerhans5. Even
though diabetes is considered to be a chronic illness,
the children’s knowledge on administration of insulin
is not reinforced by the health personnel periodically.
Insulin is secreted directly into the portal circulation,
therefore the liver which is the major site of glucose
disposal, receives the largest concentration of insulin6.
Conventionally insulin has been administered
subcutaneously using insulin or tuberculin syringes
with 26 gauze needles. To promote compliance,
alternative methods of administering insulin are
available in the market.
Administration of Insulin to Type 1 Diabetes-Current
Nursing Practice
Anjuladevi Kamaraj1, M Gandhimathi2, C Rameshc3
1Research Scholar, Annamalai University, Annamalai Nagar, 2Professor, Rani Meyyammai College of Nursing,
Annamalai University, Annamalai Nagar, 3Director of Juvenile Diabetes Projects,Voluntary Health Services, Chennai
ABSTRACT
The International Diabetes Federation's (IDF) diabetes atlas 2011 shows that 366 million people have
diabetes worldwide and by 2030, this will have risen to 552 million. At the same time, 183 million
people (50%) with diabetes are undiagnosed1. Current estimates suggest that two thirds of those
affected by diabetes live in low and middle income countries (LMIC). By 2025, the number of diabetes
cases will increase by 170% in low and middle income countries, compared to a 41% increase in
developed countries2. The total child population (0-14 years) was 1.9 billion worldwide. Some 78,000
children under 15 years are estimated to develop type 1 diabetes annually worldwide. About 49,000
children were affected with type 1 diabetes with 24% from European region and 23% from South
East Asian region1. Insulin is an important hormone concerned with regulation of carbohydrate,
protein and fat metabolism and blood glucose level. Insulin has been identified as one of the top 10
high risk medicines in treating type 1 diabetes3.
Keywords: Insulin, Type 1 Diabetes, Insulin Therapy, Insulin Administration, Insulin Delivery
DOI Number: 10.5958/j.0974-9357.5.2.054
Insulin was discovered from acid ethanol extracts
of pancreas at the University of Torondo in 1921 by
Frederick Banting, Charles Best, JJR Macleod and
James Collip. The name insulin was coined by JJR
Macleod who is a Professor of Physiology. The first
patient to receive insulin was Leonard Thompson for
whom the treatment began on 11th January, 1922.
About 50 units of insulin are required per day per
individual7. The human pancreas store about 250 units.
The insulin is a polypeptide with a molecular weight
of 5808. It has two amino acid chains called á and â
chains which are linked by disulphide bridges. The á
chains of insulin contain 21 amino acids and â chains
contain 30 amino acids. The human pancreas contains
about 1-2 million islets. The islets of langerhans consist
of 4 types of cells namely A or á cells which secrete
glucagon, B or â cells which secrete insulin, D or ã
cells which secrete somatostain and F or pp cells which
secrete pancreatic polypeptide. Synthesis of insulin
occurs in rough endoplasmic reticulum of â cells in
islets of langerhans . It is synthesized as preproinsulin
that gives rise to proinsulin. Proinsulin undergoes a
series of peptic cleavages leading to the formation of
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 7
mature insulin and C peptide. C Peptide is a
connecting peptide that connects á and â chains. At
the time of secretion, C peptide is detached8.
Physiologic Functions of Insulin
The physiological functions of insulin are as follows
The insulin
• Stimulates entry of glucose into cells for utilization
as energy course.
• Stimulates entry of amino acids into cells,
enhancing protein synthesis.
• Enhances fat storage and prevents mobilization of
fat for energy (lipolysis)
• Promotes storage of glucose as a glycogen in
muscles and liver cells (glycogenesis)
• Inhibits formation of glucose from non
carbohydrates (glyconeogenesis)
Insulin Therapy
The goal of insulin therapy is maintaining near-
normal blood glucose levels while avoiding too
frequent episodes of hypoglycemia. The glycemic
goals recommended currently by the American
Diabetes Association (ADA)7are :
• pre-prandial plasma glucose level = 70 to 130 mg/
dl
• postprandial plasma glucose level = < 180 mg/dl
•A
1c (glycosylated hemoglobin) = < 7%
Insulin regimen is a systematic plan of taking
insulin in order to preserve or restore health or to attain
near normal blood glucose level. The amount and type
prescribed on the child’s height, weight, metabolic rate,
physical maturity, blood glucose level, usual diet and
regular exercise. Insulin requirements usually increase
as the child grows. Requirements are usually even
higher during puberty due to the influence of increased
growth hormone and sex hormone secretions8 . Insulin
available for routine clinical use is derived from beef
(bovine), pork (procine) and human. Also mixed
insulin is derived from bovine and procine. Bovine
insulin differs from human insulin in three amino acids
namely A8, A10 and B30. Procine insulin differs from
human insulin in only one amino acid namely B30 .
Thus procine insulin is less immunogenic than bovine
insulin. Human insulin is pure and has the same amino
acid structure as that of native insulin. They are made
by genetic engineering or by transformation from
procine insulin by substituting alanine with threonine
in the B30 position. Mixed insulin contains a mixture
of bovine and procine insulin and it is more antigenic
than singly species9.
Insulin is available in the strengths of 40 units/ml
and 100 units /ml. The patient must ensure that the
syringes used by him or her are compatible with the
strength of the insulin used. Insulin works in a
predictable way. So, it has to be injected into
subcutaneous tissues only. The sites for self
administration of insulin are outer thighs and
abdomen because of easy access for the child. Rotation
of sites is very essential to prevent local reactions of
insulin administration.
Insulin absorption: Insulin absorption can be
affected by many factors which result in predicted
action. The factors that speed up the insulin absorption
are (1) warm/hot environment, to increase the blood
flow to the injection area (2) rubbing or massaging of
the injection area and (3)delivery of the injection into
the deeper layer of the skin. These factors may increase
the risk of developing hypoglycemia. The factors that
slow down the insulin absorption are (1) a cold
environment to reduce the blood flow to the injection
site (2) increased volume of insulin administration and
(3) unhealthy injection site (scarred/bruised skin)10.
Poor techniques and complications: Using the
incorrect needle length cannot result in expected
absorption of insulin. This may cause hypoglycemia
or hyperglycemia. The poor injection technique will
result in the development of lipohypertrophy. The site
should be changed for each injection to reduce the risk
of developing lipohypertrophy. Reuse of needle can
lead to bruising and bleeding of skin as the needle
becomes blunted by overuse. Also, infection is possible
if the needles are reused or if an injection is
administered through clothing11.
Nurses’ responsibility on administration of
insulin: Nurses can be instrumental in helping the
IDDM children by teaching them about self care
management. If the children can take care of their
needs, it will reduce the expenditure towards the
treatment12.
Vials of insulin that had been opened before several
weeks and the ones which crossed the expiry date
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8International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
should be discarded. Extra insulin vials should be
refrigerated in the temperature range 15 - 29.4 ú c
and not to be freezed. Insulin should always be stored
in a cool place even in the absence of refrigeration
facility (using ice box, mud pot containing water) and
avoid exposure to direct sunlight. The insulin vial
should be brought down to the body temperature by
gently rubbing in between the palms before
withdrawing the insulin. Otherwise, the insulin vial
should be kept outside 1 hour before the time of
administration. Any vials with discoloration,
clumping, granules or solid deposits should be
discarded. The needle should be left in the skin at least
for 10 seconds after the insulin is injected. If the
breakfast is delayed, the administration of rapid acting
insulin should also be delayed. The ready availability
of food should be ensured before administration of
insulin. Intake of food should be after 10- 15 minutes
of the administration of insulin. Blood glucose
readings should be recorded 30 minutes before each
meal and bed time. The food consumed should be
noted. Injection sites should be observed and inspected
every time of administration of insulin. The patient
should be instructed to keep sugar candy/glucose/
ID card always. Hypoglycemia and hyperglycemia
symptoms should be taught to the patients so that they
can inform the same to the care giver13.
Health education to the client and family
Whenever needed, the client or the family members
should visit the physician. Parents should ensure that
optimum health condition is maintained by adequate
sleep, rest, regular exercise, avoiding high levels of
dietary cholesterol, routine examination and treatment
for the child. The parents should monitor the
effectiveness of the therapy by checking blood glucose
level 4 times a day and glycosylated hemoglobin once
in 3 months. The parents should ensure that the insulin
and glucagon are stored in the proper manner. Parents
should be in a position to identify the sign of
hypoglycemia and hyperglycemia and to provide
necessary treatment. The parents should inform the
teacher, peers about possible precautions to be
adopted if hypoglycemia occurs. The parents should
ensure that the child is having medical identity card
with them always. The child/family members should
carry diabetes supplies while staying overnight away
from residence or during travel. The parents should
take the child for annual check up to the physician/
dentist/opthalmologist. The parents should give only
the prescribed medicines. The parents should follow
‘sick day rules’ when the child falls ill14. The child/
parents should avoid drugs or alcohol which results
in hypoglycemia/hyperglycemia. The parents should
adjust positively to the disease by using professional
assistance and learning in order to establish successful
coping patterns and develop a social support system.
Techniques to minimize painful injections
1. Insulin should be administered always at room
temperature. 2. It should be ensured that there is no
air bubbles in the syringe. 3. Before administration,
spirit applied at the site should be allowed to dry. 4.
The patient should be encouraged to keep the muscle
relaxed. 5. It should be ensured that the needle is sharp
and quickly penetrates the skin. 6.The direction of the
needle should not be changed during insertion and
withdrawal. 7. Blunt or dull needles should not be
reused.
Alternative modes of insulin delivery
The most common alternative ways to deliver
insulin are insulin pens and insulin pumps.
Insulin pens look like pens with a cartridge. Some
of these devices use replaceable cartridge of insulin.
Other pens are prefilled with insulin and are totally
disposable after the insulin is injected. Insulin pen users
screw a short, fine, disposable needle on the tip of the
pen before an injection. The users turn a dial to select
the desired dose of insulin, inject the needle and press
a plunger on the end to deliver the insulin just under
the skin. Future advances in insulin pump therapy are
likely to include closed-loop systems that can monitor
glucose levels and dispense insulin automatically,
mimicking insulin release from the pancreas15.
Insulin pumps also known as continuous
subcutaneous insulin infusion (CSII), pumps provide
a continuous adjustable supply of insulin through a
plastic tube attached to the body and eliminate the
timing hassles and blood glucose fluctuation associated
with injection.
Jet injectors are designed to deliver a fine stream
of insulin transcutaneously at high speed and high
pressure to penetrate the skin without a needle.
Emerging trends in insulin delivery systems:
Several manufacturing companies are working on
developing new ways of taking insulin from pills to
patches to mouth spray to inhalers. The concept of
delivering insulin by mouth (oral delivery) for
absorption across the intestinal wall into the portal vein
has long been regarded as a difficult challenge. But it
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 9
is clinically and commercially potential. Emisphere
technologies are also pursuing oral route of insulin
delivery taking advantage of the hepatic route of
absorption, as insulin would be delivered to the liver,
hence acting directly on hepatic glucose production
in the same way of normal physiological state16.
The patch non-invasive transdermal insulin
delivery could provide diabetic patients with sustained
physiological levels of basal insulin in a pain free
manner . This could be done first by a device that
would make microscopic holes in the top layer of the
skin and secondly the application of patch over the
skin.
Mouth spray delivers insulin through an aerosol
spray and hence they differ from inhalers. In the mouth
spray, the insulin is absorbed from inside of the cheeks
and in the back of the mouth instead of lungs.
Insulin inhaled through Insulin inhalers by humans
is more rapidly absorbed than that from subcutaneous
injection. However, the efficiency of inhaled insulin
is lower than that of subcutaneous injection. Because,
pulmonary delivery of insulin involves some loss of
drug within the inhaler or mouth during inhalation17.
CONCLUSION
The conventional method of administering insulin
may be replaced by alternative modes involving
insulin pens and pumps as these are cost effective and
time saving and avoid pains. The diabetic nurse
educator can be made available in the diabetic
OPDs so that protocol on management of the diabetes
could be taken care of and required training could be
availed periodically by the diabetic children. The
health care delivery system could ensure that the
psychological issues of the diabetic children are dealt
with by psychologists.
ACKNOWLEDGEMENT
One of the authors Mrs. Anjuladevi Kamaraj thanks
Dr.Vijayalakshmi, Principal, Rani Meyyammai College
of Nursing and Dr. C.V. Krishnaswami, Professor and
Head, Juvenile Diabetes Research Center, VHS for their
encouragement and support.
Conflict of Interest, Source of Funding and
Ethical Clearance: No conflicts of interest exist in this
paper. The work is self funded. This article does not
require ethical clearance.
REFERENCES
1.International Diabetes Federation, Diabetes atlas,
5th Edition(2011)
2. Mohammed K. Ali, Mary Beth Weber2, K. M.
Venkat Narayan ,The Global Burden of
Diabetes, The Textbook of Diabetes, Fourth
Edition, Wiley Black well publications, UK (2010)
3. Tara Lamont et al., Safer administration of insulin:
summary of a safety report from the National
patient safety agency, BMJ 2010; 341:c5269.
4. Richard I.G. holt et al., The global burden of
diabetes,4th edition, Wiley Blackwell, UK (2010)
5. S.Chauhan Nitesh, Recent advances in insulin
delivery systems: An update, World Applied
Sciences Journal, 11(12):1552-1556 (2010)
6. Dona L Wong et al, Whaley and Wong’s Nursing
care of Infants and children, 6th edition, Mosby,
New York (1999)
7. Robert B.Tattersall, The History of Diabetes
Mellitus, Textbook of Diabetes, Fourth
Edition(2010)
8. K. Sembulingam, Prema Sembulingam,
Essentials of Medical Physiology,5th edition,
Jaypee Medical publication (2010)
9. Dhruv K Sing and H.B.Chandalia, Pediatric
oncall child health care, www.ped.oncall.com
10. Down S, Kirkland F, Injection technique in insulin
therapy, Nursing times, 108:10, 18-21 (2012)
11. Jane W.Ball and Ruth C.Bindler, Pediatric nursing
:caring for children, 4th edition, Dorling
Kindersley India Pvt Ltd (2009)
12. Anjuladevi Kamaraj, Self care management of
children with type-1 diabetes, Nightingale
Nursing Times, Vol.4 Issue.1 (2008)
13. Priscilla Lemone and Karean Bruke, Medical
surgical nursing,3rd edition, Pearson
publications(2010)
14. Deborah Thomas-Dobersen, Sick-Day
Guidelines, clinical diabetes ,vol. 18, no. 3,
Summer 2000.
15. Alsaleh FM, Smith FJ, Keady S, Taylor KMG.
Insulin pumps: from inception to the present and
toward the future. J Clin Pharm Ther 2010;
35:127–138.
16. M. M. Al-Tabakha and A. I. Arida, Recent
Challenges in Insulin Delivery Systems: A
Review, Indian J Pharm Sci. 2008 May-Jun; 70(3):
278–286.
17. Quattrin T, Bélanger A, Bohannon NJ, Schwartz
SL, Efficacy and safety of inhaled insulin
(Exubera) compared with subcutaneous insulin
therapy in patients with type 1 diabetes: results
of a 6-month, randomized, comparative trial,
Diabetes Care 2004; 27 : 2622-7.
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10 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
Graduate nurses are faced with the challenge of
passing the National Council Licensure Examination-
Registered Nurse (NCLEX-RN), which is required to
practice nursing. In 2010, the National Council State
Boards of Nursing (NCSBN) reported the national
failure rate on the standardized examination for
Associate degree nurses (ADN) as 13%. Repeat test
takers had an even more significant failure rate of 45%.
Failing the NCLEX-RN has not only affected the
psychological and financial wellbeing of the graduate
nurse (GN) but has delayed entry into nursing practice;
added to the ongoing nursing shortage; and limited
the number of available nurses to care for an aging
population.1
Lived Experiences of Failure on the National Council
Licensure Examination - Registered Nurse (NCLEX-RN):
Perceptions of Registered Nurses
Mc Farquhar Claudette
1York College, City University of New York
ABSTRACT
This study was to promote a deeper understanding of the possible meanings that may be given to the
lived experiences of graduate nurses who failed the NCLEX-RN as perceived by registered nurses.
The data collected in this study were recalled memories of feelings, experienced when graduate
nurses failed the NCLEX-RN. Qualitative phenomenological study with a constructivist approach
was utilized, after conducting a pilot study. Eighteen Registered Nurses who had failed the NCLEX-
RN answered the research questions. Close face-to-face, one-on-one audio-taped in-depth interviews
allowed for listening more effectively to the voices of participants, while observing body language as
participants recalled their lived experiences of failure. The recalled experiences emerged in underlying
themes and patterns and were analyzed and organized and include: disappointment; depression;
and avoidance that evolved as temporary decreased psychological and sociological well being.
Knowledge seeking behavior and confidence evolved from: not knowing what to expect; distraction;
poor test-taking skills; and overall, inadequate preparation. Implications are for positive change to
improve NCLEX-RN test-taking outcome.
Keywords: Anxiety, Avoidance, Confidence, Failure, Test-Taking, Test-Anxiety, Lived Experience
DOI Number: 10.5958/j.0974-9357.5.2.054
Corresponding author:
Mc Farquhar, Claudette
Associate Professor,
York College, City University of New York
94-20 Guy R. Brewer Blvd., Science 110
Jamaica, NY 11451
E-mail: cmcfarquhar@york.cuny.edu
7182622054; 3476003586
The higher than expected failure rate, despite an
average 2-3 years of rigorous nursing education and
training, echoes tremendous dissatisfaction within the
health care community, 1,2,3,4,5, 6, 7,16 and has drawn
concern from educators, policy makers, and health care
agencies, who have analyzed the situation and have
concluded that there is a need to better understand
and improve NCLEX-RN failure rates.8, 2,3, 7, 15
Furthermore, personal feelings experienced by
graduate nurses (GNs) who fail the NCLEX-RN
demand to be addressed.
PURPOSE
The purpose of this study was to gain a deeper
understanding of the possible meanings that may be
given to the lived experiences of failure on the NCLEX-
RN as perceived by registered nurses (RNs). On
knowing the meaning given to lived experiences of
failing the NCLEX-RN by GNs, the information may
be used to: help influence nursing education policy
and programs; enhance the profession of nursing by
adding to the body of nursing knowledge; incorporate
in further research; anticipate and examine the needs
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 11
of future graduate nurses who must prepare for, and
take the same examination.
Limitations of the study
The generalizability of the findings from this study
is limited due to: use of a purposive sampling
procedure; a homogenous sample of 18 participants
(sixteen African American females; one Philippino; one
Hispanic); with limited cultural diversity.9
The limited population, however, facilitated
flexibility for in-depth interviews; asking of open-
ended questions; ensured participation of an adequate
number of nurses enrolled within the institution who
had failed the NCLEX-RN.10 In order to avoid
introducing biases into the study, participants
validated their interviews after they were transcribed.
Literature review
An extensive literature search was conducted to
add structure to the problem of GNs who had failed
the NCLEX-RN. Literatures were examined pertaining
to feelings experienced when GNs failed NCLEX-RN;
methods utilized in preparing to retake the NCLEX-
RN; and motivations that hindered or helped the
individual.10, 4, 12, 14 The initial search revealed
discussions on NCLEX-RN outcomes, including the
impact of negative NCLEX-RN outcome on the GN,
nursing schools, nursing education, the health care
system; and on reasoning skills and test-anxiety 2, 11, 16
METHOD
Qualitative phenomenological methodology was
chosen because it lends itself to the derivation of real
meaning through intimate recollection of memories.12,
13 Lived experiences from 18 face-to-face interviews
were tape-recorded and transcribed verbatim.
Participants responded to the main interview
questions, and several probes. As the data was
analyzed, experiences began to emerge in patterns and
themes. Each participant was given a code name, P1
through P18 to aid analysis. The constructivist
paradigm that embraces the concept of multiple
meanings that are socially and historically constructed
allowed reflection, recollection, reconstruction, and
narration of individual unique stories.12, 13
RESULTS
A phenomenological constructive approach
allowed eighteen graduate nurses to reflect, recall and
reconstruct their story of failing the NCLEX-RN in
response to the question: “Please describe what it was
like for you after finding out that you failed the
NCLEX-RN?” As stories were recalled and memories
narrated, the meaning of failure emerged in themes
and patterns of disappointment; depression; and
avoidance, which evolved as temporary decreased
psychological and sociological well being. In response
to the question, “Please describe experiences that you
believed contributed most to your initial failure on the
exam?” Participants recalled, “not knowing what to
expect; distraction; poor test-taking skills,” from which,
inadequate preparation, knowledge seeking behavior
and confidence evolved.
Through intent listening, the rich essence of
participants’ memories was felt, as their experiences
were brought back to life. The emerged themes and
patterns were analyzed and organized with attempt
of presenting the stories in similar manner.
Emerged themes and patterns: Experiences of failure
The initial question, asked in order to gain a
deeper understanding of the feelings of failure
experienced by GNs, was introduced in the following
manner. “I want you to think back on the time when
you first took the state board exam and describe that
period. “Please describe what it was like for you after
finding out that you failed the NCLEX-RN?”
Responding spontaneously, participants went back in
time, recalling and narrating lived experiences, in thick
descriptions, as if the experiences had only just
occurred. 13
Participants recalled that while failing the NCLEX-
RN brought feelings of disappointment, isolation,
depression and sadness; new challenges emerged,
demanding re-examination of prior perceptions of
exams. After identifying possible reasons for failure,
external resources to improve chances of success were
sought. Negative feelings were brief, and were
therefore considered temporary decreased
psychological and sociological wellbeing.
Several participants recalled feeling disappointed
in self, in the nursing institution from which they
graduated, and in particular, in not knowing what to
expect on the exam. Participants remembered feeling
depressed, accepting failure as justification for
inadequate preparation, and experiencing self-
imposed social isolation, with difficulty discussing
failing the exam; avoiding/hiding from others, from
fear of being labeled inadequate.
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12 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
The pattern, knowledge seeking behavior, emerged
from confidence, as participants approached friends,
NCLEX-RN preparation agencies, and institutions, to
plan/retake the exam and to become RNs. Feelings of
confidence were therefore transformed into approach
or acceptance, as participants aspired toward goal
attainment. Participants recalled persevering, not only
for self-fulfillment, but to satisfy financial and social
obligations.
Discussion of emerged themes: Feelings of failure
The temporary decreased psychological and
sociological wellbeing in response to failure, loss and
disappointment experienced by participants, is
supported in the literature as adaptive mechanisms
that protect individuals from perceived unfavorable
outcomes of failure.5, 7, 12 For example, after failing, GNs
described experiencing mood changes – feelings of
devastation, sadness, anxiety, avoidance – avoiding
exam results discussion.
The expression, temporary, was added to reflect
GN’s un-sustained decreased psychological and
sociological wellbeing. For example, all 18 participants
recalled changing from sadness and avoidance to
approach and acceptance; with renewed aspirations
and confidence, as they began seeking ways to prepare
to retake the exam. Within days, to a few months after
failing, participants recalled knowing that the exam
could be repeated; felt confident that they would
succeed; and engaged in knowledge seeking
behaviors. Information was sought from friends who
had previously taken the exam; NCLEX-RN
preparation agencies and institutions (Tables 3 and 4).
Discussion of emerged themes: Contributing factors
This open-ended question, “Please describe
experiences that you believed contributed most to
your initial failure on the exam?” was more broadly
structured to further engage participants in recalling
memories perceived as contributing to failing the
NCLEX-RN, elicited responses about feelings, and
thoughts of failing the exam. The follow-up probe,
“What else should be known about factors
contributing to your failing the NCLEX-RN?”
interjected at a point in the interview, encouraged
participants to continue their stories, from which,
verbatim excerpts are presented with very little
editing; allowing the reader to experience the rich thick
descriptions of the stories as they were narrated to
the researcher (Tables 3 and 4).13
Participant1. The main thing, I was not well
prepared. Lack of motivation.
Participant2. My inner intuition. I knew that inside
of me really, I would
say, I was not really prepared in a way, but yet still
I expected. But way down, deep in side me, I felt that
I’m not really ready. So that is one of the things that I
should have excluded and know. But that inner feeling
that you have, but you say you should go because ok,
“This one went and passed, but she wasn’t doing well
in school, how she went and passed?” But it is you,
the individual who know how you’re doing.
As participants recalled not knowing what to
expect, distractions, and poor test taking skills,
inadequate preparation emerged. For example,
participants recalled internal and external distractions
that hindered success on the exam as, being overly
anxious about perceived failure; having to joggle
family, work and school. Participants had memories
of feeling or knowing that they were not sufficiently
prepared academically as well as non-academically to
take the examination. For example, Participants
described lacking multiple choice test-taking skills.
Discrepant cases: Experiences of failure
The stories of three participants were non-
conforming in some areas. For example:
Participant 5. I was not disappointed. It really did
not have any psychological effect on me. My attitude
was that I will take it again. I went and did it because
I did not want to lose my money. I know that I didn’t
fail because of lack of knowledge. I have poor test
taking skills. Basically, it’s some kind of stigma that I
have about multiple choice questions. I never liked
them.
Discussion and Conclusion
Qualitative phenomenological approach from a
constructivist perspective was particularly chosen to
give a voice to the nurses to recall, reconstruct and
describe lived experiences of failing the NCLEX-RN.
Participants recalled memories contributing to failing
the NCLEX-RN as: distraction; poor test taking skills;
not knowing what to expect on the examination, and
overall, inadequate preparation.
Attributing failure to self, participants recalled
memories of moving from a temporary decreased state
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 13
of wellbeing; to a state of approach and confidence,
which was exemplified by the participant who stated,
“I realized that when you fail if you stay in that failure
state without moving on, then, you would be defeated.
If you try and try again then you will achieve what
you really want.” The information gleaned from this
study might benefit graduate nurses who are faced
with similar challenges of taking the NCLEX-RN.
Finally, the featured research may be replicated with a
less homogenous sample.
Table 3: Summary: Experiences of Failure
Temporary decreased psychological and sociological wellbeing P 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18
Disappointment P 1, 2, 3, 4, 6, 8, 9, 10, 11, 12, 13, 15, 17
Depression P 3, 4, 12, 13, 18
Avoidance P 1, 2, 3, 4, 8, 9, 11, 14, 16,17
Knowledge seeking behaviorConfidence P 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18
Approach or acceptance P 3, 5, 6, 7, 10, 12, 13, 15, 16, 17, 18
Aspire towards goal attainment P 1, 2, 3, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18
Discrepant cases: I had a stigmaI deserved to failI felt they wanted money P5P6P14
Note: N= 18; P = participant
Table 4: Themes and Responses: Experiences of Failure
Disappointment After a while I thought it over and with the support of friends; I decided to give it another tryVery
disappointed, because I believed that I had studied a great deal. After about a month, I prayed
and told myself it’s not the end, I will try again, and I will pass it. Distraught. My hands trembled,
and I ran to the bath roomI felt very disappointed I put the negative thoughts behind me and
began to think positively and told myself…
Depression It’s like something in your heart, they call it like bitterness When the results came, I had these
feelings as if I was nobody. The worse part was knowing that I have to study over again. I got
depressed. I was so sad and anxious.You feel sad within yourself at that moment when you get
the resultI didn’t feel happy about it I dropped the envelope. My mood went down. I became
temporarily depressed
Avoidance or hiding out It really did not have any psychological effect on me.My attitude was that I will take it again.I
knew, but I hoped that it wasn’t so, but then, deep down I knew it was going to happen. I was
devastated! I felt really bad as if I had wasted my money.I didn’t tell many people that I failed,
only one friend.I felt terrible. I felt like they wanted more money out of me. I just threw it
somewhere in a corner. It was hard letting some people know that I had failed, but some people
understood. I considered taking the exam private. When I failed no one knew. When I opened
that brown envelope and saw I had failed, I put it down.”I had this great fear. I had this friend
calling for me.
Approach or Acceptance The anxiety did not last. I decided to do another reviewI continued to study again. A period of
sadness followed by prayer and studying. I really needed my licensure to get a job I realized that
I had to give it another try I depended on God. I said that He will help me. I prayed about it. You
want to meet a goal, so you just go for itStudy like you’re going crazy I felt ok, because I felt like
if I didn’t pass, it’s because I wasn’t ready
Aspire toward goal attainment The day after I failed the exam, I picked up my mood and started study right away again. I
didn’even wait. I said,”Well,this is a fight, and I must end it.
ACKNOWLEDGEMENTS:
I wish to acknowledge Dr Frank DiSilvestro, Dr
Henry Merrill, Dr B. Folz, Dr J. Lavin & Professor
Hyacinthe McKenzie to whom I am deeply indebted
for their editorial input and dedication in mentoring
and encouraging me. Thanks to each participant,
without whom, this research would have been
impossible.
Ethical Clearance
Approval for the study was gained from Medgar
Evers College (CUNY) IRB.
I do not have an actual or potential conflict of
interest.
This article is original and has not been submitted
elsewhere for publication.
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14 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
No special Funding has been obtained or is
associated with this article.
REFERENCES
1. National Council of State Boards of Nursing
[Electronic version]. Retrieved March 20, 2013,
from http://www.ncsbn.org/1237.htm
2. Harding, M. (2010). Predictability associated with
exit examinations: A literature Review. Nursing
Education, (9). 493-497
3. Joint Commission. (2010). Initiative on the future
of nursing [Electronic version]. Retrieved March
25, 2013, from http://www.jointcommission.
org/assets1/18/RWJ_future_of_ nursing
4. Griffiths, M. J., Papastrat, K., Czekanski, K.
Hagan, K. (2004). The lived Experience of NCLEX
failure. Journal of Nursing Education, 322-325.
5. Poorman, S. G., Webb, C. A. (2000). Preparing to
retake the NCLEX-RN: the Experience of
graduates who fail. Nurse Educator, 4, 175-80.
6. Poorman, S. G., Mastorovich, M. L., Liberto, T. L.
& Gerwick, M. (2010). A cognitive behavioral
course for at risk senior students preparing to take
the NCLEX. Nurse Educator, 18, 172-175.
7. DiBartolo, M. C., & Seldomridge, Lisa. (2008). A
Review of Intervention Studies to Promote
NCLEX-RN Success of Baccalaureate Students.
CIN: Computers, Informatics, Nursing.26 (5)
785-835.
8. Davenport, N. C. (2007). A comprehensive
approach to NCLEX-RN success. Nursing
Education Perspectives, 28, 30-33
9. Polit, D. F., & Hungler, B. P. (1987). Nursing
research: Principles and methods (3rd. ed.).
Philadelphia: J. B. Lippincott.
10. Creswell, J. W. (2003). Research design:
Qualitative, quantitative, & mixed methods. (2nd
ed.). Thousand Oaks, CA: Sage Publications
11. Frith, K. H., Sewel, J. P., & Clark, D. J. (2006). Best
practices in NCLEX-RN readiness preparation for
Baccalaureate student success. CIN: Computers
informatics, nursing & Nurse Educator, 6,
322-329
12. Moustakas, C. (1994). Phenomenological research
methods. Thousand Oaks, CA: Sage Publishing.
13. Van Manen, M. (1990). Researching lived
experiences: Human science for action sensitive
pedagogy. London: State University of New York.
14. McQueen, L., Sheldon, P., & Zimmerman, L.
(2004). A collective community approach to
preparing nursing students for the NCLEX-RN
examination. The ABNF Journal
15. Morrison, S., Free, K., & Newman, M. (2002). Do
progression and remediation policies improve
NCLEX-RN passing rates? Nurse Educator, 27,
94-96.
16. Spurlock, D. R., & Hunt, L. (2008). A study of the
usefulness of the HESI Exit Exam in predicting
NCLEX-RN failure. Journal of Nursing
Education, 47; 157-166
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 15
INTRODUCTION
Human is always making simple or complicated
decisions during his life Naturally, every selection,
depending on its simplicity or sophistication, imposes
us a level of stress; therefore, having efficient coping
skills, being satisfied with the decision making process
in an innovative manner and skill of problem solving
are essential to lower the related stress.1 So, a way to
make learning meaningful is problem solving skill to
remain productive and dynamic in the field of
sciences.2 Nowadays, training and education experts
as well as curriculum planners teach the students in a
way that they can acquire the scientific facts by
themselves instead of being loaded with the facts. They
believe that students should personally think, decide
and judge about various issues instead of loading their
mind with scientific facts.3
The effect of Problem Solving Training on Decision
Making Skill in Nursing Students
Heidari M1, Shahbazi S2
1BSc, MSc, Department of Nursing, School of Nursing and Midwifery, 2BSc, M.Sc. in Nursing, Borujen Nursing
Faculty, Shahrekord University of Medical Sciences, Shahrekord, Iran
ABSTRACT
Background: Today in the areas of health care, nurses are increasingly faced with issues and situations
that are complex and the technology, understanding and acumen in the social sectors, rising health
culture, processes and frequent changes of complex disease traits and moral. Therefore, decision
making, critical thinking is to find and extremely complex. Nurses are going to decision making and
decisions are complex and constantly every choice's sensitivity is very high, so having the skills of
decision making and problem solving skills, in them, is essential. Therefore the aim of this study was
to determine the effect of problem solving training on decision-making skills in nursing students.
Materials and Method: This study is a quazi-experimental study that performed in 100 nursing
students in 2 groups of case (50) and control (50). Then, a short problem solving course based on 8
sessions of two hours during the term, was performed for the experimental group. To determine the
decision making skill the decision making questionnaire was used.
Results: The finding revealed that decision making score in nurses students is low and problem
solving course, positively affected the students ' decision making skill after the program (P<0.05).
Discussions: In general, the finding of this study indicated the improvement of the student's decision
making skill. Therefore this kind of education on problem solving in various emergency medicine
domains such as: education, research and management, is recommended.
Keywords: Problem Solving, Decision Making, Nursing Students
DOI Number: 10.5958/j.0974-9357.5.2.054
Decision-making is the most important and risky
component of health profession. Therefore, being
familiar with decision-making and application of
helpful strategies to provide the health personnel with
this skill, especially among nurses, is crucial,4 as
nursing students and nurses face specific problems in
addition to their routine procedures, which are
associated with their working environment. These
problems include working with numerous individuals
and treatment team personnel as well as the patients
and their families who are struck with disasters, being
in agonizing and happy moments of life and death etc.
which put the personnel at risk of high stress.5 Nurses,
in their professional role should make many critical
decisions associated with patients’ survival in every
day of their work. So, clinical decision making is a
complicated process.6
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16 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
On the other hand, the patients and their families
expect emergency nurses to make the best decision in
relation with their needs. Various studies have shown
that emergency nursing students lack problem solving
and decision making skills. Meanwhile nowadays, this
shortage, especially in emergency conditions when
they should be capable of solving the problems
appropriately, thoroughly and quickly, seems to be a
great defect.5 This study aimed to investigate the effect
of problem solving skill education on decision making
ability of nursing students in Broujen.
MATERIALS AND METHOD
This is a quasi- experimental two group pretest post
test study in which the effect of problem solving
education (independent variable) on the ability of
decision making in students of nursing (dependent
variable) in two groups of education (n=50) and control
(n=50) was investigated. The subjects of this study
were all term six and term eight associate degree
students of nursing (no=100) in nursing school of
Broujen who were interested in attending the present
study. Sampling method was availably with equal
same size of the population studied.
The subjects were randomly assigned to case and
control groups. Although the subjects had the lowest
contact with each other, the students in study group
were asked to keep the intervention confidential from
control group during the study. Then, all subjects filled
the questionnaire of demographic variables in which
it was tried to consider all influencing confounding
factors on decision making ability. These factors
included subjects’ age, marital status, residential area,
past semesters average, education, parents’ age and
education, numbers of children, any history of mental
diseases or mental drug consumption, and history of
attending emotional intelligence, stress control, Yuga,
problem solving and decision making classes in past
six months in the both groups. There was no significant
difference concerning the aforementioned factors in
study and control groups.
Students’ decision making skill was assessed before
and after intervention with tool of decision making
questionnaire. A 20 item questionnaire was designed.
Each question was scored between 0.25-1 through
likert scale in four levels.
The lowest score of the questionnaire was five and
the highest was 20. To confirm content validity, the
questionnaire was distributed among eight experts and
was confirmed by them. The reliability was confirmed
in a pilot study on ten students of nursing in term four
in Shahrekord nursing school (Cronbach alpha= 0.87).
In addition, the reliability was also calculated among
15 sophomore students of nursing in Shahrekord
nursing school, and Cronbach alpha of 0.74 was
obtained.
Despite these two tests, for further confirmation,
the reliability of the questionnaire was checked by
pretest post test method with a two week interval
yielding equal students’ score correlation of 0.66 in the
first and second time. In order to be sure about group’s
homogeneity, total average and rare score of students’
decision making skill were calculated and compared
yielding no significant difference. Then, education
program of problem solving was held in eight two
hour sessions during eight weeks by presence of study
group and through group discussion, brain storming
and three member group discussion with conduct of
the related teacher in Broujen nursing school with help
of Dezorrila and Gold Fried social problem solving
model.6
The stages of this model are as follows
Stage one: General direction
- The ability to detect the problem
- Acceptance of the problem as a natural
phenomenon, potential to change
- Believing in problem solving framework efficacy
when faced with the problems
- High self-efficacy expectation to conduct the model
- Having the habit of stop, think, and then struggle
to solve a problem
Stage two: Defining and framing the problem
- Collecting all available data, distinguishing the
facts from the hypotheses needing a research
- Problem analysis
- Defining realistic goals
Stage three: Production of alternative solution
- Defining a spectrum of possible solutions
- Possibility of selecting the best answer from all
existing answers
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 17
Stage four: Decision making
- Prediction of possible outcomes for each action
- Paying attention to benefits of these outcomes
Stage five: Performing problem solving
- Conducting the selected method
Stage six: Evaluation
- Observation of the results
- Evaluation
All educational sessions were designed based on
this model and in each session, one stage was
conducted. Descriptive and inferential statistics (direct
T-test, paired T-test and chi-square) were adopted to
analyze the data through SPSS / 16.
FINDINGS
This study was conducted on 100 students of
nursing. Mean age of the subjects was 23.42 ±0.52. 65%
of subjects were female and 45% were male. Before
intervention, in order to be sure that the groups were
identical, total average and students’ decision making
ability were investigated in both groups. Total Average
means score and standard deviation of the students
in case and control groups were 15.75 ±0.52 and 15.58
± 0.63 respectively.
Mean score and standard deviation of decision
making ability in case and control groups were
14.76±3.57 and 14.59± 4.01 respectively.
T test showed no significant difference between
these means. Chi-square test also showed no
significant difference in case and control groups
concerning variables of residential area, parents’
education level, the level of being interested in
studying the course, parents’ age and sex and a recent
crisis in the family. There was no history of attending
classes of Yoga, problem solving, emotional
intelligence and stress control in any of the groups.
Mean scores of decision-making skill before
intervention in case and control groups were
14.76±3.57 and 14.59± 4.01 respectively.
Independent t- test showed no significant
difference between these two means before
intervention (p>0.05), but after intervention, these
means increased to 16.06 ±2.85 in case group and
14.60± 3.98 in control group, and independent t- test
showed a significant between these means (t=8.72,
p<0.05) (table no. 1).
Table 1: Comparison of decision-making skill means
scores before and after intervention between study and
control groups
Study Control P value
Mean & SD Mean & SD Statistics
Before 14.76±3.57 14.59± 4.01 0.496 t=1.04df=58
After 16.06 ±2.85 14.60± 3.98 0.000 t=8.72df=58
Mean difference of decision making score before
and after intervention were calculated. In addition,
mean score differences were compared in case and
control groups and showed a significant difference
(t=9.68, p<0.05).
Mean score of students’ decision-making in case
group increased from 14.76±3.57 to 16.06 ±2.85 after
intervention. Paired t-test showed a significant
difference between these two means (t=12.97, p<0.05).
In control group, mean score of decision making
was 14.60±3.98 after intervention, and no significant
difference was seen in mean scores before and after
intervention (p>0.05) (table no. 2).
Table 2: Comparison of decision-making skill mean
scores before and after intervention between study
and control groups
Study Control
Mean & SD Mean & SD
Before 14.76±3.57 14.59± 4.01
After 16.06 ±2.85 14.60± 3.98
P value 0.000 0.369
Statistics t= -12.97df=29 t= -1.030df=29
DISCUSSION
The results of the present study revealed an increase
of decision making skill among students of nursing
after education of problem solving skill. The level of
decision making skill has been restrictedly studied in
nursing and midwifery students. Paryad studied
clinical decision making among nursing students and
reported that most of the subjects were able to make
useful decisions.7
The researcher believes the inconsistency between
the results of the above study and the present study
can be due to the difference in curriculum of these two
courses as in nursing, education of nursing process
leaves the students in decision making situations
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18 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
resulting in a more effect on their level of decision
making skill. Martin reported nursing students’ low
decision making ability, which is consistent with the
findings of the present study.8 Nekouee also reported
that the level of decision-making was average among
midwifery students.9
Gunnarsson conducted a study in Sweden and
investigated the influencing factors on decision
making among nurses in emergency wards and
reported various factors affecting their decision-
making ability such as patients related factors,
environmental factors, colleagues related factors,
patients’ personal affairs related factors, team leader
function, personnel’s knowledge and ethical conflicts.
He concluded that these factors make decision-making
as a very difficult process for these personnel and
sometimes result in unsuccessful decisions.10 Sands
investigated clinical decision-making in mental health
triage in 15 personal of emergency medicine in
Australia and reported that most of the decisions in
these teams were made based on the subjects’ previous
experiences although they had not passed any specific
educational programs about mental health triage. He
argues that it should be noted that there is not
necessarily a significant association between the correct
decisions and personnel’s level of experience.11 With
regard to the results of the present study and the
importance of enabling the associate degree students
of nursing concerning decision-making skill, although
the instructors often believe that these students can
make simple and complex decisions during their
education based on what they have already learned,
the students are weak at this skill. Therefore, to make
the best decisions, the students should be provided
with education of problem solving and decision
making skills.
With regard to aforementioned issues, it can be
concluded that application of problem solving skill
education, especially in form of a group work method,
plays a key role in students’ cognitive, emotional and
psychomotor maturation. With regard to nurses critical
profession and the important role of decision-making
and problem solving ability among them, it is hoped
that empowerment of these two skills, which were
studied in the present study, can professionally and
scientifically promote nurses and put this profession
in its deserved place.
ACKNOWLEDGEMENT
The results of the research project is Shahrekord
University of Medical Sciences and all fees are paid
by the Department of Medical Research. The authors
declare no conflict of interest.
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through understanding the capabilities of
successful nurse graduates. Nurse Education
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Aiattollahi A. The effect of problem solving skill
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4. Solivan MP. Management and leadership in
nursing. Translation to Persian by: Givi M.
Tehran. Nnor Danesh Pub 1998; (4) 50-58.
5. Altun I. The perceived problem solving ability
and values of student nurses and midwives.
Nurse Education Today 2003; 23(8) 575-584.
6. D-zurilla T. Chang E. Samna L. Self-esteem and
social problem solving as predictors of aggression
in college students. Journal of Social and Clinical
Psychology 2007; 22(4) 424-440.
7. Paryad E, Javadi N, Fadakar K, Asiri Sh.
Relationship between critical thinking and
clinical decision making in nursing students. Iran
Journal of Nursing 2011; 24(73) 63-71.
8. Martin C. The theory of critical thinking of
nursing. Nurse Education Perspective 2002; 23(5)
243-247.
9. Nekuei N, Pakgohar M, Khakbazan Z, Mahmudi
M. [Assessment of clinical decision making in
midwifery students]. Iranian Journal in Medical
Education 2002; 2(6) 49-55.
10. Gunnarsson M, Warrén Stomberg. Factors
influencing decision making among ambulance
nurses in emergency care situations. International
Emergency Nursing 2009; 17(2) 83-89.
11. Sands N. An Exploration of clinical decision
making in mental health triage. Archives of
Psychiatric Nursing 2009; 23(4) 298-308.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 19
INTRODUCTION
Medication errors (MEs) are of the most important
problems in all hospitalized patients 1 which can be
used as an indicator for determining the level of
patient’s safety in hospitals 2. The National
Coordinating Council for Medication Error Reporting
and Prevention (NCC MERP) defines a “medication
error” as: “ any preventable event that may cause or
Registered Nurses Perception of Medication Errors: A
Cross Sectional Study in Southeast of Iran
Zahra Esmaeli Abdar1, Haleh Tajaddini2, Azam Bazrafshan1, Hadi Khoshab3, Asghar Tavan4, Giti
Afsharpoor5, RN Masoud Amiri6, Hossein Rafiei7, Mohammad Esmaeili Abdar8
1Department of Clinical Research, 2Neuroscience Research Center, Kerman University of Medical Sciences, Kerman,
Iran, 3Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Bam University of Medical
Sciences, Bam, Iran, 4Shafa Hospital, 5Shahid Bahonar Hospital, 6Social Health Determinants Research Center,
7Department of Intensive and Critical Care, School of Nursing and Midwifery, Shahrekord University of Medical
Sciences, Shahrekord, Iran, 8Department of Medical- Surgical Nursing, School of Nursing and Midwifery, Kerman
University of Medical Sciences, Kerman, Iran
ABSTRACT
Aim: Nurses have an important role in decreasing Medication Errors (MEs). The purpose of this
study was to determine registered nurses perception of MEs.
Method: In a cross-sectional study conducted in four educational hospitals in southeast of Iran, 238
registered nurses working within these hospitals were studied. Data were collected using Iranian
nurses' medication errors questionnaire.
Results: Of the 238 nurses, 93.1% were women. Factors such as lack of staff to patients ratio, nurses
fatigue from hard work, having difficulty to read physician's writing on the patients file, nurses'
heavy workload and work in night shift were the most common causes of MEs development which
determined by nurses.
Conclusion: MEs may affect negatively on patients' health. Nursing educational systems should
have more attention to nurses' perception on MEs and could consider their view in planning and
education in order to decline MEs.
Keywords: Medication Error, Nurse, Perception, Cross Sectional
DOI Number: 10.5958/j.0974-9357.5.2.054
Corresponding author:
Mohammad Esmaeli Abdar
Department of Medical-Surgical Nursing, School of
Nursing and Midwifery, Kerman University of
Medical Sciences, Kerman, Iran
Email : Mesmaeli87@gmail.com
Phone: 989133425513
lead to inappropriate medication use or patient harm
while the medication is in the control of the health care
professional, patient, or consumer. Such events may
be related to professional practice, health care
products, procedures, and systems, including
prescribing; order communication; product labeling,
packaging, and nomenclature; compounding;
dispensing; distribution; administration; education;
monitoring; and use” 3. These errors not only may have
adverse influences on patients,4, 5 but also may
negatively affect nurses and organizations 4.
Incidence of MEs of hospitals settings in developing
countries is high 1, 4. Jennane and colleagues in 2011
surveyed on the incidence of MEs in an intensive care
unit (ICU) of an educational hospital in North Africa1.
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20 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
They reported that most of patients in their ICU
encountered with MEs especially in time of drug
ordering and transcribing 1. They have also found that
increasing use of antibiotics and anticoagulants may
raise the rate of MEs in ICU 1. In 2012, Seidi and
colleagues examined pediatric nurses’ perceptions on
the causes of MEs and potential barriers to report them
in the pediatric wards of an educational hospital in
Iran 6. Most common causes of MEs reported by Iranian
pediatric nurses were being unable to check medicinal
orders (73.9%) and errors in the medication
administration (64%). Seidi and colleagues also
reported that less than half of MEs errors occurred in
pediatric wards, had been reported by Iranian pediatric
nurses to their supervisor 6. In another study, Tang and
colleagues surveyed nurses’ views on the factors
contributing to MEs 7. Main affecting factors on MEs
rate determined by Tang were the personal neglect,
heavy workload and new staff 7. They also reported
that risk of MEs occurrence is higher in some wards
such as medical wards and ICU 7. In addition,
Koohestani and colleagues focused on the barriers to
report the medication administration errors by nursing
students 8. They reported that nursing students usually
did not report MEs to their instructors. Two main
reasons for not reporting ME among nursing students
were administrative barriers such as its potential
negative feedback and fear of being recognized as
inappropriate staff 8.
Overcrowding ward and lack of nurses’ personnel
as well as high volumes of activity combined with
increased numbers and dosages of medication
prescribed could be increase the risk of MEs by nurses
7, 9. Despite the importance of the nurse’s task in
preventing MEs, 7, 10 very few studies have been
performed in this regards in Iranian context. In order
to plan for preventing and decreasing rate of MEs,
understanding of nurse’s perception of MEs could be
very helpful. This study was thus designed to examine
the Iranian registered nurses perception of MEs.
METHOD
In a cross-sectional study conducted from
September 2012 to January 2013 in four educational
hospitals in Kerman, Southeast of Iran, 239 qualified
registered nurses working within these hospitals were
studied. Nursing, as a general practice, can be studied
in universities; however, unlike some western
countries, Iran does not differentiate by rank within
licensed nursing personnel, and RN is the only
professionally recognized rank. On successful
completion of nurse education programs, graduates
are automatically granted the status of registered
nurse, which is the minimum legal and educational
requirement for professional nursing practice.
Registered nurses must complete a four year bachelor’s
degree at a nursing college. The written permission
was obtained from deputy of research and also the
Ethics’ Board of the Kerman University of Medical
Sciences and written consent letters were filled in by
all respondents. In addition, all participants were
promised that all data would remain anonymous, kept
confidential and be stored safely. Participants
answered individually and returned the tests to the
researcher. Data collection tool was “ Iranian Nurses
Medication Errors’ Questionnaire” developed by
Soozani . This questionnaire contains 21 question
related tothe nurses’ perception of MEs. Each question
was scored as “none=0; low=1; moderate= 3 and high=
4”. The questionnaire was divided into three categories
including: 1) items related to nurses (questions number
1 to 7), 2) items related to work setting (questions
number 8 to 13) and 3) items related to nurses’ mangers
(questions number 14 to 21) 11. Data were presented
by mean and standard deviation and SPSS software
(version 18.0) were used.
RESULT
Of 238 nurses participated in this study, 93.1% (n=
213) were women. The mean age of participants was
32± 7.4 years and mean years of experience was 9.3±7.5
years. 47% (n= 112) of participants have worked in
acute care setting (ICU, NICU, CCU and emergency
department).
Nurses’ responses to 21 questions have been shown
in table 1. Nurses reported that items related to
category one (items related to nurses) had more effect
on MEs compared to other categories. In category 1
(items related to nurses), most common causes
determined by nurses were “lack of staff to patients
ratio and nurses fatigue from hard work”. In category
2 (items related to work setting), most common reasons
determined by nurses were “having difficulty to read
physician’s writing on the patients file”. In category 3
(items related to nurses’ mangers), most common issue
determined by nurses was “nurses heavy workload”.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 21
Table 1: Nurses response to questionnaire items
Question Without effect Low effect Moderate effect High effect
1. Disappointment and indifference towards the nursing profession 50 (21%) 60 (25.2%) 59 (24.8%) 69 (30%)
2. Unfamiliarity of nurses with medication 22 (9.1%) 62 (26.1%) 60 (25.2%) 94 (39.5%)
3. Nurses financial problems 48 (20.2%) 65 (27.3%) 62 (26.1%) 63 (26.5%)
4. Nurses family problems 40 (16.8%) 63 (26.5%) 75(31.6%) 60 (25.2%)
5. Nurses psychological problems 17 (7.1%) 43 (18.1%) 75 (31.6%) 103 (43.2%)
6. lack of staff to patients ratio 5 (2.1%) 14 (5.9%) 46 (19.3%) 173 (72.7%)
7. Nurses fatigue from hard work 3 (1.3%) 13 (5.5%) 54 (22.7%) 168 (70.6%)
8. Wards environmental noise 10 (4.2%) 71 (29.8%) 96 (40.3%) 61 (25.6%)
9. Methods that used for control and supervising wards 29 (12.2%) 62 (26.1%) 102 (42.9%) 45 (18.9%)
10. Medication room environment (light, physical space, etc.) 15 (6.3%) 59 (24.8%) 106 (44.5%) 58 (24.4%)
11. Type of drugs arrangement in shelves 18 (7.6%) 54 (22.7%) 105 (44.1.8%) 61 (25.6%)
12. Routs of drugs administration (oral, intravenous, etc.) 23 (9.7%) 81 (34%) 84 (35.3%) 50 (21%)
13. Difficult to read physician’s writing on the patients file 11 (4.6%) 33 (13.9%) 70 (29.4%) 124 (52.1%)
14. Difficult to read patients drugs forms 15 (6.3%) 47 (19.7%) 77 (32.4%) 99 (41.6%)
15. Lack of enough time because of workload 12 (5%) 48 (20.2%) 102 (42.9%) 76 (31.9%)
16. Nurses heavy workload 6 (2.5%) 23 (9.7%) 75 (31.5%) 134 (56.3%)
17 . Type of worked setting 36 (15.1%) 48 (20.2%) 88 (37%) 66 (27.7%)
18. Morning work shift 65 (27.3%) 90 (37.8%) 49 (20.6%) 34 (14.3%)
19. Evening work shift 66 (27.7%) 71 (29.8%) 78 (32.8%) 23 (9.7%)
20. Night work shift 35 (14.7%) 42 (17.6%) 87 (36.6%) 74 (31.1%)
21. Complicated rules of drug administration 32 (13.4%) 63 (26.5%) 90 (37.8%) 53 (22.3%)
DISCUSSION
Our results revealed that lack of staff to patients
ratio, nurses’ fatigue from hard work, having difficulty
to read physician’s writing in the patients’ files, nurses
heavy workload and working at night shifts were most
common causes of MEs determined by Iranian
registered nurses.
Medication therapy is an important nursing task
of Iranian nurses 11. It should be considered that
physicians are responsible for prescribing medications
and nurses are only responsible for preparing and
administering medications. Having appropriate
knowledge about nurses’ perception on MEs may be
effective for planning of decreasing incidence of this
problem. Results of present study showed that items
related to own characteristics of nurses had more
effects on MEs. Unver and colleagues studied
perspectives of newly graduated and experienced
nurses about MEs in a military hospital in Turkey 12.
Similar to our findings, they used modified
Gladstone’s scale of MEs and found that nurse
exhaustion and distraction are two most common
causes of MEs 12. For decreasing rate of MEs, they
suggested that educational systems have to consider
during the training process of nurses the
understanding causes of MEs and related prevention
methods 12. Using the same questionnaire, Soozani and
colleagues studied nurses’ perception of MEs in Iran
11. They have also reported that lack of staff to patients’
ratio, nurses’ fatigue from hard work and having
difficulty to read physician’s writing on the patients’
files is most common causes of MEs 11. They have also
suggested that lack of trained nurses in medication
therapy may affect negatively on patients’ health and
it should be considered by nursing manager 11.
Our participants have also reported that some
environmental factors such as noise, light and having
difficulty to read physician’s writing on the patients’
files may increase the risk of MEs. Mahmood and
colleagues in USA examined nurses’ perceptions of
effects of physical environmental factors on occurrence
of MEs in acute care settings 13. Some physical
environmental factors determined by nurses in
Mahmood’s study were inadequate space in charting
and documentation area, lengthy walking distances to
patient rooms, insufficient patient surveillance
opportunity, lack of visibility to all parts of the nursing
unit, small size of the medication room, inappropriate
organization of medical supplies, high noise levels in
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22 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
nursing unit, poor lighting, and lack of privacy in the
nursing stations 13. Soozani and colleagues have also
mentioned environmental factors effect on rate of MEs.
Most common environmental cause determined by
Soozani was high level of noise 11.
With regards to the items related to the manger
nurses, working shift (morning, evening and night)
was a factor determined as an effective factor in
increasing risk of MEs in previous studies. Our nurses
reported that risk of MEs development is higher at
night shifts. Similar to our finding, Soozani and
colleagues reported similar findings 11. However, in
contrast to our finding, Kim and colleagues who
studied on Nurses’ perceptions of medication errors
and their contributing factors in South Korea reported
that most MEs occurred by nurses at day shifts 14. This
difference might be due to the differences in nursing
systems between Iran and the South Korea hospitals;
i.e., in Iran, less number of nurses allocated to work at
night shifts in comparison with morning and evening
shifts. In addition, in Iran, more experienced nurses
usually work at day shifts (Morning and evening).
Lack of nurses to patients ratio and lack of experienced
nurses at night shifts in Iranian hospitals setting may
be increase the risk of MEs development in this work
shift. At night shifts, some environmental factors such
as poor lighting could also increase the risk of MEs
development in this work shift compared to morning
and evening shifts.
Limitations
The respondents were predominantly female,
which limits the generalisability of the results to male
nurses. As this study was based on a convenience
sample and participation was voluntary, there might
have been a selection bias which could affect on
generalizability of the results to all nurses.
Furthermore, use of the self-reported questionnaires
may have lead to an overestimation of some of the
findings due to the variance observed in different
methods.
CONCLUSION
Nursing educational systems should have more
attention to nurses’ perception on MEs and may
consider their view during planning and education
towards decreasing MEs. Lack of staff to patients’ ratio,
nurses’ fatigue from hard work, having difficulty to
read physician’s writing on the patients’ files, nurses’
heavy workload, working at night shift, nurses’
financial problems and lack of knowledge about
medication therapy are the most important factors
which may affect on the increasing risk of MEs
development by nurses.
REFERENCES
1. Jennane N, Madani N, Oulderrkhis R, Abidi K,
Khoudri I, Belayachi J, Dendane T, Zeggwagh
AA, Abouqal R. Incidence of medication errors
in a Moroccan medical intensive care unit. Int
Arch Med 2011;4:32.
2. Cheraghi MA, Nikbakhat Nasrabadi AR,
Mohammad Nejad M, Salari A. Medication Errors
Among Nurses in Intensive Care Units (ICU). J
Mazand Univ Med Sci 2012; 22(Supple 1):
115-119.
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http://www.nccmerp.org/about MedErrors. html.
4. Mrayyan MT, Shishani K, Al-Faouri I. Rate,
causes and reporting of medication errors in
Jordan: nurses’ perspectives. J Nurs Manag
2007;15(6):659-70.
5. Schelbred AB, Nord R. Nurses’ experiences of
drug administration errors. J Adv Nurs
2007;60(3):317-24.
6. Seidi M, Zardosht R. Survey of nurses’
viewpoints on causes of medicinal errors and
barriers to reporting in pediatric units in hospitals
of Mashhad University of medical sciences.
Journal of Fasa University of Medical Sciences
2012;3: 142-147.
7. Tang FI, Sheu SJ, Yu S, Wei IL, Chen CH. Nurses
relate the contributing factors involved in
medication errors. J Clin Nurs 2007;16(3):447-57.
8. Koohestani HR, Baghcheghi N. Barriers to the
reporting of medication administration errors
among nursing students. Aust JAN 2009; 27(1):
66-74.
9. Chang Y, Mark B. Effects of learning climate and
registered nurse staffing on medication errors. J
Nurs Adm 2011;41(7-8 Suppl):S6-13.
10. Mark BA, Belyea M. Nurse staffing and
medication errors: cross-sectional or longitudinal
relationships? Res Nurs Health 2009;32(1):18-30.
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11. Soozani A, Bagheri H, Poorhydari M. Survey
nurses view about factors affects medication
errors in different care units of Imam Hossein
hospital in Shahroud. Knowledge and Health
Journal 2007; 3: 8-13.
12. Unver V, Tastan S, Akbayrak N. Medication
errors: perspectives of newly graduated and
experienced nurses. Int J Nurs Pract
2012;18(4):317-24.
13. Mahmood A, Chaudhury H, Valente M. Nurses’
perceptions of how physical environment affects
medication errors in acute care settings. Appl
Nurs Res 2011;24(4):229-37.
14. Kim KS, Kwon SH, Kim JA, Cho S. Nurses’
perceptions of medication errors and their
contributing factors in South Korea. J Nurs
Manag 2011;19(3):346-53.
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24 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
Environmental sanitation practices gained very
much importance from ancient Indian civilization
(Indus Valley Civilization 3000 B.C). But these practices
were introduced in the hospital system only in the post
Registered Nurses Perception of Medication Errors: A
Cross Sectional Study in Southeast of Iran
Abdul Jaleel1, R Jeyadeepa2
1Medical Supetrintendent, Karuna Medical College Hospital, Palakkad, 2Vice Principal, Karuna College of Nursing,
Palakkad
ABSTRACT
Environmental sanitation practices were very much a part of the ancient Indian Civilization but such
practices were introduced in the hospital system only in the post Vedic period. Among the health
team members Nurses are the one who spend most of their time in direct patient care. Segregation is
the key to Hospital Waste Management and Nurses are responsible for Segregating Hospital Waste.
So educating the nurses on Hospital Waste Management is the need of this hour.
Objectives:
1. Assessment of Knowledge and Practice of Nurses On Hospital Waste Management
2. Education to Nurses on Hospital Waste Management.
3. Reassessment of Knowledge and Practice of Nurses on Hospital Waste Management
Hypothesis:
1. Education improves the average knowledge of nurses on Hospital Waste Management
2. There is an association between knowledge and demographic characters of the nurses.
This study was supported with relevant literature.
Methodology:
1. Research design: One group pretest post test design was adopted.
2. Setting: Conducted in Karuna Medical College hospital.
3. Population & Sampling: Simple random sampling
4. Tool: The questionnaire
DATA ANALYSIS: The area wise score was assessed or an average there was 46% gain in knowledge
score of nurses on hospital waste management. To compare the pretest and post test knowledge
scores paired't' test was used. The calculated't' value is 3.58 which is greater than the table value
0.01% level of significance. To find out the association between the demographic variables on the
pretest knowledge scores Karl Pearson's co-efficient of correction was used. There was an inverse
correlation between age and knowledge and positive relationship between experience and qualification
on knowledge score on hospital waste management was found.
Keywords: Education, Hospital Waste Management, Nursing Personnel, Segregation
DOI Number: 10.5958/j.0974-9357.5.2.054
Vedic period (600 – 300 B.C) by Rahula sanskritiyana
(son Of Buddha). Modern India witnessed the
appointment of sanitary commissioners in three major
provinces during the British regime in the year 1864.
Bio Medical Waste was brought to focus in the west.
During 1980’s when the European office convened a
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 25
work group of medical specialists, hospital engineers
and administrators from 19 countries at Bergen and
concluded the desired need for a systemic approach
to handle the biomedical waste with special emphasis
on awareness, segregation and source reduction.(1,5)
All human activities inevitably produce waste and
in some cases it is not only hazardous to water, air and
soil but also to all living creatures existing on the earth.
One of the most dangerous wastes to the environment
and human beings is industrial waste; similarly
biomedical waste possesses numerous health hazards.
Nurses are responsible and accountable for
professional behavior which involves nursing process,
co – operation with other health team members,
current legislation which affects the nursing practice
according to professional code of ethics, policies of
the employing agency and customs and values of the
society in which the nursing care is being provided.
Skills and precautions in managing hospital waste
which reduces the risk of hospital acquired infection
infections will help the nurses to protect their own
health and the public health. Hence they should be
educated with the latest information and skills in
managing hospital waste. (2, 3, 4, 6)
Need for the Study
In 1983, the WHO stated that the hospital
wastes are dangerous threats to ecological balance and
public health. Waste generated by the hospital if
allowed to enter in waste stream without proper
disposal would cause unimaginable loss to the society.
This will lead to outbreak of communicable diseases,
diarrhoeal epidemics, water contamination and
radioactive fall outs.
Among the health team members nurses are the
one who spend more time in direct patient care.
Segregation is the key to hospital waste management.
Nurses are responsible for the segregation of the waste.
So educating the nurse on hospital waste management
is an important task. (7, 11)
Statement of the problem:
Education to nursing personnel on hospital waste
management in a selected hospital, Palakkad, Kerala.
OBJECTIVES
1. Assessment of knowledge and practice of nurses
on hospital waste management.
2. Education to nurses on hospital waste
management.
3. Reassessment of knowledge and practice of nurses
on hospital waste management.
Hypothesis
1. Education improves the average knowledge of the
nurses on hospital waste management.
2. There is a relationship between age of nurses and
the pretest knowledge score on hospital waste
management.
3. There is a relationship between experience of
nurses and the pretest knowledge score on hospital
waste management.
4. There is a relationship between qualification of
nurses and the pretest knowledge score on hospital
waste management.
Review of literature
A three year study carried out in Jordan revealed
that 1000 odd persons involved in patient related
activities, 248 health care workers had needle stick
injuries of which 34.6% are staff nurses, 19%
environmental workers, 15.7% interns, 11.7% residents,
8.5% practical nurses, 6% technicians. The study also
revealed that needle stick and sharp injuries occur
frequently in developing countries where safer
disposals faciliries are required. (Paul.et.al, 1995) 12
Right to live in a clean environment is one of the
fundamental right which has been developed through
biomedical waste management and handling rules,
1998 under the environmental protection act 1986. The
rules regulate the disposal of biomedical wastes
including human anatomical waste, blood and body
fluids, medicines and glass ware, soiled liquid,
biotechnology waste and animal waste. The objective
is to take all steps to ensure safety of health and
environment. The biomedical waste rules make the
generator of the waste liable to segregate, pack, store
and dispose off the hospital waste in an
environmentally sound manner (Sharma et.al., 1993).8
A study to assess the total biomedical waste
produced in Kollam district revealed that the average
biomedical waste generation per bed per day is 180
grams. Dental facilities produce 650 grams of infectious
waste per day. This study recommended that every
bit of infectious waste should e treated and disposed
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26 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
off. A properly planned project for the management
and disposal of these hazardous wastes should be
implemented and carried out at the earliest. Presently
individual waste management facilities are not
advised. The infectious waste constitutes around 30%
of the total waste. All the other waste can be considered
as harmless domestic waste. The treatment of
infectious waste being very costly, segregation of waste
at source is necessary. Proper training on this aspect
of the health care workers is necessary (Nair, 2002)13
Cost effective suggestion to improve the hospital
waste management include training to hospital staff
on segregation of waste at the point of generation, use
of colour bags for collection of hazardous and non
hazardous waste and enactment of law inclusive of
financial punishment provision and its strict
application National Consultation on Bio Medical
Waste Management, 2000).10
IMAGE a sub organization under IMA started a
common treatment facility at Kanjikode, Palakkad. It
gives training to the health care workers. Kerala state
council for science, technology and environment,
Kerala state pollution control board, Clean Kerala
mission, Universities, Professional organizations,
Productivity council, NGOs etc taken lead in
awareness and education activities. (IMA 2003).14
A study to assess the effectiveness of information
booklet on biomedical waste management revealed
that the information booklet was found highly
acceptable and useful for nurses. To comply the
biomedical waste management and handling rules
and to safe guard their own health nursing staff must
have adequate knowledge in performing their duties
that should ensure safe handling, collection, storage,
treatment and disposal of biomedical waste (Ritu
Singh et.al., 2002).9
METHODOLOGY
Research design
One group pretest post test design was adopted
for this study.
Setting
The study was conducted in a 450 bedded medical
college hospital in Palakkad, Kerala. The hospital has
all facilities has like outpatient departments,
laboratory and other investigation facilities, medical
ward, surgical ward, OBG ward, paediatric ward,
orthoward, ENT & Ophthalmology ward, Skin & VD
ward, Psychiatry ward, Medical ICU, Coronary care
unit, Surgical ICU, Gynec ICU, Neonatal ICU and
Pediatric ICU.
Population and Sampling:
In the entire hospital 162 nurses are working in
different units. Large number of nurses is working in
medical wards, surgical wards and operation theatre.
On an average there are seven nurses in each ward.
All nurses are in some or other form involved in
generating and handling the waste. Sample size was
determined by using degree of precision method. N =
89.3.
Inclusion criteria
1. Nurses who provide direct patient care.
2. Whoever is available at the time of data collection.
Exclusion criteria
1. Nurses who are not willing to participate in the
study.
2. Nurses who joined newly during the time of data
collection.
Instruments and tools for data collection
The instrument used for data collection was a
structured questionnaire. It consisted of 44 questions
for assessing the knowledge and practice of nurses of
nurse on hospital waste management.
Reliability and Validity
Tool was prepared with the help of literature review
and expert guidance. The reliability and validity was
tested through the pilot study.
Technique of data collection
Data were collected through the pre tested
questionnaire. All the nurses who fulfill the inclusion
criteria were selects as samples. After selecting the
samples the questionnaire was issued to them and the
data were collected. After the assessment education
was given with the help of an information booklet. Each
nurse was provided with an information booklet.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 27
Reassessment was done after five days with the help
of the same questionnaire.
Techniques of data analysis
Frequency table was formulated for all baseline
data. The frequencies were tabulated to understand
the knowledge of nurses on hospital waste
management. Paired ‘t’ test was used to analyze the
significant difference in the knowledge score before
and after education. Karl pearson’s correlation and co
efficient test was used to find out the influence of
independent variable on the dependent variable.
DATA ANALYSIS
Majority of the nurses were between the age group
of 21 to 25 years studied General Nursing and
Midwifery course and having below 5 years of
experience. The knowledge of nurses was assessed
through the questionnaire. The scores obtained by the
nurses classified into grades like excellent, good,
average, poor and very poor. Majority of the nurses
were under the category of very poor and only one
nurse was in the category of good during the pretest.
Where as in post test 18 nurses got excellent score, 59
nurses got good score, 11 nurses got poor score and
no one was under the category of very poor. Paired‘t’
test was calculated to assess the improvement in the
knowledge score. The calculated ‘t’ value is 3.58 which
is higher than the table value. Hence it can be inferred
that the education has significantly improved the
knowledge of nurses on hospital waste management.
To find the association between the independent and
dependent variable Karl Pearson’s correlation and co
efficient was used. The calculated r value to find the
association between ages and pretest knowledge score
is -0.07 which indicates inverse correlation between
age and knowledge. The calculated r value to find the
association between experiences and pretest
knowledge score is 0.07 which shows positive
correlation between the experience and knowledge.
The calculated r value to find the association between
qualification and knowledge is 0.09 which shows the
positive correlation between qualification and
knowledge.
It is clearly observed in the present study that the
nurses lack their knowledge in all aspects of hospital
waste management. Education helped them to gain
knowledge in various aspects of hospital waste
management.
Table No 1. Socio Demographic statuses of Nurses
S. No Character No of Nurses
Male Female Total
1Age in Years
20 – 25 12 34 46
25 – 30 6 15 21
30 – 35 3 9 12
35 – 40 0 6 6
Above 40 0 5 5
2Marital Status
Married 15 16 31
Unmarried 6 53 59
3Educational Qualification
B.Sc (N) 9 20 29
GNM 12 49 61
4Experience
Below 5 years 13 53 66
5 – 10 years 6 13 19
Above 10 years 2 3 5
Graph No 1 Scores according to the grade
Graph No 2 Comparison of pretest and post test scores according
to the areas
Table No 2. Mean, Mean Difference, Standard Deviation and “t” value between pre and post test knowledge scores
Group Mean Mean Difference Standard Deviation Degree of freedom “t” value
Nurses Pre test = 17.4 Post test = 45.18 27.01 72.08 0.01 3.38
6. Jeyadeepa--24-29.pmd 1/6/2014, 9:30 AM27
28 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Limitations of the study
1. This study was limited to provide education only
to the staff nurses.
2. This study was aimed only to promote the
knowledge level of the nurses. Practice was not
assessed.
3. Attitude of the nurses towards hospital waste
management was not assessed.
Major findings of the study:
1. It was found that nurses had 75% of knowledge in
terminologies, after education it was improved to
89.6%.
2. The study revealed that nurses had 55.5%
knowledge in classification of hospital waste, after
education it has been improved to 86.49%.
3. The study showed that nurses had only 6%
knowledge in sources and hazards of hospital
waste but education improved their knowledge up
to 58.5%.
4. The study revealed that nurses obtained only 8.5%
score in legal provision but after education it was
improved to 72.6%.
5. It was found that the nurses had only 19.47%
knowledge in segregation after education it was
improved to 70.2%.
6. Nurses had only 15% knowledge in hospital waste
management plan. Education improved the
knowledge to 68.8%.
7. The study showed that 7.15% score was obtained
by the nurses in role of nurse in hospital waste
management during the assessment but education
improved the knowledge to 62.66%.
Suggestions for further study
1. Similar study can be conducted to class IV workers.
2. Similar study can be done to compare the
knowledge of nurses working in Government and
Private hospitals.
3. Knowledge, attitude and practice of nurses on
hospital waste management can be assessed.
Recommendations
1. Ongoing in – service education to nurses on
hospital waste management with periodic
reinforcement can be done to enhance the
knowledge of nurses on hospital waste
management.
2. Education may be given to class IV workers on
safe handling of hospital waste.
3. Mass media like Television, Newspaper and
movies can be used to educate the health workers
on hospital waste management.
CONCLUSION
This study was taken up to assess the knowledge
level of nursing personnel in the hospital on hospital
waste management because this is an important issue
not only to the hospitals but also for the society as a
whole.
The nursing personnel in the hospitals do not
possess adequate knowledge on hospital waste
management though it is an important issue. The
hospital authorities should take necessary steps to
educate all personnel working in the hospital which
will not only safe guard the personnel in the hospital
but also the society at large. Hence it can be concluded
that education provided to nursing personnel on
hospital waste management will certainly help them
to improve their knowledge and practice in managing
the hospital waste.
ACKNOWLEDGEMENT:
We render our humble and grateful thanks to the
Heavenly Lord for having showered his blessings on
us in completing the project successfully.
We express our deep sense of gratitude and
respectful regards to the Management, Dean, Faculty,
Staff Nurses and other staff of Karuna Medical College,
Vilayodi, Chittur, Palakkad for their constant support
and encouragement for the completion of this project
successfully.
We proudly express our gratitude to our family
members for their assistance and co operation
throughout the study.
Conflict of Interest: None
Source of Funding: None
Ethical Clearance: Got ethical clearance from the
Institutional Ethical Committee before the study.
6. Jeyadeepa--24-29.pmd 1/6/2014, 9:30 AM28
International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 29
REFERENCES
1. American College of Nurse Midwives,” Green
Birthdays”,Health care without Harm, March
2001. Bano Retigua,” Continuing Education in
Nursing,” The Nursing Journal Of India,(xxx1x)
(12),sep 1990.Pp 16-20.
2. Dean. M.”Continuing Education for Nursing
personnel,” The Nursing Journal Of India,(X1x)
(9),june 1993,Pp 28-32.
3. Geethanjali Baveja et.al,”Hospital Waste
Management An Overview”, Hospital Today, (v)
(9),September 2000,Pp 485-486.
4. Julie Price Joan Moss,”The fit fall Of PRACTICE
Nursing”,Nursing Times,(94) (30),july 1998,Pp
68-75.
5. Kishore Jungal,”Hospital Waste Management in
India’”Indian Journal of Occupational and
Envionmental Medicine, (3) (2) April-june 1999,
Pp 79-84.
6. Narrender,”In service Education,” The Nursing
Journal Of India, (xxv), (14),November 1990,Pp
73-77.
7. Niyati.K.P, “ABC Of Waste Minimization The
Indian Scenario,” Health ACTION, AUGUST
2002
8. Sharma B.R,”Right To Healthy Environment Vis-
à-vis Biomedical Waste”, Hospital Today,(v11)
(9),September 2002.
9. Ritu Singh et.al,”The role Of AN Information
Booklet On Biomedical Waste Management for
Nurses”,The Nursing Journal O f India,(1xxxx111)
(12), December 2002,Pp 271-272.
10. Sharma Madhuri, Hospital waste Management
And Its Monitoring,New Delhi: Jaypee
publications,1st edition ,2002.
11. Prabhakar Usha,Neelam Makhija, “Biomedical
Waste Management-A study To Assess The
knowledge Of Nursing Personnel”,The Nursing
Journal Of India,(x1v) (8), August 2004.
12. Paul et.al, Fact Sheet: Medical Waste
Management, April 1999
13. Nair et.al, A study to assess the total biomedical
wastes produced in kollam district, Kerala, Nov
2002
14. Nagarajan Shyma. S, Is our biomedical waste
management system progressive? Pharma Biz
Hospital Review, Sep 2003
6. Jeyadeepa--24-29.pmd 1/6/2014, 9:30 AM29
30 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
A number of nurse researcher have focused their
efforts on exploring psychomotor skill acquisition.
While there are a number of related studies involving
the development of skills in the laboratory, little is
known if hands-on practice to a simulated low-fidelity
mannequin is the best effective teaching strategy in
giving subcutaneous injections.
Education in nursing involves learning in clinical
laboratory to give opportunity to apply the theoretical
concepts, rules, and propositions they have learned in
the classroom. These concepts integrate the blooms
taxonomy of learning domains of cognitive
(knowledge) which involves knowledge and
development of intellectual skills. Psychomotor (skill)
Two Teaching Strategies In Subcutaneous Injection: A
Comparative Study
Khadijah C Bautista1, Nazik M A Zakari2
1Medical Supetrintendent, Karuna Medical College Hospital, Palakkad, 2Vice Principal, Karuna College of Nursing,
Palakkad
ABSTRACT
The aim of this study is to compare the two different teaching strategies among nursing students of
College of Nursing in giving subcutaneous injection by applying bloom's taxonomy of learning
domains. Quasi-experimental design was utilized in this study. Twenty one nursing students from
BSN 2nd year were recruited to participate and divided into two groups in separate nursing skills lab
. A performance checklist guide has been used to experimental group who performed subcutaneous
injection with pricking of the needle to a simulated low fidelity mannequin and control group without
pricking of the needle. Post test was used on both groups to evaluate student's performance in
subcutaneous injection with pricking of needle . Mildly to moderately difference in cognitive and
psychomotor skills was existed between groups. However, there is no significant difference in both
groups in affective skill. Based on study findings, it suggests that skills that have been practice with
hands-on in the nursing skills lab prior to clinical performance will contribute on student's learning
competency in cognitive and psychomotor domains regardless of the difficulty of skill presented
and number of students performed.
Keywords: Hands-on Practice, Learning Domains
DOI Number: 10.5958/j.0974-9357.5.2.054
Corresponding author:
Khadijah C Bautista
Instructor
College of Nursing, King Saud University
PO Box 69512, Riyadh, 11547
Kingdom of Saudi Arabia
which requires varying levels of well coordinated
physical activity that includes physical movement,
coordination, and use of motor-skill areas. And
affective (attitude) includes the manner in which to
deal with things emotionally; it involves willingness
to listen, responding, valuing, organizing, and
characterization.1
The learning of nursing skills in a laboratory is
an essential part of the curriculum.
It is here that students are introduced to skills,
concepts and procedures and get to practice to a
simulated mannequin.2 It has involved using of
oranges to practice injections, learning CPR, inserting
Foley catheters to a mannequin, or role playing. These
are all simulations in one form or another, and what
they have in common is that they are done in an
artificial situation so the students are later able to
practice safely on actual patient care in clinical setting.3
Giving subcutaneous injection is one of anxiety-
producing skills that needs hands-on practice in the
laboratory prior to actual clinical performance. Suling
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 31
Li (2007) reported that practice in laboratory setting
that is more closely resemblance the clinical
environment will enhance student’s learning and
reduces anxiety. It will allow students to critically
analyze their own actions, reflect on their own skill
sets and clinical reasoning.4 Simulated experiences
offer the opportunity for diverse styles of learning
wherein both student and educator are actively
engaged that not offered in the classroom such as
laboring patients and delivery, pediatric experience,
patients with cardiac issues or mental health patients
by using simulated mannequins.5 These experiences
will increase student’s confidence without
jeopardizing patient safety.6
However, sometimes simulations are used for
learning without “hands-on” opportunities, because
the psychomotor activity is dangerous or equipment
is not readily available or the student’s number are
too large or the instructor is not prepared to do so.7
Nursing education is one where many cognitive and
psychomotor skills need to be imparted to the students.
And these restricted situations will create undesired
outcomes during both in-class lectures and laboratory
practices.8 Nursing is a discipline that requires
precision and practice, it requires competency and
accuracy in able to practice and apply nursing skills
and procedures in a safe manner during actual patient
care.9 The purpose of this study is to answer the
research question; “ Is there difference among
experimental and control group in cognitive, affective,
and psychomotor skills of learning in giving
subcutaneous injection by comparing two teaching
strategies?”
METHODOLOGY
Research Design and Samples
A quasi experimental design has been utilized
in this study, to compare the two teaching strategies
in subcutaneous injection. It was carried out in
nursing laboratory at King Saud University, College
of Nursing; Saudi Arabia. Twenty One nursing
students second year had been selected to participate.
Samples were divided randomly into two groups with
separate nursing skills lab, experimental group (10
students) and control group (11 students).
Instrument and Data Collection
Participants from both groups has given a
performance checklist guide (17 steps) developed by
the researcher. It was corrected properly by group of
nursing educators
to validate appropriateness of the items. In this
study, data collection was done in two days. On first
day, the checklist guide was explained and
demonstrated by researcher in nursing laboratory by
using a simulated low fidelity mannequin. After
demonstration, participants were distributed on
separate nursing lab. Both groups were given a chance
by researcher to practice the skill without grading a
score, experimental group with pricking of needle to
a mannequin while the control group without pricking
of needle . Post test was done on second day;
participants from both groups had been evaluated
individually by using same checklist guide as
evaluation tool. All participants were requested to
give subcutaneous injection with actual pricking of a
needle to a mannequin. The performance rating
checklist was categorized on scale ratings as 5 = 100%
(excellent), 4 = 90% (very good), 3 = 80% (good), 2 =
70 % (fair), 1 = 60% (poor). The steps listed on the
subcutaneous injection checklist guide with 17 items
were subdivided by applying the bloom’s taxonomy
of learning domains.
Steps no.1,3,4, and 17 are considered in cognitive
domain, to evaluate their knowledge acquisition on
the skill; Steps 6,7, 8, 9, 10, 11,12,13,14, and 15 are in
psychomotor domain, to evaluate their physical and
motor skill coordination. And steps 2, and 16 are in
affective skill, to evaluate their attitude of valuing,
organizing and characterization . Table 1 illustrates
the details of the checklist guide/performance rating
scale during demonstration and evaluation of the
researcher as categorized on domains of learning.
Table 1: Checklist Guide/Performance Rating Scale
Steps in Subcutaneous Injection Domains of Score
Learning
1. Verbalize medication rights: Right patient, medicine, Cognitive 5100 490 380 270 160
dose, route, time, & recording.
2. Close curtain. Explain procedure to patient. Affective
3. Select appropriate injection site. Cognitive
4. Relocate site using anatomical land marks. Cognitive
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32 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Table 1: Checklist Guide/Performance Rating Scale
Steps in Subcutaneous Injection Domains of Score
Learning
5. Put on the gloves. Clean site in circumrotation Psychomotor
outward with alcohol swab.
6. Keep alcohol swab between fingers of non dominant hand Psychomotor
7. Remove cap of needle by pull its tip-off in straight manner
with one hand while other hand holding the syringe. Psychomotor
8. Use thumb and forefinger and gently grasp fatty tissue
on appropriate site Psychomotor
9. Hold syringe between thumb and forefinger of dominant
hand as if grasping dart with bevel point upward Psychomotor
10. Administer injection: Prick/insert the needle at Psychomotor
45 or 90 0 angle. Angles varies with amount of subcutaneous
tissue, selected site, and needle length.
11. After needle enter the site, grasp syringe with non dominant Psychomotor
hand to avoid moving of syringe.
12 . With dominant hand push plunger to inject the medicine Psychomotor
slowly. No aspiration before inject of heparin or insulin.
13. Placing antiseptic swab and apply contra-act pressure at site Psychomotor
while withdrawing the needle.
14. Apply gently pressure over injection site, but don’t massage. Psychomotor
15 . Discard uncapped needle in sharp box container. Psychomotor
Wash hands after procedure
16. Follow after care. Cover the patient, put the side rails up, Affective
give emotional support to patient
17. Record: Evaluation of patient for the effects/ side Cognitive
effects of the drug.
The data analysis was obtained by using SPSS
software package to facilitate the percentage scores
and average mean; Mann Whitney U test to evaluate
the difference between the groups with significance
level was set as p=0.0001<0.05.
RESULTS
The participants of BSN second year were
requested to join in this study, they considered young
in age ranging from 19 to 23 yrs of old and not married
(Table 2).
Table 2: Distribution of Age by the Participants
Age: Total no. of Percentage:
samples n= 11
23 and above 0 0
21 -22 3 14.28%
19 - 20 18 85.7%
Although they varies on knowledge level of very
good to excellent but no students are lower than good
on GPA (Table 3).
Table 3: Distribution of General Percentage Average
(GPA) by the Participants
GPA Rating out of 5.0 Total no. of Percentage
samples n=11
4.5 - 5.0 Excellent 4 19.04%
3.75 – 4.49 Very Good 12 57.14%
2.75– 3.74 Good 5 23.80%
Below 2.75 0 0
Table 4. Shows that experimental group got the
excellent score in three domains of learning on post
test while control group has the lowest mark on
psychomotor skill (80%).
Table 4: Student’s Performance in giving
Subcutaneous Injection in Three Domains of
Learning.
Domains of Learning Experimental Control
Group Group
1. Cognitive Skill 92 % 87.7 %
2. Psychomotor Skill 94 % 80 %
3. Affective Skill 95 % 93.61 %
Mildly difference was noted between the groups in
cognitive skill (Table 5) when verbalizing the
medication rights (p= 0.081), anatomical landmark
(p=0.082), and documentation of care (p=0.082).
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 33
Table 5: Mildly Difference between Experimental and Control group in Cognitive Skill
Checklist Group No. of Percentage Mean Mann- Sig.
Guide students Whitney p=0.0001
Step no. U Test <0.05
1 Experimental 10 100% 5 51.000 *.081
Control 11 90% 4
3 Experimental 10 83% 3.3 48.000 0.598
Control 11 85.45% 3.5455
4 Experimental 10 100% 5 40.000 *.082
Control 11 94.54% 4.4545
17 Experimental 10 85% 3.5 52.000 *.082
Control 11 89% 3.9091
Table 6 revealed that moderately difference was
noted between the groups in psychomotor skill when
holding the syringe (p= 0.000), grasping the fatty tissue
(p=0.000), holding syringe (p=0.001), pricking of
needle (p=0.029), infusing medication (p=0.005), and
withdrawing the needle (p=0.005)
Table 6: Moderately Difference between Experimental and Control group in Psychomotor skills.
Checklist Group No. of Percentage Mean Mann- Sig.
Guide students Whitney
Step no. U
5 Experimental 10 98% 4.8 0.602 50.5
Control 11 96% 4.6364
6 Experimental 10 94% 4.4 0.143 34.5
Control 11 90% 4.0909
7 Experimental 10 96% 4.6 **.000 2
Control 11 70% 2
8 Experimental 10 90% 4 **.000 4
Control 11 70% 2
9 Experimental 10 91% 4.1 **.001 9.5
Control 11 71% 2.1818
10 Experimental 10 96% 4.6 **.029 24.5
Control 11 80% 3.0909
11 Experimental 10 91% 4.1 **.005 17
Control 11 75.45% 2.5455
12 Experimental 10 91% 4.1 **.008 19
Control 11 77.27% 2.7273
13 Experimental 10 95% 4.1 **.002 21.5
Control 11 79% 2.9091
14 Experimental 10 92% 4.2 **.000 8
Control 11 72.70% 2.2727
15 Experimental 10 96% 4.6 0.128 44
Control 11 100% 5
Moreover, Table 7 revealed that no significant
difference was noted between groups in affective skill
when verbalizing how to respect patient’s integrity
by closing the curtain, explaining procedure (p=0.326),
and aftercare (p=0.867).
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34 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Table 7: No Difference between Experimental and Control Group in Affective skill.
Checklist Group No. of Percentage Mean Mann- Sig.
Guide students Whitney
Step no. U
2 Experimental 10 98% 4.8 0.326 45.5
Control 11 94.50% 4.4545
16 Experimental 10 92% 4.2 0.867 53
Control 11 92.72% 4.2727
Note: *= mildly difference; **= moderately difference; ***= strongly difference
DISCUSSION
In this study, to compare the two teaching strategies
in subcutaneous injection by applying learning
domains; mildly difference was noted in cognitive skill,
and both groups got very good on their evaluation
score. Students can easily understood the skill
demonstration when it was right after classroom
lecture; it was reflected based on their post test scores.
The control group is mildly lower than experimental
group since missing hands-on practice will affect their
performance . Psychomotor requisition involves
physical, motor and cognitive coordination.1
Moderately difference was noted on both groups
in psychomotor skill; while experimental group got
excellent score, control group got good during post
test and it’s satisfactory.
This is due to the fact that groups had given a
chance to practice subcutaneous injection before post
test despite the control group of not pricking the
needle. Also not grading a score will made the students
comfortable and not pressured to practice the skill.
This was reflected on Table 5; steps 5, 6 and 15, that
no difference were existed (p= 0.602), however these
steps are no actual hand pricking. We can say based
on the results that hands-on practice by experimental
group contributed an excellent score on their
psychomotor performance. Indeed, the result signifies
that even the students are in simulated laboratory
without hands-on experience will not be as competent
as those who did so. Baldwin (1991) proved that
students who are new to a content area will generally
benefit more from “hands-on” learning than from
mediated learning within the psychomotor domain.10
It is in clinical laboratory that many skills are perfected.
Nursing education is one where many cognitive and
psychomotor skills need to be imparted to the students.
However, adverse conditions like the lack of clinical
lab buildings, crowded classes, a dearth of expert
educators, and limited materials lead to restrictions in
creating the desired behavior during both in-class
lectures and laboratory practice.7 Infante (1985) on
her classic study of the clinical laboratory noted that
opportunity for observation and practice are essential
element of clinical learning.11 Simulated hands-on
experiences offer the opportunity for diverse styles of
learning that not offered in the class room environment
and can result in an increase of confidence felt by the
student.12 No significant difference was noted in
affective skill, both groups got excellent on their post
test score. Participants understood very well the
correct attitude of patient care, as it was mentioned
on the checklist guide the importance of respecting
patient’s rights, maintaining privacy, communication
skills and emotional support before and after giving
a procedure.
CONCLUSION
The main conclusion drawn from this study that
actual performance in all aspects of learning; hands-
on skills that have been practice in a simulated nursing
laboratory prior to clinical performance in the hospital
has significant contribution on the competency of
student’s cognitive, psychomotor and affective skills.
However, materials and technologies are somewhat
helpful on this regard. Simulated mannequin is one
of the examples wherein the students are somehow
can able to use artificial setting of implementing
various skills prior to actual patient care. The results
of this research study address to educators the
importance of hands-on practice to give more
emphasis and consistency in the future regardless of
the difficulty of skill presented and number of students
performed.
Limitation of the study is that the evaluation phase
was done in nursing laboratory.
For future study, I will recommend participants
should be in the hospital setting with actual
performance of giving subcutaneous injection to a real
patient. I will suggest installation of high fidelity
mannequins and innovative nursing equipments to
7. Khadijah saudi--30-35.pmd 1/6/2014, 9:30 AM34
International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 35
nursing laboratory in order to help educators to
improve teaching strategies and learning designs.
ACKNOWLEDGEMENT
I would like to acknowledge Dr. Nagat El-Morsy,
my head department for her help and support.
REFERENCES
1. Clark, DR. The Art and Science of Leadership
[serial on the internet]. 2004 [cited August 1, 2011].
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2. Jefferies, PR. Simulation in Nursing Education:
From Conceptualization to Evaluation. New
York, NY: National League for Nursing; 2007. 1-
9 p.
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2012] available from: http://www.nova.edu/
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4. Suling Li, The Role of Simulation in Nursing
Education [serial on the internet]. 2007 [cited
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org/ The role of Simulation in Nursing
Education.
5. Jefferies, PR.; Rizzolo, MA. Designing and
implementing models for the innovative use of
simulation to teach nursing care of ill adults and
children: A national, multi-site, multi-method
study. New York: National League for Nursing;
2006.
6. Kyle, RR.; Murray, WB. Clinical Simulation:
Operations, Engineering and Management.
Burlington, MA: Academic Press; 2008
7. Souers, C. A comparison of two teaching
strategies for nursing skill acquisition. Master of
science in nursing. Louisville, Kentucky:
Bellarmine College; [serial on internet], 1998
[cited April 2012] available in international
journal of caringsciences.org/...10.% 20
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8. Decker S, Sportsman S, Puetz L, and Billings L.
The evolution of simulation and its contribution
to competency. J Contin Educ Nurs, 2008; 39(2),
74-80.
9. Deniz, O. International Journal of Caring Science
September-December Vol. 5 Issue 3[serial on
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10. Baldwin A, Hill P, Hanson G. Performance of
Psychomotor skills: A Comparison of two
teaching strategies; Journal of Nursing 1991; 30:
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11. Infante, MS. The Clinical laboratory in Nursing
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36 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
Delinquency is a kind of abnormality when an
individual deviates from the course of normal social
life. His behaviour is called ‘Delinquency’. The word
juvenile has been derived from a Latin term “juvenis”
Effectiveness of Behavioral Modification Therapy in
Coping with Adjustmental Problems among Juvenile
Delinquents
Kishanth Olive1, Sheeba2
1Sister Tutor, Department of Psychiatric Nursing, College of Nursing, Jawaharlal Institute of Postgraduate Medical
Education & Research, Puducherry, 2Head Of Department, Adhiparasakthi College of Nursing, Melmaruvathur,
Kancheepuram District
ABSTRACT
Objective:
• To assess the level of adjustmental problem among juvenile delinquents.
• To evaluate the effectiveness of behavioral modification therapy in coping with adjustmental
problems among juvenile delinquents.
• To correlate the effectiveness of behavioral modification therapy in coping with adjustmental
problem among juvenile delinquents with the selected demographic variables.
Materials and Method This study was concluded in male juvenile delinquent with adjustmental
problems of observational home and special school, Government of Puducherry, ariyakuppam,
Puducherry, India. Quasi - Experimental Design (one group pre-test, post-test) was adopted. And a
total of 50 juvenile delinquents was selected for the study, who met the inclusion criteria and the total
time exposed was 8 to 112 hours, to assess the effectiveness of behavioral modification therapy in
coping with adjustmental problems among juvenile delinquents.
Results: The first objective revealed that among 50 individuals 42(84%) had moderate level of
adjustmental problems and 8(16%) had severe level of adjustmental problems on the assessment
day. The second objective exposed that after giving behavioral modification therapy the overall
mean was 25.98 with standard deviation of 1.37 on the evaluation day. The third objective revealed,
there was a significant correlation between the behavioral modification therapies and the demographic
variables such as age, type of family, marital status of parents, and residence.
Conclusion: A total number of 50 samples were selected for this study. On the first day, the level of
adjustmental problems was assessed by using modified James Watson and Richard ongoing
assessment of juvenile delinquents. On the last day, the evaluation was done by using the same tool.
In pretest out of 50 samples 08 individuals exhibited severe adjustmental problems and 42 individuals
exhibited moderate adjustmental problems. It was found that 47 individuals exhibited mild
adjustmental problems and 03 individuals exhibited moderate adjustmental problems which show
that the behavioral modification therapy was effective in reducing the level of adjustmental problems
among juvenile delinquents.
Keywords: Effectiveness, Behavioral Modification Therapy, Adjustmental Problem, Juvenile Delinquents
DOI Number: 10.5958/j.0974-9357.5.2.054
meaning thereby young. The term delinquency has
also been derived from the Latin initiative
“delinquere” means go away.1
Juvenile crime is one of the nation’s serious
problems. Concern about it is widely shared by federal,
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 37
state, and local government officials and by the public.
In recent years, this concern has grown with the
dramatic rise in juvenile violence that began in the mid-
1980s and peaked in the early 1990s.2
Juvenile delinquency laws are characterized by the
denature that they prescribe many acts which are
regarded as non-criminal if indulged in by elder
persons like drinking, smoking, viewing adult films
or reading adult literature, etc. The first legislation
converning children which came in 1850 was the
Apprentic Act which provided that children in the age
group of 10-18 convicted by courts were intended to
be provided with some vocational training which
might help their rehabilitation. It was followed by
Reformatory Schools Act, 1897.3
According to National governmental organizations,
India says that juvenile crime has increased by 3.8%
nationally (14,975 cases in 2008 from 14,423 in 2006).
And about 1,327 murdered cases were reported in 2008
up from 1,304 in 2006 (an increase of 1.8%).Uttar
Pradesh reported the highest number (390) accounting
for 29.4% of cases was committed by juvenile
delinquents.4
Crimes committed by juveniles show a slight
increasing trend (0.41% to 0.49%) as share of total
Indian penal code crimes reported in the State during
2004 to 2008. This increase can be attributed to
reclassification of age limit of juvenile boys and girls
to “Non-completion of eighteen years of age”. Same
pattern has been observed in the Juvenile Crime Rate
also (1.07 to 1.30) between the years 2004 and 2008.
Incidence and rate of Juvenile delinquency under
INDIAN PENAL CODE during 2004 – 2008 have been
increased. About 858 Indian penal code cases were
registered against Juveniles during 2008, 14.1% more
than 2007.5
Prevalence of Juvenile delinquency under various
crime heads of Indian penal code during 2007 and 2008.
Theft (410 – 47.79%) accounted for the highest
incidence of juvenile delinquency cases followed by
hurt (158 – 18.41%), burglary (106 – 12.35%), murder
(26 – 3.03%), riots (23 – 2.68%), attempt to commit
Murder (17 – 1.98%), robbery (13 – 1.52%), rape (7 –
0.82%), causing death by negligence (6 – 0.70%),
molestation (5 – 0.58%), kidnapping and abduction and
dacoity (each 3 – 0.35%) of 858 cases under Indian penal
code registered against them during 2008. Juvenile
delinquency (Indian Penal Code) district-wise states
that juvenile delinquency under various crime heads
of Indian penal code (district/ city wise). In Thanjavur
133 recorded the highest incidence followed by
Chennai 220, Madurai 69, Virudhunagar 46,
Ramanathapuram 45, Kanniyakumari 37, Theni 37,
Erode 35, Cuddalore and Puducherry 29, the juvenile
delinquent apprehended district/city-wise during
2008.5
Incidence of Juvenile Delinquency Under Indian
Penal Code 2004 – 2008
MATERIALS AND METHOD
The data collected from the male juvenile
delinquents, arriyankupam, Puducherry, who met
with the inclusion criteria, by using demographic
variables and tool, was entered into the coding sheet
on SPSS soft for detail data analysis. The main study
was conducted for juvenile delinquents with
adjustmental problems who are in observation homes
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38 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
and special school, Ariyankuppam, Puducherry. The
individuals who met the inclusion criteria were
selected by using simple random sampling method.
The duration of the interview ranged from 15-20
minutes for each individual. Assessment was done
with the help of standardized tool. Based on the scores,
behavioral modification therapy like positive
reinforcement, negative reinforcement, relaxation
technique, recreational therapy, group therapy,
vocational therapy was given. On the seventh day,
effectiveness of behavioral modification therapy was
evaluated with the help of standardized tool.
OBSERVATION & RESULTS
Organization of Data
The study findings are presented in the following
sections.
Section A : Frequency and percentage distribution of demographic variables of juvenile delinquents with adjustmental problems.
Section B : Frequency and percentage distribution of assessment and evaluation scores of effectiveness of behavioral modification
therapy with adjustmental problems.
Section C : Mean and standard deviation of assessment and evaluation scores of juvenile delinquents with adjustmental problems.
Section D : Mean and standard deviation of improvement score for effectiveness of behavioral modification therapy using paired‘t’
test.
Section E : Correlation between effectiveness of behavioral modification therapy in coping with adjustmental problem among
juvenile delinquents and with selected demographic variables and with selected demographic variables.
Table 1. Frequency and Percentage Distribution of Demographic Variables Among the Juvenile Delinquents N=50
S. No Demographic Variables Frequency Percentage
1. Age
a. 12 to 13 years 14 28
b. 13 to 15 years 16 32
c. 16 to 18 years 20 40
2. Religion
a. Hindu 32 64
a. Muslim 06 12
b. Christian 12 24
3. Educational status of father
a. Non – literate 08 16
b. Primary level 24 48
c. Secondary level 12 24
d. Graduate and above 06 12
4. Educational status of mother
a. Non – literate 10 20
b. Primary level 17 34
c. Secondary level 13 26
d. Graduate and above 10 20
5. Occupational status of father
a. Unemployed 06 12
b. Daily wager 25 50
c. Self employed 16 32
d. Professional 03 06
6. Occupational status of mother
a. Home maker 06 12
e. Daily wage 27 54
b. Self employed 09 18
c. Professional 08 16
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 39
Table 1. Frequency and Percentage Distribution of Demographic Variables Among the Juvenile Delinquents N=50
(Contd.)
S. No Demographic Variables Frequency Percentage
7. Type of family
a. Joint family 08 16
b. Nuclear family 42 64
8. Family income per month
a. Up to Rs.1,000 /- 04 08
b. Rs.1,001 - Rs.3,000/ 19 38
c. Rs.3,001 - Rs.5,000/- 19 38
d. Above Rs.5,001/- 08 16
9. Marital status of parents
a. Widow / Widower 11 22
b. Remarried 14 28
c. Divorced / Separated 25 50
10. Residence
a. Urban 11 22
b. Rural 39 78
11. Supportive system
a. Health personnel 30 60
b. Family and relatives 04 08
c. National governmental organizations 16 32
Table 1, it implies the distribution of respondents
according to certain demographic factors like age,
religion, educational status of father and mother,
occupational status of father and mother, type of
family, family income per month, residence, and
supportive system.
Among 50 juvenile delinquents, 14(28%) were in
the age group of 12 – 13yrs, 16(32%) were in the age
group of 14 – 15 yrs and 20(40%) were 16 - 18 yrs.
Regarding the religion, 32(64%) were Hindus, 06(12%)
were Muslims, 12(24%) were Christians. The
educational status of the father reveals that 08(16%)
are non-literates, 24(48%) are primary level, 12(24%)
are had secondary level and 06(12%) are graduate and
above. The educational status of the mother reveals
that 10(20%) are non-literates, 17(34%) are primary
level, 13(26%) are had secondary level and 10(20%) are
graduate and above. The occupational status of father
shows that 06(12%) were unemployed, 25(50%) were
daily wager, 16(32%) were self-employed, 03(06%)
were professional.
The occupational status of mother shows that
06(12%) were homemakers, 27(54%) were daily wager,
09(18%) were self-employed, 08(16%) were
professionals. In the type of family, 42(84%) belonged
to nuclear family and 08(16%) belonged to joint family.
Among the respondents, 04(08%) had the family
income of up to Rs.1000, 19(38%) Rs.1001-3000, 19(38%)
Rs.3001-5000 and 08(16%) were earning more than
Rs.5000 per month. In regard to the marital status of
parents, 11(22%) were widow/widower, 14(28%) were
remarried and 25(50%) were divorced. About 11(22%)
of the people were living in urban and 39(78%) were
living in rural areas. When asking about the source of
supportive system, 30 (60%) received health
information from health personnel, 04(08%) received
health information from family and relatives and
16(32%) received information from national
governmental organizations.
Table 2. Frequency and Percentage Distribution of Assessment and Evaluation Score for Effectiveness of
Behavioral Modification Therapy N = 50
Health status Assessment Evaluation
No. % No. %
Mild — — 47 94
Moderate 42 84 03 06
Severe 08 16 — —
Total 50 100 50 100
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40 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Table 2 Shows the comparison between assessment
and evaluation score of effectiveness of behavioral
modification therapy in coping with adjustmental
problems of juvenile delinquents and also reveals that
the frequency and percentage distribution. In this table
during assessment phase 42(84%) had moderate
adjustmental problems, 08(16%) were having severe
adjustmental problems and during evaluation phase,
after receiving behavioral modification therapy
47(94%) were having mild adjustmental problems and
03(06%) of patients were having moderate
adjustmental problems.
Table 3. Mean and Standard Deviation of Assessment
and Evaluation Scores of Juvenile Delinquents
S. Status of Mean Standard Class
No adjustmental problems deviation Interval
1. Assessment 37.38 3.13 36.41 – 38.35
2. Evaluation 25.98 1.37 25.56 – 26.40
Table 3 reveals that the overall mean was 37.38 with
the standard deviation of 3.13 with confidential
interval of 36.41 – 38.35 on the assessment day. The
mean was 25.98 with the standard deviation of 1.37
with confidential interval 25.56 – 26.40 on the
evaluation day.
TAble 4. Mean Aand Standard Deviation of
Improvement Score for Effectiveness of Behavioral
Modification Therapy Using Paired ‘T’ Test N = 50
Status of Mean Standard Paired Confidential
adjustmental problems deviation test interval
Improvement score 11.4 1.76 56.36 112.81 -123.84
* P < 0.01 level significant
Table 4 reveals the improvement between
assessment score and evaluation score. The mean was
11.4 with standard deviation of 1.76. The calculated
value (56.36) was greater than the table value (2.73).
There was a significant improvement in coping with
adjustmental problems of juvenile delinquents. It
shows effectiveness of behavioral modification therapy
was highly effective at p<0.01 level.
Table 4. Correlation between Selected Demographic Variables and effectiveness of Behavioral Modification
Therapy in Coping with Adjustmental Problem among Juvenile Delinquents N=50
S. No. DemographicVariables Assessment Evaluation
Moderate Severe Mild Moderate r
1. Age
a. 13 to 14 years 12 02 14 - 0.9S
b. 14 to 15 years 13 03 14 02
c. 16 to 18 years 17 03 19 01
2. Religion
a. Hindu 30 02 30 02 -0.7 NS
b. Muslim 04 02 06 0
c. Christian 08 04 11 01
3. Educational status of father
a. Non – literate 06 02 07 01 -0.3 NS
b. Primary level 22 03 22 02
c. Secondary level 10 02 12 0
d. Graduate and above 04 01 06 0
4. Educational status of mother
a. Non – literate 08 02 09 01 -0.1 NS
b. Primary level 15 02 16 01
c. Secondary level 10 03 12 01
d. Graduate and above 09 01 10 0
5. Occupational status of father
a. Unemployed 05 01 06 - 0.4NS
b. Daily wage 21 04 23 02
c. Self employed 14 02 15 01
d. Professional 02 01 03 -
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 41
Table 4. Correlation between Selected Demographic Variables and effectiveness of Behavioral Modification
Therapy in Coping with Adjustmental Problem among Juvenile Delinquents N=50
S. No. DemographicVariables Assessment Evaluation
Moderate Severe Mild Moderate r
6. Occupational status of mother
a. Home maker 05 01 06 0 -0.1 NS
b. Daily wage 25 02 26 01
c. Self employed 06 03 08 01
d. Professional 06 02 07 01
7. Type of family
a. Joint family 06 02 07 01 0.8 S
b. Nuclear family 36 06 14 02
8. Family income per month
a. Up to Rs.1,000 /- 02 02 03 01 0.2 NS
b. Rs.1,001-Rs.3,000/ 17 02 18 01
c. Rs.3,001-Rs.5,000/- 18 01 19 0
d. Above Rs.5,001/- 05 03 07 01
9. Marital status of parents
a. Widow/ Widower 08 03 11 - 0.9S
b. Remarried 12 02 13 01
c. Divorced 22 03 23 02
10. Residence
a. Urban 08 03 09 02 0.9S
b. Rural 34 05 38 01
11. Supportive system
a. Health personnel 26 04 28 02 -1.5 NS
b. Family and relatives 03 01 04 0
c. National governmental organizations 13 03 15 01
S - Significance, NS - No Significance, P - < 0.001
Table - 4 reveals the correlation between the
demographic variables such as age, religion,
educational status of father, educational status of
mother, occupation status of father, occupation status
of mother, type of family, marriage, residence and
supportive system with the effectiveness of behavioral
modification therapy. Statistically there was a
significant positive correlation between the
demographic variable such as age, type of family,
marital status of parents and residence.
DISCUSSION
The study findings have been discussed in terms
of the objectives of theoretical basis and hypothesis. A
total number of 50 samples were selected for the study.
The adjustmental problem level of each and every
individual was assessed with the help of standardized
tool. Based on the assessment the behavioral
modification therapy was planned and implemented
for the individual with adjustmental problems and
effectiveness of behavioral modification therapy was
assessed on seventh day.
The first objective was to assess the level of
adjustmental problem among juvenile delinquents
Table 4.2 revealed that among 50 individuals 42(84%)
had moderate adjustmental problems and 8(16%)
had severe adjustmental problems on the
assessment day. Among 50 individual overall mean
was 37.38 with standard deviation of 3.13 on the
assessment day.
The second objective was to evaluate the
effectiveness of behavioral modification therapy in
coping with adjustmental problems among juvenile
delinquents Table 4.3 and 4.4 revealed that after giving
behavioral modification therapy the overall mean was
25.98 with standard deviation of 1.37 on the evaluation
day. The improvement score with the assessment and
evaluation showed the mean of 11.4 with the standard
deviation of 1.76.
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42 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
The third objective is to correlate the effectiveness
of behavioral modification therapy in coping with
adjustmental problem among juvenile delinquents
with the selected demographic variables Table-4.5
there was a significant correlation between the
behavioral modification therapy and the demographic
variables such as age, type of family, marital status of
parents, and residence.
ACKNOWLEDGEMENT
The author is thankful to the, Mr. Selvam, Jail
Warden, Observation Home and Special School,
arriyankuppam, Puducherry, Dr. N. Kokilavani., Ph.D,
Principal, APCON, Dr. Debajit., MD, Associate
Professor, Department of psychiatry, MAPIMS, for
providing permission and guidance to carry out this
work successfully.
Ethical Clearance
The titled study “Effectiveness of behavioral
modification therapy in coping with adjustmental
problems among juvenile delinquents” was approved
by the dissertation committee on March 2010. The
disseratation committee includes, Dr. N. Kokilavani,
Ph.D., Principal and HOD of Research, Prof. Sheeba,
M.Phil., HOD, Department of psychiatric Nursing,
APCON, Melmaruvathur, and Dr. Debajit Gogoi, MD,
HOD department of psychiatry, MAPIMS,
Melmaruvathur.
Conflict of Interest: Nil
REFERENCES
1. Carson Robert, C. Butcher James, N (1992)
“Abnormal Psychology and Modern life” 9th
edition, Harper Colins publications.
2. http://www.nap.edu/openbook. php?
record_id=9747&page=14
3. http://educationdewsoftoverseas.com/
vakilno4/junvenileeact/introduction.htm
4. Mary C. Townsend (2006), “Psychiatric Mental
Health Nursing” 5th edition, Jaypee publications,
New Delhi.
5. Ponnudurai (2003) “An epidemiological study of
juvenile delinquency”, Indian Journal of
Psychiatry, vol.74.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 43
INTRODUCTION
Assessment plays a major role in the process of
nursing education, in the lives of nursing students and
in society by certifying competent practitioner who can
take care of the people. The objective Structured
Clinical Examination (OSCE) is an approach to
students’ assessment in which aspects of clinical
competence are evaluated in a comprehensive,
consistent and structured manner, with close attention
to the objectivity of the process (Byrne & Smyth, 2007).
Objective Structured Clinical Examination” (OSCE)
Objective Structured Clinical Examination - Emerging
Trend In Nursing Profession
G Muthamilselvi1, P Vadivukkarasi Ramanadin2
1Professor cum PrincipalVinayaka Mission's College of Nursing, Pudhucherry, 2Asst. Professor, Dept. of OBG, Mata
Sahib Kaur College of Nursing, Mohali, Punjab
ABSTRACT
Assessment of clinical competence is an essential, mandatory requirement for health care profession.
But it became a tough job for nurse educator as it poses several challenges in terms of objectivity and
reliability. The OSCE which is the performance based method helps to overcome these challenges.
This study was undertaken with the aim of assessing the knowledge, attitude & exploring the opinion
towards OSCE among the nursing faculty by using mixed method. Knowledge on OSCE was assessed
by using Structured Questionnaire with 15 items & attitude was assessed by using five point Likert
scale with 10 items. Unstructured Questionnaire was formulated to explore an opinion. Non -
Probability, Convenient sampling technique was used to select Thirty Nursing Faculty. Study findings
shows that the Nursing Faculty have 40% Excellent knowledge, 47% of them have Adequate and
13% of them have inadequate knowledge and also it shows that 73% of them have positive attitude
& 27% of them have negative attitude towards OSCE. Correlation between Knowledge & Attitude
towards OSCE reveals that moderately negative correlation. Opinion on OSCE was explored &
grouped under "Opinion on OSCE", "Client Care", "Clinical Evaluation", "Utilization of Resources" &
"Difference between OSCE & Traditional method of Clinical Examination". The study recommends
that the Nursing Faculty should develop positive Opinion & skill in preparing the students by using
OSCE.
Keywords: Objective Structured Clinical Examination, Sequential Research Method, Qualitative Research
Approach & Interview Schedule
DOI Number: 10.5958/j.0974-9357.5.2.054
Corresponding author:
P Vadivukkarasi Ramanadin
Asst. Professor
Dept. of OBG
Mata Sahib Kaur College of Nursing, Mohali, Punjab
Mobile No.: 7696732898
Mail Id: krishraghav2010@gmail.com
pvadivuram2010@yahoo.com
evolved from medical education in Scotland, and has
been used extensively in nursing worldwide. It is now
widely accepted as a fit-for-purpose instrument for
measuring clinical reasoning skills with a high degree
of technical fidelity (Ahmad, Ahmad & Abu Bakar,
2009). The OSCE was introduced by Dr. Ronald M.
Harden in the 1970s as ‘‘an approach to the assessment
of clinical competence in which the components of
competence are assessed in a planned or structured
way with the attention being paid to the objectivity of
the examination1.’’ The examination consists of
multiple, standard stations at which students must
complete 1 to 2 specific clinical tasks, often in an
interactive environment involving patient actors (ie,
standardized patients) 2. OSCE has become a common
method to assess learner performance across a variety
of health professions disciplines. Most notably, OSCE
is a component of entry-to-practice licensing
examinations, including the United States Medical
Licensing Examination, the Canadian Pharmacist
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44 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Qualifying Examination, and the Medical Council of
Canada Qualifying Examination3-5. To maintain
examination validity and authenticity, a representative
sampling of real-world skills should be tested6.
Consequently, use of a blueprint that defines
examination domains (eg, knowledge, skills,
behaviors, complexity) to guide OSCE station
development along with group (rather than
individual) writing of OSCE cases with peer review
has been recommended6-8.
OSCE is now an established part of the repertoire
of clinical assessment skills in many nursing schools
around the world. Nursing faculties in Egypt use a
range of assessment techniques that are appropriate
for testing students’ outcome. However, in Egypt, there
is no available evidence for using OSCE in nursing
education. OSCE is a new issue that needs capacity
building for Egyptian nursing faculties. A baseline
survey in the assessment of competency resulting from
medical and nursing education in Egypt (2006)
reported that skills assessed are poorly performed by
four learner groups (medical & nursing
undergraduates, nurse intern and house officers) in
both medical and nursing faculties Furthermore,
clinical training as it is currently organized and
implemented for the competencies assessed is
inadequate for all learner groups of all regions in Egypt
(Health Workforce Development, 2006) 1.
OSCE has been widely and increasingly used since
it was developed. Researches have shown that it is an
effective evaluation tool to assess practical skills.
Currently, the ability of simulation to meet the needs
of practice education remains limited (Pierre,
Wierenga, Barton, Branday & Christie, 2004). In
addition, (Ahmad, Ahmad & Abu Bakar, 2009) added
that OSCE is developed to reduce bias in the
assessment of clinical competence; it is not now
without the pitfalls of other assessment methods. In
particular, the need for more rigorous evaluation of
OSCEs in nursing education programs has been
highlighted (Brosnan, Evans, Brosnan, & Brown 2006);
(Miller, 2009) as these assessments are directed towards
assurances that passing students can practice safely
in the clinical setting with patients. In many instances
the OSCE process has been adapted to test trainees
from different healthcare related disciplines. In nursing
education principles of OSCE can also be used in a
formative way to enhance skills acquisition through
simulation (Alinier, 2009) 9.
OBJECTIVES
• To assess the knowledge regarding Objective
Structured Clinical examination among the
nursing faculty working in selected Nursing
Institutions at Puducherry”.
• To assess an attitude regarding Objective
Structured Clinical examination among the
nursing faculty working in selected Nursing
Institutions at Puducherry”.
• To correlate the knowledge & attitude regarding
Objective Structured Clinical examination among
the nursing faculty working in selected Nursing
Institutions at Puducherry”.
• To explore an opinion on OSCE among nursing
faculties working in selected Nursing Institutions
at Puducherry”.
MATERIALS & METHOD
As Sequential research design was adopted for this
study both Quantitative & Qualitative approach was
used simultaneously. Thirty Nursing Faculty working
in Vinayaka Mission’s College of Nursing,
Pudhucherry were selected by using Non- Probability,
Convenient Sampling method. Quantitative method
was used to assess the Knowledge & Attitude.
Knowledge on OSCE was assessed by using Structured
Knowledge Questionnaire with 15 items and four
option was provided. Each correct response were
scored one and wrong response was scored zero.
Attitude towards OSCE was assessed by using five
point Likert scale with 10 items. The scoring was
ranging from -2 to +2 for strongly disagree to strongly
agree. Qualitative method was used to explore an
opinion on OSCE. Interview schedule was planned
with Unstructured Questionnaire to explore an opinion
towards OSCE. Content Validity of the tool was
obtained from the experts of Nursing Profession &
Statistician. Reliability of the tool was done by using
Split half technique & Spearman Brown Prophecy
Formula which shows 0.82 that is highly reliable. Data
were analyzed by using both descriptive and
inferential statistics. Correlation between Knowledge
& Attitude was assessed by Karl Pearson Correlation
Co-efficiency.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 45
FINDINGS
Quantitative Analysis
Table 1. Nursing Faculty Level of Knowledge on Objective Structured Clinical Examination N = 30
S. No Knowledge
Excellent Adequate Inadequate
Frequency Mean Frequency Mean Frequency Mean
Percentage Percentage Percentage
1 12 40% 14 47% 4 13%
Table No 1 shows that 40% of the Nursing Faculty
had excellent knowledge on OSCE, 47% of them had
adequate knowledge & 13 % of them had inadequate
knowledge.
Table 2. Nursing Faculty Attitude Towards Objective Structured Clinical Examination N = 30
S. No Attitude
Positive Negative
Frequency Mean Frequency Mean
Percentage
122 73% 8 27%
Table No 2 denotes that 73% of them had Positive attitude & 27% of them had negative attitude towards OSCE.
Table 3. Correlation between knowledge & Attitude on Objective Structured Clinical Examination among the
Nursing Faculty
S. No Knowledge Attitude Correlation (r) Inferences
Frequency Mean Percentage Frequency Mean Percentage
1 161 54% 96 16% -0.044 Moderately
negative
correlation
Table: 3 depicts that there is moderately negative correlation between knowledge and attitude on OSCE.
Qualitative Analysis
Exploring Opinion on OSCE
• Opinion on OSCE
Present study reveals the inner aspects of Nursing
Faculty on OSCE. Study participants were
expressed that “OSCE can be one of the method
of clinical evaluation” to measure the clinical
performance of nursing students.
• Client care
Participants felt that “holistic care and direct client
care may not be possible, but the student’s skill
may be evaluated”.
• Clinical Evaluation
They expressed that “OSCE may not help to
evaluate the maximum number of students. But
it may offer equal opportunity to all the students
to perform nursing skill. Evaluation on the entire
domain is questionable”
• Utilization of Resources
Subjects felt that “OSCE requires more than two
examiners for evaluation. It is very exhaustive
procedure. It may need more time, effort for
preparation, money & material”.
•Difference between OSCE & Traditional method
of Clinical Examination
Samples felt that “Overall OSCE is a more stress
full and superficial method of clinical examination.
It may be very thorny for today’s scenario with
faculty turnover.
DISCUSSION
OSCE is one of the best method of clinical
examination for the present scenario for the safe
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46 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Practice. Many of the developed countries adopted
OSCE is one of the method of clinical examination.
OSCE as a performance-based assessment is a well
established student’s assessment tool for many
reasons: competency- based, valid, practical and wise
effective mean of assessing clinical skills that are
fundamental to the practice of nursing and other health
care related professions (Ainier, 2003). The study
conducted in 108 US colleges and schools of pharmacy
with interviews of a representative sample of 88
programs (81.5% participation rate). Thirty-two
pharmacy programs reported using OSCEs; however,
practices within these programs varied. Eleven of the
programs consistently administered examinations of
3 or more stations, required all students to complete
the same scenario(s), and had processes in place to
ensure consistency of standardized patients’ role
portrayal. Of the 55 programs not using OSCEs,
approximately half were interested in using the
technique. Common barriers to OSCE implementation
or expansion were cost and faculty members’
workloads. The study concluded that there is wide
interest in using OSCEs within pharmacy education10.
A comparative study conducted to evaluate the
effectiveness between traditional & Objective
Structured Clinical Examiantion shows that the
moderate correlation found between individual
attainment in OSCE examinations and on traditional
pharmacy practice examinations at the same level. It
was concluded that OSCEs add value to traditional
methods of assessment11.
A study conducted on An Introduction of OSCE
versus Traditional Method in Nursing Education:
Faculty Capacity Building & Students’ Perspectives
shows that the 57% of faculty members knew nothing
about OSCE and 98.6% of them had no experience in
using OSCE; also a high statistical significant
differences between OSCE and traditional assessment
groups in the first and second trial (t = 2.423, p= 0.016),
and (t= 6.23, p= 0.000) respectively. The students’
achievements were better with OSCE. Faculty staff
members indicated that, OSCE saves time (76.3%),
prepares highly qualified competent students (62.5%)
and improve students’ performance (62.5%). It was
concluded that OSCE examination offers an attractive
option for assessment of students’ competency. It
provided particular strengths in terms of faculty staff
objectivity and reliability of the assessment process for
all students, especially when compared with other
methods of assessing practice9.
CONCLUSION
As we are always strive for the better way of
education, this study was intended to bring out the
actual knowledge, attitude & opinion of the nursing
faculty towards OSCE. The present Study reveals that
though knowledge is high attitude towards OSCE was
slightly negative. So faculty should be imparted with
enough knowledge on OSCE.
“OSCE not teach you mostly how to examine the
student rather it teaches the students HOW to learn”
Conflict of Interest: There is no conflict of interest.
ACKNOWLEDGEMENT
We are thankful to all the Nursing Faculty who
participated and contributed their valuable time &
opinion towards the study.
Sources of Support: None
Ethical Clearance: Study objectives were explained to
all the Nursing Faculty & Informed consent have been
taken before the study.
REFERENCES
1. Harden RM. What is an OSCE? Med Teach.
1988;10(1):19-22.
2. McAleer S, Walker R. Objective structured clinical
examination (OSCE). Occas Pap R Coll Gen Pract.
1990;46:39-42.
3. The Pharmacy Examining Board of Canada.
http://www.pebc.ca. Accessed August 26, 2010.
4. The Medical Council of Canada. http://
www.mcc.ca. Accessed August 25, 2010.
5. The United States Medical Licensing
Examination. http://www.usmle.org. Accessed
August 26, 2010
6. Barman A. Critiques on the objective structured
clinical examination. Ann Acad Med Singap.
2005;34(8):478-482.
7. Austin Z, O’Byrne C, Pugsley J, Munoz LQ.
Development and validation processes for an
objective structured clinical examination (OSCE)
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for entry-to-practice certification in pharmacy: the
Canadian experience. Am J Pharm Educ. 2003;
67(3): Article 76.
8. Harden RM. Twelve tips for organizing an
objective structured clinical examination (OSCE).
Med Teach. 1990;12(3-4):259-264
9. Shadia A.E, Hanan A, Hanaa A, Hewida A.H,
1Nagwa Abd El Fadil and 4Inas H. El Shaeer. An
Introduction of OSCE versus Traditional Method
in Nursing Education: Faculty Capacity Building
& Students’ Perspectives. Journal of American
Science 2010;6(12) retrieved from http://
www.americanscience.org
10. Deborah A. Sturpe, PharmD. Objective
Structured Clinical Examinations in Doctor of
Pharmacy Programs in the United States.
American Journal of Pharmaceutical Education
2010; 74 (8) Article 148.
11. Stewart Brian Kirton, Laura Kravitz, MRPharmS.
Objective Structured Clinical Examinations
(OSCEs) Compared With Traditional Assessment
Methods. American Journal of Pharmaceutical
Education 2011; 75 (6) Article 111.
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48 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
Cardiovascular disease (CVD) is a leading cause
of morbidity and premature mortality in women and
men in most of the industrialized world, and many
developing countries. In India, about 10 to 14% (more
than 50 million people) of the adult population suffer
from CAD. The reported prevalence of CAD in adult
surveys has risen four-fold in 40 years and even in rural
areas the prevalence has doubled over the past 30
years. It is estimated that by 2020, CVD will be the
largest cause of disability and death in India.
Studies have demonstrated significant positive
associations between modifiable CAD risk factors and
the presence and extent of atherosclerotic lesions in
the aorta and coronary arteries and CAD risk factors
in childhood were associated with increased carotid
intima-media thickness in adulthood.
Primary prevention among children & adolescents
is a particularly important issue in India, due to high
population numbers and wide economic, social, and
health disparities among its population. The
population’s economic, social, cultural, and
geographic disparities contribute to wide variations
in nutritional health, smoking behaviours, and
Empowering Children and Adolescents on Prevention of
Coronary Artery Disease
Ramya K R1, Kiran Batra R2
1Asst.Professor, Jubilee Mission College of Nursing, Thrissur, Kerala, 2Principal, Silver Oaks College of Nnursing,
Abhipur, Punjab
ABSTRACT
Emerging epidemiological evidence is compelling for the importance of childhood and adolescence
in the development of risk for coronary artery disease (CAD).It is important in India as it has a huge
adolescents and children population along with the existing economic, social, and health inequalities
among the general population. The literature indicates that a lengthy time interval occurs between
exposure to high risk factors and the development of disease, and that many such high risk exposures
begin in young adolescence. well-documented trends on tobacco, physical activity, hypertension,
diet, obesity present an immediate obstacle to achieving future reductions in CAD disease burden
These findings underline the value of targeting children and adolescents for primary prevention
efforts in health care and health education for the attainment of overall healthy population in our
country.
Keywords: Coronary Artery Disease, Risk Factor, Adolescents, Primary Prevention
DOI Number: 10.5958/j.0974-9357.5.2.054
problems related to mental and physical stress. In
Indian culture, health promotion and disease
prevention are not relevant until the process interferes
with life processes. Many parents do not perceive their
child as obese or see it as a problem. Empowerment is
frequently associated with changing health behaviors.
Significance
1. Risk behaviours, such as smoking, alcoholism,
consuming a high fat diet, and drug use, are often
adopted in young adolescence and extend into
adulthood
2. Smoking, consuming high fat diets, sedentary
lifestyle, can result in disease outcomes such as
obesity, hypertension, type II diabetes leading to
CAD which is the main cause of morbidity and
mortality.
3. It is easier to inculcate healthy behaviours at a
young age rather than to modify behaviours at
later ages
4. Rapid economic growth, globalization, and
aggressive marketing are all leading to a dramatic
shift in the diet and living behaviours of
individuals, families and communities.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 49
5. Changes in activity patterns as a consequence of
the rise of motorized transport, sedentary leisure
time activities such as television watching will lead
to physical inactivity.
6. High prevalence of non-conventional risk factors
like hyperinsulinaemia, insulin resistance,
lipoprotein A etc which probably explain the
malignant, precocious nature of CAD that typically
affects Indians.
7. Stressful or traumatic circumstances in childhood
also appear to increase the risk of CVD later in life.
There was a dose–response relationship between
the number of childhood exposures to adverse
experiences and the number of risk factors for
chronic disease later in life.1
Trends in Major Determinants of Cad
Tobacco Use
In India an estimated 5500 adolescents start using
tobacco every day, joining the 4 million young people
under the age of 15 years who already regularly use
tobacco. Gllobally, about 10 %of adolescents currently
use tobacco in any form. Nearly 25 % try their first
cigarette before the age of 10 years &19 % are
susceptible to initiating smoking during the next year.
National Youth Risk Behavior Survey revealed that 31
%of students had smoked, and passive tobacco smoke
exposure levels ranged from 56–84%.
OBESITY
Among school-going children and adolescents in
India aged 10–18 years, the prevalence of overweight
was 1.7 % in boys and 0.8 % in girls.2Factors attributed
this trend are increasing affluence among populations
and their increasing urbanization, nutrition and
physical activity transitions.
Physical Activity
Only 54.2% of high school students nationwide
were enrolled in physical education classes on one or
more days of an average school week, and only 33%
were enrolled in daily physical education. Only 35.8%
of high school students reported recommended levels
of moderate-to-vigorous physical activity of at least
60 minutes per day at least five days per week3.61.5%
of children between the ages of 9 and 13 did not
participate in any organized physical activity during
their nonschool hours, and 22.6% did not engage in
any free-time physical activity4.
Sedentary behaviors such as television viewing are
considered risk factors for obesity in children and
adolescents. Current national estimates indicate that
37.2% of students watched television at least three
hours per day on an average school day.
Hypertension
Systolic and diastolic blood pressures have
increased substantially for all children and youths.5
These higher blood pressures are partially due to the
increased incidence of overweight. The prevalence of
hypertension rises progressively with increasing body
mass index and approximately 30% of overweight
youths have hypertension.6
Cholesterol
Approximately 10% of adolescents between the
ages of 12 and 19 have total cholesterol levels exceeding
200 mg/dl7.In a Study, 75% of children aged 5 to 18
with total cholesterol levels above the 90th percentile
at baseline went on to have elevated cholesterol levels
(200 mg/dl or higher) at the ages of 20 to 258. Roughly
70% of children with elevated total cholesterol in
childhood continued to have elevated levels in young
adulthood9.
Diabetes
The prevalence of type 2 diabetes in adolescents is
4.1 in 1,000 individuals; more than double the
prevalence of type 1 diabetes.This is a particular
concern with regard to CAD risk, as the diabetes in
adults as a CAD risk equivalent10.
Marketing That Influence Tobacco Use and
Nutrition
Adolescents, going through a physically and
emotionally tiring period, might be easily swayed by
advertisements focusing on issues related to identity,
peer culture, emotions, and sexuality11.Children are
targeted due to their indirect influence over household
food purchases, their direct spending on food and
beverages, and their potential as future adult
consumers. Studies have found that the amount of time
spent watching TV predicts the number of times
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50 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
children ask for products at the grocery store, with a
majority of the products being the ones advertised on
TV. Several studies have demonstrated that cigarette
retail marketing increases the likelihood of youth
smoking uptake.
Principles and Strategies for Empowerment
1. Simplify and tailor the prescription for behavioral
change to the individual and family
characteristics, needs, and resources.
2. Use of culturally specific methods and materials
3. Ask about the behavior at every contact.
4. Recognition of Rights of adolescents to health
information and services.
5. Interactive teaching- learning process
6. Involve the parents/family as partners in the
behavioral change process.
7. Provide information in multiple developmentally
and culturally appropriate venues.
8. Specific strategies like Assess, monitor, and
document patterns of behavior change at every
healthcare visit.
9. Provide developmentally appropriate behavior-
specific information tailored to the adolescents’
and family’s cultural background, needs, and
resources.
10. Identify realistic goals for behaviors with the
adolescent and family.
11. Include activities to assist families to monitor
behaviors targeted for change.
12. Mobilize family and social support.
13. Provide self-efficacy enhancement and an
atmosphere of clinical empathy.
14. Develop a health-promoting reward system for
positive behavior change.
APPROACHES AND METHODS
School-Based Programs
School environment presents a particularly ideal
location for health promotion interventions, because
on school days, these children spend nearly half of their
waking hours in school.
A school-based cluster randomized tobacco
cessation trial in India of 30 public and private
elementary schools showed that an intervention that
included information provision, interactive classroom
activities, and roundtable discussions reduced
experimentation, intentions to use tobacco, and offers
of tobacco among the intervention schools12. The Project
“Mobilizing Youth for Tobacco Related Initiatives in
India found that after a rigorous 2-year tobacco use
prevention intervention, students in the intervention
schools were significantly less likely than controls to
exhibit an increase in cigarette or bidi smoking and
intend to smoke or chew tobacco in the future13.
These interventions have included components
such as school self-assessment; nutrition education;
nutrition policy for school meals; social marketing;
student involvement and empowerment; curricular
enhancements that focus on decreased television
viewing, reduced consumption of soft drinks and foods
high in total and saturated fat, increased fruit and
vegetable intake, and increased moderate and vigorous
physical activity; parent outreach; and home-based
activities. Thus, there are models of programs that have
been effective at changing behavioral risk factors and,
in some cases, preventing or reducing overweight and
obesity.
There is convincing evidence that physical
education (PE)-based strategies are effective for
increasing and maintaining physical activity in school
children14.In addition to PE improving playgrounds in
schools, providing play equipment to schools, or
incorporating activity breaks into the elementary
school classroom can have positive effects on
improving physical activity levels among students, but
few studies have rigorously evaluated these
approaches.
Tobacco Control
The government of India adopted a comprehensive
legislation for controlling tobacco use known as the
Cigarette and Other Tobacco Products Act in 2003. This
act, along with other provisions, banned the sale of all
tobacco products to youth younger than 18 years and
within 100 yards of educational institutions. The World
Health Organization’s Tobacco Free Initiative was
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 51
launched for tobacco control through research, policy,
surveillance, capacity building, and global
communications. The Framework Convention for
Tobacco Control is a major public health treaty that
was adopted by the World Health Assembly in 2003.
Among its provisions is an explicit mention of banning
the sale of tobacco products to legal minors, and
although it has provisions that are applicable for all
ages, its principles are particularly targeted to youth,
the most vulnerable group to initiate tobacco use.
The government of India launched the National
Tobacco Control Program to build capacity of the states
to effectively implement the tobacco control laws and
also to bring about greater awareness about the ill
effects of tobacco consumption. Antitobacco
advertising can be effective in deterring children and
preadolescents from taking up the habit in the first
place. Antitobacco marketing, combined with other
strategies to restrict tobacco use, can be an effective
strategy in reducing the impact of tobacco promotion.
Restricting Food Marketing
Sustained and aggressive marketing restrictions,
curtailing advertising of unhealthful food products
such products aimed pointedly at children and
adolescents in television, and the banning of in-school
marketing, accompanied by the promotion of healthful
foods such as fruits and vegetables, are some examples
of steps that can be and have been taken to this end.
Mass Media
Adolescents are particularly susceptible to
experimenting with alcohol and tobacco use, targeting
campaigns focused on these risk factors of younger
age groups is a rational strategy to increase awareness
of, improve attitudes toward, and change intentions
to increase healthful eating and physical activity in the
lives of the target audience. The campaigns can adopt
multiple elements to communicate its message,
including television, radio, and print commercials;
shopping center and shopping cart advertisements;
media partnership activities; a campaign website; an
information line; and distribution of other reading
material.
Adolescent Driven Advocacy
Over the past decade, a number of youth-driven
initiatives have targeted reduction in CVD risk factors
and demonstrated the potential power in the energy
and enthusiasm of young people.
Global Youth Meet (2006) on Health, engaged in
awareness, advocacy, and research related to health
promotion. The group aims to connect young people
from around the world, forming a global alliance of
national, regional, and global partnerships that can
collectively promote common causes. These include
advocating for tobacco control, healthful diets, regular
physical activity, environmental protection, gender
equality, women’s health, and reduction of alcohol and
drug abuse.
Framework For Nurses
Individual refers to biological, genetic,
demographic, and learning history influences within
any person. The individual level is nested within the
family environment, which includes influences such
as role modeling, feeding styles, provision and
availability of foods, and other aspects of the home
environment. The third level, the microenvironmental
level, refers to the local environment or community in
which the family and home are immediately nested.
This includes local schools, playgrounds, walking
areas, and shopping markets that enable or impede
healthful eating behaviors. Level 4 is the
macroenvironmental level. This level refers to broader
economic policies, laws, and industry policies that
operate at the regional, state, national, and
international levels. The influence of level 4 factors can
be pervasive and project down to individual choices.
The model recognizes the importance of both the
nesting of levels within one another and reciprocal
influences among levels.
Fig. 1. Multilevel framework for identifying facilitators or barriers
among adolescents
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52 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Role of Nurse: Elements for Action
Collaboration
1. Successful empowerment requires ready access
and collaboration among paediatic, clinical
psychology, sociology, and public health services
to ensure that adolescents achieve their social and
educational potential without increasing the long-
term risks.
2. Disseminate information to parents and families
during all contact points for help and advices.
3. Collaboration between paediatic and adult cardiac
care at the stage of transition to adult care.
Research and development
1. Identify major health conditions in terms of
contribution to India’s disease burden
2. Estimate the incidence and prevalence levels of the
diseases at present and in future
3. List the causal factors underlying the spread of the
diseases
4. Suggest, based on evidence, the most cost-effective
preventive and curative strategies, for reducing the
disease burden, particularly among the poor
5. Indicate what interventions should be provided
where and by whom
6. Collaboration between the multiple agencies
sponsoring and funding research into
empowerment of CAD could prevent duplication.
7. Continued development of measures of personal
well-being, treatment satisfaction and other
subjective aspects of risk reduction; adolescents’
and cares’ psychological needs; tools for measuring
knowledge, skills and beliefs; strategies for
motivation and empowerment
Education and training
1. Continuing education and motivation of those
involved is necessary if high standards are to be
maintained.
2. The high prevalence of risk factors of CAD in the
population means that all those working in
hospital, primary and community care will
encounter adolescents with coronary artery risk
factors.
CONCLUSION
Accumulation of cardiovascular risk begins early
in life, and evidence on rising rates of childhood
obesity and smoking as well as emerging evidence on
the effects of early nutrition on later cardiovascular
health support the value of empowering children &
adolescents early and continuing prevention efforts
throughout the life course by nurses.
Conflict of Interest: Nil
Does not exit. There is no conflicts exist in the above
article since the authors have not received any direct
or indirect assistance in the form of analyzing,
preparing, writing the manuscript from any other
individuals.
Source of Funding
This is not funded by any commercial firm, private
foundation, or government.
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Williams, DP Chapman, RF Anda. Insights into
causal pathways for ischemic heart disease:
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2004;110(13):1761–6.
2. WHO Global InfoBase. Overweight & obesity
(BMI) country data. Geneva: World Health
Organization; 2008 www.euro.who.int/__data/
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3. KD Eaton, L Kann, S Kinchen. Youth risk behavior
surveillance:US,2005. MMWR Surveill Summ.
2006;55(5):1-108.
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Physical activity levels among children aged 9–
13 years: United States, 2002. MMWR Morb
Mortal Wkly Rep. 2003;52(33):785–8
5. Muntner P, He J, Cutler JA, et al. Trends in blood
pressure among children and adolescents. JAMA.
2004;291(17):2107–13.
6. Sorof J, Daniels S. Obesity hypertension in
children: a problem of epidemic proportions.
Hypertension. 2004;40(4):441–7
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7. Rosamond W, Flegel K, Friday G, et al. Heart
disease and stroke statistics—2007 update. Circu
2007;155:69 -71
8. RM Lauer, WR Clarke. Use of cholesterol
measurements in childhood for the prediction of
adult hypercholesterolemia: the Muscatine Study.
JAMA. 1990;264(23):3034–8.
9. Webber LS, Srinivasan SR, Wattingney WA.
Tracking of serum lipids and lipoproteins from
childhood to adulthood: The Bogalusa Heart
Study. Am J Epidemiol 1991;133(9):884–99
10. SR Daniels, DK Arnett, RH Eckel. Overweight in
children and adolescents: pathophysiology,
consequences, prevention, and treatment. Circu
2005;111(15):1999-2012
11. M Story, S French. Food advertising and
marketing directed at children and adolescents
in the U.S. IJBNPA 2004;1(1):3.
12. KS Reddy, M Arora, CL Perry, B Nair, A Kohli,
LA Lytle, M Stigler, D Prabhakaran. Tobacco and
alcohol use outcomes of a school-based
intervention in New Delhi. Am J of Hea Behavior.
2002;26(3):173–81
13. CL Perry, MH Stigler, M Arora, KS Reddy.
Preventing tobacco use among young people in
India: Project MYTRI. Am J of Pub Hea
2009;99(5):899–06
14. PJ Naylor, HA McKay. Prevention in the first
place: Schools a setting for action on physical
inactivity. Brit J of Sports Med. 2009;43(1):10–3
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54 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
Pakistan is a developing country that is struggling
with a rising child mortality and morbidity. In 2010,
under five child mortality rate in Pakistan was reported
as 87 per 1000 live births1. In fact, achievement of
Millennium Development Goal # 4 to reduce child
mortality by 2015 seems unlikely as Pakistani holds
limited health care professionals in the field of Child
Health2,3. The rising morbidity and mortality rates
among young children indicates that Pakistan needs
trained health care professionals especially trained
nurses to promote child health in society. Hence, from
an educationist perspective, a pressing need was
viewed to appraise whether the existing pediatric
nursing curriculum is consistent with the health needs
of the Pakistani pediatric population. Considering the
regional and international trends, this paper appraises
the strengths and limitations of the operationalized
Pediatric Health Nursing curriculum in Pakistan, and
explores the way forward to strengthen knowledge,
skills and attitudes of future Pediatric nurses in
Pakistan.
Pediatric Baccalaureate Nursing Curriculum in Pakistan:
Strengths, Limitations and Recommendations
Shela Akbar Ali Hirani1, Jacqueline Maria Dias1
1Assistant Professor, Aga Khan University School of Nursing and Midwifery, Stadium Road, Karachi, Pakistan
ABSTRACT
Pakistan is a developing country that has been struggling with rising child mortality and morbidity
rates since many decades which indicates that this country needs trained Pediatric nurses to promote
child health. From an educationist perspective, a pressing need was viewed to appraise whether the
existing Pediatric Health Nursing curriculum is coherent with the health needs of the Pakistani
pediatric population. Therefore, considering the regional and international trends, the existing
Pediatric Health Nursing curriculum of the Higher Education Commission (HEC)/Pakistan Nursing
Council (PNC) was reviewed and analyzed. The review of the Pediatric Health Nursing curriculum
revealed that all of its components are in alignment with the HEC/PNC objectives, and it gives
coverage to the four main , including "integration of knowledge derived from humanities and science",
"effective communication", "health promotion", and "nursing process". The analysis also showed
that the course can be further improved by involving students in lab based simulation exercises,
adding practice sessions for communication, utilizing community sites for students' clinical practice,
and offering sessions on Pediatric medications and drug dosage calculation.
Keywords: Baccalaureate, Curriculum, Nursing, Pakistan, Pediatric Health
DOI Number: 10.5958/j.0974-9357.5.2.054
Background of Pediatric Baccalaureate Nursing
Curriculum in Pakistan
In Pakistan, the Bachelor’s of Science in Nursing
(BScN) is a four-year professional education program
which intends to prepare a safe clinical nurse who will
be able to provide comprehensive care to the Pakistani
population at primary, secondary and tertiary care
settings4. In 2006, the Pakistan Nursing Council (PNC)
in collaboration with Higher Education Commission
(HEC) established for the first time a new national
curriculum for the four-year Baccalaureate nursing
programme thereby ensuring consistency in the
delivery of the BScN curriculum across all the BScN
accredited schools of nursing in Pakistan as well as
ensuring that the curriculum respond to the rising
burden of diseases in Pakistan5,6. Within HEC
curriculum, the Pediatric health nursing curriculum
was envisioned considering the health needs of
pediatric population in Pakistan. The HEC proposed
Pediatric Health Nursing course is of 6 credits and has
both a theoretical and practical component.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 55
Operationalized Pediatric Nursing Curriculum in
Pakistan: Strengths, Limitations and Recommendations
The analyzed strengths, limitations and
recommendations of the operationalized Pediatric
Health Nursing curriculum are discussed below:
Sequence and Alignment: Within HEC/PNC
curriculum, Pediatric Health Nursing curriculum is
offered in the third year of BScN progarmme. The
sequencing of Pediatric Health Nursing curriculum in
the BScN programme reveals an attempt to meet the
HEC/PNC objectives that intends to enable students
to derive knowledge from humanities and sciences.
The sequence of Pediatric curriculum further assures
that before proceeding to specialty based Pediatric
Health Nursing concepts, students gain familiarity
with the natural sciences subjects like “Anatomy and
Physiology” and “Microbiology”, as well as they
develop know how of basic concepts in nursing
through courses like “Fundamentals of Nursing”,
“Nursing Ethics”, “Adult Health Nursing” and
“Pharmacology” that are offered during first and
second year of the BScN programme. Society of
Pediatric Nursing (SPN) recommendations indicates,
“Required curricula in all professional nursing
education programs must have readily discernable
pediatric nursing content built upon theoretical and
empirical knowledge of…anatomical, functional, and
pathophysiologic differences between adults and
children” (p. 88)7. In view of literature, placement of
the Pediatric course after Adult Health Nursing course
seems justified because this sequence enables students
to develop their comfort level with the care of Adult
patients before caring for pediatric patients. Also, with
this sequence students could be facilitated to
appreciate anatomical, physiological, pathological, and
care giving differences between adult and pediatric
clients which is an essential consideration. Moreover,
the placement of Pediatric nursing curriculum in BScN
programme seems aligned with the principle of
moving from simple to complex and one course
building on the other5. As Pediatric Health Nursing
curriculum is offered parallel with other courses,
including “Reproductive Health”, “Tropical and
Communicable Disease”, “Culture Health and
Society”, “Teaching and learning”, “Developmental
Psychology”, and “English”, this provides opportunity
to students to integrate the learnt concepts in Pediatric
Health Nursing into theory and clinical component of
parallel courses and vice versa.
Course and Clinical Objective: Behavioral
objectives describe what the learner will be able to do
at the end of a learning experience8. Based on this
premise, the existing Pediatric health nursing
curriculum has five course objectives and seven clinical
objectives surrounding the theme of health promotion,
communication skills, curative aspect, and
rehabilitation aspect. Table 1 depicts the course and
clinical objectives of the course. Keeping in mind the
present national needs, objectives seem to provide
accomplishment of the learning experiences of
Baccalaureate nursing students.
Course Content: Analysis of course content reveals
its consistency with the HEC/PNC objectives, course
objectives and clinical objectives. Consistent with the
literature the course gives adequate coverage to
recommended concepts including: growth and
development, health promotion, safety and injury
prevention7,9,10, family-centered approach11, and
disabilities12. Literature highlights the importance of
considering context relevancy in curriculum13. It was
noted Pediatric health nursing course gives extensive
coverage to the content on the theme of child health
promotion, curative aspects, and nursing process. The
emphasis placed on these three aspects seems justified
because the included content under these themes are
essential to enable future nurses to meet the needs of
Pakistani pediatric population at diverse community
and hospital setups.
A limitation that was noted was that Pediatric
pharmacological concepts are superficially discussed
throughout the course. Also, other than in skills lab,
no separate session is offered on Pediatric drug dosage
calculations. Pediatric medications are more
sophisticated than adults; therefore, students need
prior hand preparation to practice safely at bedside.
Literature shares, “…since weight-based dosing is
needed for virtually all drugs in pediatrics, ordering
medications typically involves more calculations than
for adults” (p. 2115)14. Also, several other study
findings support that uncommon and complex
preparation and administration of Pediatric drug
increases the chances of medication errors15,16. As the
aim of the BScN programme is to prepare safe nurse
who could safely work at bedside, therefore, it is
recommended to devote considerable time in theory
and skills lab teaching to prepare students for Pediatric
medications.
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56 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
As one of the core competencies outlined in the
HEC/PNC curriculum is communication, it was
analyzed the existing Pediatric nursing curriculum
gives only two hours coverage to the content in theory
class only. It was analyzed that the skills lab teaching
does not give any practice session to prepare students
to establish effective communication skills with
pediatric patients of diverse age groups. From practical
aspect it was analyzed that communicating with
hospitalized children is one of the biggest challenge
because children have very short attention span and
sick children show more irritability if health care
professionals try to communicate with them.
Therefore, it was viewed that current course content
on “communication” is insufficient to enable nursing
students to demonstrate effective communication with
children. Literature emphasizes that Pediatric nursing
education must facilitate nursing students to establish
effective communication with children by offering
them practical experience with well children17.
Clinical Placements: Clinical objectives and HEC
core competencies suggest utilization of both hospital
and community based Pediatric setups for the
achievement of the clinical objectives. However, it was
identified through informal conversations with other
Pediatric nurse-educators in the country that only
hospitals are utilized for Pediatric clinical experience.
Literature suggests that overemphasis on hospital
based teaching and neglect of community based setups
like daycare centers, outpatient clinics, refugee/
internally displaced people’s camps etc. as clinical
placement is one of the drawback of undergraduate
child health nursing curriculum13. Literature further
suggests, “Helping students to become aware of the
communities around them will help them to
appreciate the less-than-ideal living circumstances
from which some of our patients come” (p. 747)18.
Several other literature also highlight that Pediatric
Health Nursing curriculum must address health needs
of sick, disabled and well children to enable students
to learn and apply principles of growth and
development, and community based child health
promotion9,19,20. This indicates that along with hospital
setup alternative clinical placements should be sought
to provide students with sustentative clinical
experience.
Teaching/Learning Strategies: Several teaching
learning strategies including: discussion,
demonstration, guest lecture, field trip, role play,
sharing of clinical experience, group presentation,
literature review, group work, and tutorials are
utilized. These strategies are in alignment with the
course objectives. Literature further indicates that use
of teaching strategies like clinical experience, role plays,
and sharing of clinical experience provide ways to
instill cultural competence in curriculum21. Moreover,
it was analyzed that the field visit is appropriately
chosen as teaching learning strategies because it
enables nursing students to integrate theory into
practice. Literature underscores that field visits
enhance community based learning opportunities for
students, and help students to gain insight about
community services available for children and their
families22. Few of the strategies that are not currently
utilized but are valuable in enhancing students’
learning at classroom and clinical are recommended
these include play therapy workshop and case studies
that would enhance creativity, problem solving and
critical thinking among students23. Besides that, the
pediatric nursing curriculum could have included self-
study modules for giving coverage to the content that
has already been covered in other courses. Moreover,
as presently skills lab based teaching in majority of the
schools of nursing of Pakistan mainly focuses on
demonstration and return demonstration; therefore,
utilization of lab based simulation exercises is
recommended as teaching strategy during lab based
teachings to enhance students’ learning23, promote their
critical thinking7,9,24, and enable them to recognize
clinical based errors25,26.
Course Assessment Criteria: The assessment
criteria include two paper pencil tests, one group
presentation, and one clinical case based assignment.
All these assessment criteria that are meant to assess
course content taught during theory, skills and clinical,
were found in alignment with the identified BScN
programme objectives, course and clinical objectives.
In view of the total credits of Pediatric course, the
assigned assessment criteria seems appropriate and is
sufficient to assess the content that is being covered in
the course.
CONCLUSION
Review ofoperationalized Pediatric Health
Nursing curriculum of an undergraduate programme
in Pakistan revealed that sub-components in the course
including course description, course objectives,
content, and assessment criteria are in alignment with
the terminal objectives of the BScN programme. The
entire course gives broader coverage to the four main
themes including “integration of knowledge derived
from humanities and science”, “effective
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 57
communication”, “health promotion” and “nursing
process”. Utilization of integrated approach in overall
curriculum was viewed as the greatest strength of the
undergraduate Pediatric health nursing curriculum.
It was analyzed that Pediatric curriculum could be
improved by involving students in lab based
simulation exercises, adding practice sessions for
communication, utilizing community sites for clinical
practice, and offering sessions on Pediatric
medications and drug dosage calculation.
Table 1. Course and Clinical Objectives of the Pediatric Baccalaureate Curriculum in Pakistan
Course Objectives:
At the end of the course, learners will be able to:
1. Develop awareness on common health issues of the children in Pakistan
2. Discuss principles of growth and development and its deviation in all aspects of nursing care
3. Discuss the impact of hospitalization on the child and family
4. Discuss the role of a family in the care of sick children in Pakistani Context
5. Integrate pharmacological knowledge into care of sick children
Clinical Objectives
At the end of the course, students will be able to:
1. Apply principles of growth and development in all aspects of nursing care
2. Identify the impact of hospitalization on the child and family and utilize the strategies to decrease the stress of hospitalization
3. Integrate therapeutic play to minimize stress of a child during hospitalization
4. Utilize Gordon’s Functional Health Pattern effectively when providing care to a child and family with acute or chronic illness
5. Utilize communication skills that facilitate therapeutic relationship with children, their families and health care team members
6. Identify needs and give health education to child / family at their level of understanding to promote health and prevent disease
7. Integrate pharmacological knowledge in the care of sick children
ACKNOWLEDGEMENT
We are grateful to the Aga Khan University School
of Nursing and Midwifery for allowing us to review
the existing Pediatric Baccalaureate Nursing
Curriculum.
Source of Funding: None
Ethical Clearance: Not required
Conflict of Interest Disclosure: The authors of this
manuscript declare that the manuscript is an original
work and does not hold any potential or actual conflict
of interest.
REFERENCES
1 The World Bank. Mortality rate, under-5 (per
1,000) 2011; http://data.worldbank.org/
indicator/SH.DYN.MORT.
2 Hirani SA, Kenner C. Effects of Humanitarian
Emergencies on Newborn and Infant’s Health in
Pakistan. Newborn and Infant Nursing Reviews
2011; 11 (2): 58-60.
3 Kenner C, Hirani SA. Safety Issues in Neonatal
Intensive Care Units in Pakistan. Newborn and
Infant Nursing Reviews 2008; 8 (2): 69-71.
4 Higher Education Commission. Curriculum of
Nursing Education, BScN 2006; http://
www.hec.gov.pk/InsideHEC/Divisions/
AECA/CurriculumRevision/Documents/
Nursing%20Education%202006.pdf.
5 Dias JM, Ajani K, Mithani Y. Conceptualization
and operationalization of a baccalaureate nursing
curriculum in Pakistan: Challenges; hurdles and
lessons learnt. Procedia-Social and Behavioral
Sciences 2010; 2 (2): 2335-2337.
6 Pakistan Nursing Council. List of PNC
recognized institutions for Diploma program,
Degree program and Post Basic Diploma
program 2011; http://www.pnc.org.pk/
Recognized_Institutes.htm.
7 Lynch ME. Society of Pediatric nurses education
committee: Policy statement-Child Health
Content Must Remain in the Undergraduate
Curriculum. Journal of Pediatric Nursing 2007;
22 (1): 87-89.
8 Bastable SB. Behavioral objectives. In Bastable SB
(Ed.), Nurse as Educator (2nd ed.). Sudbury, MA:
Jones and Bartlett 2003.
9 Linder LA, Pulsipher N. Implementation of
simulated learning experiences for Baccalaureate
Pediatric nursing students. Clinical Simulation
in Nursing 2008; 4: e41-e47.
10 Pridham KF, Broome M, Woodring B. Education
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for the nursing of children and their families:
Standards and guidelines for Pre-licensure and
early professional education. Journal of Pediatric
Nursing 1996; 11 (5): 273-280.
11 Curry DM. SPN News: Position statement on
Family-centered care content in the nursing
education curriculum. Society of Pediatric Nurses
2008.
12 Seccombe JA. Attitudes towards disability in an
undergraduate nursing curriculum: A literature
review. Nurse Education Today 2006; 27: 459-465.
13 Rawat MS, Kamal S. Education for Primary
Pediatric care. Indian Journal of Pediatrics 1997;
64: 369-372.
14 Kaushal R, Bates DW, Landrigan C, McKeena KJ,
Clapp MD, Federico, et al., Medication errors and
adverse drug events in Pediatric Inpatients.
Journal of the American Medical Association
2001; 285 (16): 2114-2120.
15 Fortescue EB, Kaushal R, Landrigan CP, McKenna
JK, Clapp MD, Federico F, et al. Prioritizing
strategies for preventing medication errors and
adverse drug events in Pediatric in patients.
Pediatrics 2003; 111 (4): 722-729.
16 Taxis K, Barber N. Causes of intravenous
medication errors: an ethnographic study. Quality
& Safety in Health Care 2003; 12: 343-348.
17 Thyer S. An Australian Pediatric nursing
education experience. Pediatric Nursing 1992; 18
(1): 80-85.
18 Blair M. Training and Education as a means of
increasing equity in Child Health Teaching of
Undergraduates. Pediatrics 2003; 112 (3): 747-748.
19 Lieber MT. Community-Based Pediatric
experiences: Education for the future. Journal of
Pediatric Nursing 1997; 12 (2): 85-88.
20 Task Force on the Future of Pediatric Education.
The Future of Pediatric Education II. Organizing
Pediatric education to meet the needs of infants,
children, adolescents, and young adults in the 21st
century. Pediatrics 2000; 105: 161-212.
21 Cuellar NG, Brennan AM, Vito K, Siantz ML.
Cultural competence in the Undergraduate
Nursing curriculum. Journal of Professional
Nursing 2008; 24 (3): 143-149.
22 Cummins A, McCloskey S, O’Shea M, O’Sullivan
B, Whooley K, Savage E. Field visit placements:
An integrated and community approach to
learning in Children’s nursing. Nursing
Education in Practice 2010; 10 (2): 108-112.
23 Billings DM, Halstead JA. Teaching in Nursing:
A guide for faculty. Philadelphia: Elsevier Inc,
2005.
24 Baldwin KB. Friday night in the Pediatric
emergency department: A simulated exercise to
promote clinical reasoning in the classroom.
Nurse Educator 2007; 32 (1): 24-29.
25 Lambton J. Integrating simulation into a Pediatric
nursing curriculum: A 25% solution? Simulation
in Healthcare 2008; 3 (1): 53-57.
26 Lambton J, O’Neill SP, Dudum T. Simulation as a
strategy to teach clinical pediatrics within a
pediatric curriculum. Clinical Simulation in
Nursing 2008; 4 (3): 79-87.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 59
INTRODUCTION
AIDS epidemic has become one of the greatest
threats to human health and development. Statistics
for the end of 2010 indicate that around 34 million
people are living with HIV. Each year around 2.7
million more people become infected with HIV and
1.8 million die of AIDS.
HIV or AIDS is a major threat for humanity in the
world especially in developing countries.The global
HIV/AIDS situation for adolescents is deadly serious,
and the need for a stronger, focused response is urgent.
Young people are particularly vulnerable to HIV
infection because of risky sexual behaviour and
Knowledge, Attitude And Practices Of Adolescents
Related To HIV/AIDS in Selected Schools of Delhi
Smriti Arora1, Jyoti Sarin2
1Assistant Professor, Faculty of Nursing, Hamdard University, Rufaida College of Nursing, Hamdard University,
Hamdard Nagar, New Delhi, 2Principal, MM College of Nursing, Mullana, Ambala, Haryana
ABSTRACT
Introduction: In India, the largest and most populated countries in the world, with over one billion
inhabitants, it is estimated that around 2.5 million Indians are living with HIV. Adolescents comprise
about 22% of the population of India (1). This large group of population contains high potentiality
for social and economic development of the country in future. According to NFHS 2005 and 2006, the
prevalence of HIV infection among 15-19 years age group is 0.04%. There is paucity of data in Delhi
regarding awareness on HIV/ AIDS among adolescents, which is required to plan an education
program for them.
Objective: This study was conducted among 175 school going adolescents studying in class 11 and
12 to assess their knowledge, attitude and practices related to HIV/AIDS and to assess the relationship
of selected variables with their KAP scores.
Method: The study was conducted in two conveniently selected urban government schools in East
Delhi. The data was collected from 175 students using a valid and reliable structured KAP
Questionnaire.
Result: It was found that more than 50% of adolescents had inadequate knowledge, stigmatizing
attitude and followed unsafe practices towards HIV/AIDS.
Conclusion: There is a need to educate young adults and equip them with the appropriate information
and skills to enable them to protect themselves from HIV/AIDS. HIV/AIDS education with greater
participation of school is recommended.
Keywords: Knowledge, Attitude, Practices, Adolescents, HIV/AIDS
DOI Number: 10.5958/j.0974-9357.5.2.054
substance use, because they lack access to accurate and
personalized HIV information and prevention
services, and for a host of other social and economic
reasons. An estimated 11.8 million young people aged
15-24 are living with HIV/AIDS (2). Moreover, about
half of the 6,000 new infections each day occur among
young people. Adolescents constitute a considerable
proportion of India’s population (22%). They are a rich
human resource and an important part of the
development process. Spread of HIV among young
people in India is a growing cause for concern. School
children of today are exposed to the risk of being
victims of HIV/AIDS which was quite unknown to
their predecessors a few decades ago. The epidemic
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60 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
of HIV/AIDS is now progressing at a rapid pace
among young people. Young people form a significant
segment of those attending sexually transmitted
infection (STI) clinics and those infected by HIV.Decline
in the traditional control over youth by family and
schools, increase in age at marriage, changes in social
values and exposure to media and aspirations are some
of the features of the modern society which have
heightened the permissiveness in sexual
experimentation and led to incidence of HIV/AIDS.
OBJECTIVES
The objective of the study was to assess the
knowledge, attitude and practices related to HIV/
AIDS of adolescents and to assess the relationship of
selected variables with their KAP scores.
MATERIAL AND METHOD
This descriptive cross sectional study was
conducted among 175 adolescents studying in class
11 and 12, in two conveniently selected urban govt.
schools in East Delhi. Both the schools are affiliated
with CBSE having classes from first to twelfth. Mostly
the students from middle class family seek admission
to these schools. The per annum income of parents of
the students studying in these schools is around two
lakhs. The medium of instruction is English in both
the schools. The permission was sought from the
principals of the schools, parents of adolescents and
verbal assent was taken from students. Following null
hypotheses were framed for the study:
HO1: There will be no significant association
between knowledge, attitude and practice scores of
adolescents related to HIV/AIDS and the selected
variables i.e. gender, religion, parents’ education and
stream of education as assessed by structured KAP
questionnaire at 0.05 level of significance
HO2: There will be no significant correlation
between
1. Knowledge and Attitude scores
2. Attitude and Practice scores and
3. Knowledge and Practice scores as assessed by
structured questionnaire at 0.05 level of
significance.
The data was collected from students using a
structured knowledge questionnaire, attitude scale and
a practice checklist. The tools were validated by nine
experts from nursing and medical field. Knowledge
questionnaire consisted of 52 objective type items
eliciting information about the mode of transmission
and prevention of HIV /AIDS. It contained 29 MCQs
and 23 true false items. Each MCQ contained a
statement followed by four options. There was only
one correct response. Every correct response was given
one score. The 23 true false items contained statements
having possible choices of “True, False, and Don’t
Know”. The “Don’t Know” as an option was included
to reduce the probability of guessing, as guessing
causes some variation in performance from item to
item, which tends to lower the test reliability. The items
were prepared under the following heads: magnitude
of HIV/AIDS, mode of transmission, management and
prevention. The maximum score for knowledge was
52. The reliability was assessed using KR 20 and it was
found to be .85. The test retest reliability was done
within a gap of 10 days on 20 students to assess the
stability of the tool. The value of pearson’s r was .85.
Difficulty level and discrimination index were also
calculated for the 52 items.
Attitude scale consisted of 33 positive and negative
statements measuring attitude towards people living
with HIV/AIDS and safer sex. There were 16 positively
worded and 17 negatively worded statements.
Cronbach alpha was used to assess the reliability of
five point structured rating scale containing 33 items.
Its value was .79. Maximum score in the attitude area
was (33x5) 165 and the minimum score was (33x1) 33.
Practice checklist was used to determine the
expressed practices of adolescents towards practice of
safe sex. It contained 24 items eliciting information
about safer sex, skin piercing, condom use, blood
donation and common household practices. There
were twelve statements each corresponding to safe and
unsafe practices. The answer of each statement was
either ‘Yes’ or ‘No’. Each correct response was awarded
‘one’ score and incorrect response “zero”. The
maximum score in structured practice questionnaire
was 24 and the minimum score zero. The reliability
for structured practice questionnaire was calculated
using Kuder Richardson 20 (KR 20) formula on 20
subjects. The value of KR 20 for the practice
questionnaire containing 24 items was .76.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 61
The KAP of adolescents was categorized as follows
Variable Category % Score
Knowledge Adequate knowledge Above 75% 39-52
Moderate knowledge 51-75% 26-38
Inadequate knowledge Upto 50% 0-25
Attitude Favorable attitude 67.4 - 100 112-165
Moderately favorable attitude 33.4 - 67.3 56- 111
Unfavorable attitude Upto 33.3 33-55
Practice Safe practice 76-100 19-24
Unsafe practices Upto 75 0-18
The questionnaire was distributed to the students
studying in class 11 and 12 after formal administrative
approval. It took around 45-60 minutes to complete
the entire questionnaire.
The data was tabulated in Microsoft excel and
analysed using SPSS 16 with appropriate descriptive
and inferential statistics. Level of significance was kept
at 0.05 level.
RESULTS
1. Demographic characteristics: The range of age
of adolescents was from 15-17 years. Mean age
was 16.75 years. As shown in table 1, Majority of
the students belonged to science group. Maximum
students were Hindus followed by Muslims and
Sikhs. There were more male students as
compared to female students. Maximum number
of fathers and mothers were educated upto tenth
class.
2. KAP scores of adolescents: As shown in table 2,
56.6% of adolescents had knowledge below mean,
52.6% of adolescents had below mean attitude
scores and 57.7% of adolescents had below mean
practice scores. Areawise distribution of KAP
scores is summarized in table 3. Only 20.6% were
aware about correct mode of transmission of HIV
infection and 22.9% were having knowledge of
correct preventive measures. In the attitude
component, 45.7% of the students had favourable
attitude towards people living with HIV/AIDS
(PLHA). None of the student was sexually active.
Merely 37.1% of the students were aware of safe
sex practices. Only 27.1% followed safe practices
related to skin piercing and 18.3% expressed that
they would hug or kiss a person with HIV/AIDS.
3. Association between adolescents’ KAP scores
and selected variables: As seen in table 4, there
was a significant relationship between gender of
the students and their knowledge (p= .002) scores.
Male students had significantly higher knowledge
about HIV/AIDS than the females. There was no
gender difference observed in the attitude (p= .52)
and practice (p=.55) scores. There was also no
significant relationship between the religion and
knowledge (p= .64), attitude (p= .18) and practice
(p= .99) scores of students about HIV/AIDS.
The relationship between parents’ education and
KAP scores was assessed using one way ANOVA.
There was a significant relationship between
fathers’ education and adolescents’ knowledge
scores and no significant relationship observed
between fathers’ education and adolescents’
attitude and practice scores. There was a significant
relationship observed between mothers’ education
and adolescents’ practice scores but no relationship
seen between mothers’ education and knowledge
and attitude scores.
There was no significant relationship between the
stream of students and their KAP scores. The
knowledge, attitude and practices of students
about HIV/AIDS are independent of the stream
in which they are in.
Thus the null hypothesis HO1 is partially rejected
with regard to religion, parents’ education and
stream of education of students.
4. Correlation between Knowledge, Attitude and
Practice scores of adolescents related to HIV/
AIDS: As shown in table 5, there was a statistical
significant relationship between knowledge and
attitude scores, attitude and practice scores and
practice and knowledge scores. Thus the null
hypothesis HO2 is rejected. The findings suggest
that the knowledge, attitude and practices of
adolescents are related to each other.
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62 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Table 1: Demographic characteristics of adolescents N=175
Variable Categories Frequency %
Stream Science 109 62.3
Commerce 66 37.7
Religion Hindu 131 74.6
Muslim 32 18.3
Sikh 74
Christian 5 2.8
Gender Male 95 54.3
Female 80 45.7
Fathers’ education Illiterate 12 6.86
Upto 10th 123 70.3
Upto 12th 34 19.4
Graduate and above 6 3.4
Mothers’ education Illiterate 62 35.4
Upto 10th 92 52.6
Upto 12th 17 9.7
Graduate and above 4 2.3
Table 2: KAP scores of adolescents related to HIV AIDS N=175
Variable Maximum Mean SD Above Below
score mean f (%) mean f (%)
Knowledge 52 14.80 3.38 76(43.4%) 99(56.6%)
Attitude 165 103.2 6.28 83(47.4%) 92(52.6%)
Practice 24 11.30 2.57 74(42.3%) 101(57.7%)
Table 3: Areawise distribution of KAP scores among adolescents N=175
Area Frequency %
Knowledge Students who answered correctly
• Magnitude of HIV/AIDS 25 14.3
• Mode of transmission 36 20.6
• HIV physiology 27 15.4
• Testing and treatment 30 17.1
• Prevention of HIV/AIDS 40 22.9
Attitude Students with favourable attitude
• Attitude towards HIV infection 46 26.3
• Attitude towards PLHA 80 45.7
• Attitude towards safer sex 47 26.9
Practice Students following safe practices
• Practices related to safer sex (abstinence, single partner, condom use) 65 37.1
• Practices related to skin piercing 38 21.7
• Practices related to blood donation 26 14.9
• Common household and social practices (kissing, hugging, sharing utensils ) 32 18.3
Table 4: Association between adolescents’ KAP scores and selected variables N=175
Variable Category f Knowledge Attitude Practice
Mean (SD) F p Mean (SD) F p Mean (SD) F p
Gender Male 95 15.37(5.2) 9.78 .002* 103.72(5) .43 .52 11.39 (2.3) .37 .55
Female 80 13.04(4.6) 103.19(5.7) 11.18(2.4)
Religion Hindu 131 14.51(5.2) .57 .64 103.9(5.5) 1.7 .18 11.26(2.4) .04 .99
Muslim 32 14.06(4.8) 102.8(5.1) 11.41 (2.4)
Sikh 7 13.14(4.5) 100(3.3) 11.29 (1.3)
Christian 5 12 (2.1) 101.6 (3.2) 11.40(2.1)
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 63
Table 4: Association between adolescents’ KAP scores and selected variables N=175 (Contd.)
Variable Category f Knowledge Attitude Practice
Mean (SD) F p Mean (SD) F p Mean (SD) F p
Father’s education nil 12 15.58(4.56) 4.13 .01* 103(4.09) .86 .47 11.50(3.3) .07 .98
Upto 10th 123 13.55(4.95) 103.33(5.44) 11.25(2.2)
Upto 12th 34 15.71(4.75) 103.56(5.44) 11.38(1.9)
Graduate 6 19.17(5.46) 106.83(7.03) 11.17(2.32)
and above
Mother’s education nil 62 13.47(4.9) 1.9 .13 103.08(5.2) .26 .85 11.48(2.4) 2.8 .04*
Upto 10th 92 14.38(5.2) 103.57(5.3) 11.13(2.24)
Upto 12th 17 16.24(4.6) 104.24(6.5) 10.76(2.25)
Graduate 4 17.25(5.5) 104.25(2.9) 14.25(1.5)
and above
Stream of education Science 109 14.24 (4.7) .05 .83 103.55(5) .06 .81 11.46 (2.4) 1.49 .22
Commerce 66 14.41 (5.6) 103.35(5.7) 11.02(2.2)
*p value significant < 0.05 level
Table 5: Correlation between knowledge, attitude and practice scores of adolescents related to HIV/AIDS N=175
Variables rp
Knowledge and Attitude .6 .00*
Attitude and Practice .53 .00*
Practice and Knowledge .47 .00*
*p value significant < 0.05 level
DISCUSSION
Adolescence is a phase of physical growth and
development accompanied by sexual maturation, often
leading to intimate relationships. Among various risk
factors and situations for adolescents contracting HIV
virus are adolescent sex workers, child trafficking,
child labor, migrant population, childhood sexual
abuse, coercive sex with an older person and biologic
(immature reproductive tract) as well as psychological
vulnerability.
Low levels of knowledge about general aspects and
transmission of HIV/AIDS have been observed in the
current study which is congruent to the findings
amongst secondary school students in Kolkata (3). A
similar observation was made amongst a group of
secondary school students belonging to Udupi district
in Karnataka (4), in that only 24.3% were aware about
the existence of drugs while a slightly higher number
of school students (34%) in Mumbai (5) knew about the
availability of antiretroviral drugs.
In the current study a significant positive
relationship was observed between knowledge
attitude and practice scores of adolescents related to
HIV/AIDS whereas Yinglan Li (6) reported a weak
positive relationship between attitudes and practice
intentions (r = .140, p = .036) among Chinese nursing
students related to HIV/ AIDS. No significant
associations between knowledge levels, attitudes, and
practice intentions were found. Samkange-Zeeb FN,
Spallek L, Zeeb H. (7) did a systematic review of
published literature on awareness and knowledge of
STDs among school-going adolescents in Europe and
analyzing the findings on condom use, it was
concluded that knowledge does not always translate
into behaviour change.
Adolescents constitute a considerable proportion
of India’s population (22%). They are a rich human
resource and an important part of the development
process. Good health of adolescents will help in raising
the health status of the community. Reaching
youngsters at an impressionable age before they
become sexually active can lay the foundations for a
responsible lifestyle, including sex and marriage. Right
information, an enabling environment and supportive
services help adolescents take informed decisions
regarding important health issues and contribute to a
better future.
ACKNOWLEDGEMENT
The authors acknowledge the students and
principals of Sarvodaya Bal Vidyalaya and Sarvodaya
Kanya Vidyalaya who cooperated to conduct the study
without which this study would not have been
possible.
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64 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Conflict of Interest: None
Source of Funding: Nil
Ethical Clearance: The permission was obtained from
the Education officer of the east zone of New Delhi
and IRB, Jamia Hamdard for conducting the study.
REFERENCES
1. UNESCO. Case studies. STDs/HIV/AIDS
(India), 2003. Available from: http://
www.unescobkk.org/ ips/arh-web/
demographics/india2.cfm.
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adolescents02.pdf
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G, Ganesh K, Gandewar K, et al. Impact of school-
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6. Yinglan Li. Chinese nursing students’ HIV/AIDS
knowledge, attitudes, and practice intentions.
Applied Nursing Research. 2008;21(3):147-152
7. Samkange-Zeeb FN, Spallek L, Zeeb H.
Awareness and knowledge of sexually
transmitted diseases (STDs) among school-going
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published literature. BMC Public Health. 2011 Sep
25;11:727.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 65
INTRODUCTION
Parents are architects of nation’s future “The
Children”. Parental beliefs and attitudes are regarded
as filters through which the behavior of the infant is
channelled and the thoughts and ideas of the parents
are mutually regulated with the infant. The child views
the world through their parents’ eyes. These eyes need
to have a clear vision or the child’s worldview will be
blurred.
The optimal development of children is considered
vital to society. It is essential to assess the value of
Mothers Knowledge on Domains of Child Development
Miby Baby1, Sangeetha Priyadarshini2, Sheela Sheety2
12nd year Msc Nursing, 2Assistant Professor, Manipal College of Nursing, Manipal University, Manipal, Karnataka,
India
ABSTRACT
Background: Child development refers to the biological, psychological and emotional changes that
occur in human beings between birth and the end of adolescence, as the individual progresses from
dependency to increasing autonomy.
Objectives: The objectives of the study were to assess the knowledge of mothers regarding the domains
of child development and to find the association between the knowledge scores of mothers and
selected variables like age, education, monthly income, type of family, area of living and source of
information.
Method: A descriptive survey approach was used .Data was collected from 144 mothers by
administering the questionnaire on domains of child development and demographic proforma.
Descriptive and inferential statistics were used to analyse the data.
Results: Among the 144 mothers, majority (74%) had average knowledge regarding domains of child
development and the mean percentage score was maximum (53.63%) in the area related to moral
development. A significant association was found between knowledge and age of the mother (χ2=9.704,
P=.032).
Conclusion: The finding gives an insight for nurses to develop better education and parenting training
programs for mothers to bridge the gap in the knowledge child development.
Keywords: Knowledge, Mothers, Domians Of Child Development
DOI Number: 10.5958/j.0974-9357.5.2.054
Corresponding author:
Mrs. Miby Baby
2nd year Msc Nursing
Manipal College of Nursing Manipal
Manipal University, Manipal,
Karnataka. India. Pin: 576104
Email: miby88@gmail.com
caregivers because they are what truly make society
function. They prepare the next generation for school,
work, and decision-making. So it is important to
educate the parents or caretaker on the social,
cognitive, emotional, and educational development of
children. A child’s entire future largely depends on
how he / she are nurtured. Increased knowledge of
age-specific milestones allows parents and others to
keep track of appropriate development.
Statement of the problem
“A descriptive study to assess the knowledge on
domains of child development among the mothers in
selected health centres of Udupi District, with a view
to develop an information booklet”.
OBJECTIVES
— To assess the knowledge of mothers regarding the
domains of child development
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66 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
— To find the association between the knowledge
scores of mothers and selected variables like age,
education, monthly income, type of family, area
of living and source of information.
— To develop and validate an information booklet
on domains of child development
Hypothesis
H1: There will be a significant association between
mothers’ knowledge level on domains of child
development and variables like age, education,
monthly income, type of family, area of living, and
source of information.
Research methodology
The present study was aimed to assess the existing
knowledge of mothers regarding domains of child
development. To achieve this objective, survey
approach and a descriptive design was used.
Population
The population consisting of mothers having a child
in the age group of 0-3 months of age who attended
the RMCW centres of Udupi District.
Sample
The sample of the present study consisted of all
the mothers with a child between 0-3 months of age
who met the sampling criteria and visited the
immunization clinics of Rural Maternity and Child
Welfare Centres of KMC, Manipal.
Sampling technique
Purposive sampling technique was adopted to
select the study samples from rural maternal and child
welfare centres.
Sampling criteria
The following criteria are set for the selection of
sample:
Mothers
• who had a child of 0-3 months of age
• who visited the immunization clinics of Rural
Maternity and Child Welfare Centers of KMC
Manipal
• who were able to read and understand Kannada.
• willing to participate in the study
Sampling criteria
The following criteria are set for the selection of
sample:
Mothers
• who had a child of 0-3 months of age
• who visited the immunization clinics of Rural
Maternity and Child Welfare Centers of KMC
Manipal
• who were able to read and understand Kannada.
• willing to participate in the study
Tools
Tool 1: Demographic proforma
The demographic proforma consisted of nine items
such as name and address, age of mother in years, age
of the child in months, previous exposure to
knowledge on domains of child development, sources
of health related information, type of family,
educational status, area of living and the monthly
income of the family. The respondents were instructed
to fill the proforma.
Tool 2: Structured knowledge questionnaire
The structured knowledge questionnaire was
developed to determine the knowledge of mothers
regarding domains of child development. Based on the
literature review a blue print was developed and the
items were constructed as per the blue print. The areas
included were -biological, sensory, social, cognitive
and moral development of the child according to their
age.
The questionnaire included 30 items of MCQ type
questions and each item had 3 distractors and one
correct answer. The respondents were requested to
choose the most correct answer and put a tick mark
(Ö) in the space provided against the best possible
answer. Each correct answer carried a score of one and
each wrong answer carried a score of zero. The scores
were categorized arbitrarily as
• 24-30 : Excellent
• 16-23 : Good
• 8-15 : Average
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 67
• 7 and below : Poor
Plan for data analysis
Descriptive statistics in terms of frequencies and
percentage was used to analyze sample characteristics
and knowledge level. Chi square test was used to find
the association between knowledge and selected
demographic variables.
Major findings of the study
Section 1: Sample characteristics
The samples included in this study were mothers with
a child 0-3 months of age.
• Most of the mothers i.e. 65 (45.1%) were in the age
group of 25-30
• Majority of mothers i.e. 99 (68.8%) were from joint
families.
• Out of 144 mothers, 41 (28.5%) had educational
qualifications of high school level
• 77 (53.5%) came under the income group of
Rs.4001-8000
• Majority of the subjects i.e 89 (61.8) reported health
personnel as their source of information
• Most of them (53.5%) had previous information
regarding the domains of child development.
• Majority (69.4%) lived in rural area.
Section 2: Knowledge of the mothers
the poor category and none of the mothers belonged
to the excellent category
Section 3: Area wise knowledge of mothers
Fig. 1. Pie diagram showing percentage distribution of knowledge
of mothers on domains of child development
The above diagram showed that out of 144,
majority i.e 107 (74%) had average knowledge and 30
(21%) had good knowledge and 7 (5%) came under
Fig. 2. Bar chart representing area wise mean percentage score of
knowledge level of mothers on domains of child development
The data presented in figure 2 revealed that mean
percentage score was maximum (53.63%) in the area
related to moral development and the minimum mean
percentage score of 36.63% was in the area related to
sensory development.
Section 4 : Mean, median and standard deviation
of knowledge scores
Table 1: Range, Mean, median and standard deviation
of knowledge scores n=144
Range Mean Median Standard
deviation
5-23 13.43 14 3.46
The data in the table 1 represented the mean and
standard deviation of knowledge scores of mothers and
it was 13.43 and 3.46 respectively. The maximum score
obtained was 23 and minimum score was 5.
Section 5: Association between knowledge and
selected variables like age, education, monthly income,
type of family, area of living and source of information
In order to determine the statistical significance
between knowledge and selected variables, chi square
was computed. The data showed that there was a
significant association between knowledge and age of
the mother (÷2=9.704, p=.032). The null hypothesis was
rejected with regard to this variable and research
hypothesis was accepted. But there was no significant
association between knowledge and selected variables
like education, monthly income, type of family, area of
living and source of information, thus null hypothesis
was accepted with regard to these variables.
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68 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
CONCLUSION
The present study concluded that the majority of
mothers had average knowledge regarding domains
of child development and most (20.8%) of them had
good knowledge but none of the mothers came in the
excellent category. This shows that mothers have some
knowledge about child development. The study also
revealed that the knowledge of mothers on domains
of child development is associated with age of the
mother. Results gives a insight for nurses to develop
better education and parenting training programs for
mothers to bridge the gap in the knowledge.
Recommendations
Based on the study findings, the following
recommendations were made:
• A similar study can be conducted using probability
sampling
• A similar study can be conducted among the health
care providers especially the staff nurses who are
working in the paediatric unit
• A comparative study can be done between the
mothers of rural and urban areas
• Replication of the study in different parts of the
world on a larger sample would help to draw
conclusions that are more accurate and generalize
to a larger population.
Limitations
• Data was collected only from mothers who were
present during the data collection period
• The study used purposive sampling, so
generalization of the study was limited to the
sample.
ACKNOWLEDGEMENT
We thank”The almighty god” for His blessings
during our study. We acknowledge whole heartedly
the participants of the study
Also we express our sincere gratitude to Dr. Anice
George, Dean, MCON, MU, Manipal and Dr. Baby S.
Nayak, Professor and HOD, Department of Child
Health Nursing, MCON, MU, Manipal for providing
us an opportunity to undertake this study.
Conflict of Interest: No
Ethical clearance: Institutional ethical committee
clearance is obtained. Also informed consent is
obtained from the participants of the study
REFERENCES
1. Sharma N, Sapru R, Gupta P. Maternal beliefs of
dogra mothers of Jammu and their child’s
perceived competence in preschool. Journal of
Human Ecology. 2004; 15(2): 153-156.
2. Kail R E. Children and Their Development:
Prentice Hall; 2006.Available from http://
en.wikipedia.org/wiki/Child_development
3. Child care. [internet].Available from http://
en.wikipedia.org/wiki/Child_care
4. Thomas S, Vijayakumar C, Siva R, Isaac R.
Parenting children under three years of age in a
south Indian setting. Journal of paediatric
nursing. 2007 Sept; 33(5):421-426.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 69
INTRODUCTION
Adolescence is a period of transition from
childhood to adulthood: it assumes critical position in
the lifecycle of human beings, characterized by an
exceptionally rapid rate of growth. 1 Many adolescents
make poor nutritional and lifestyle choices that put
them at risk of health problems2. Occurrence of series
of nutritional problems like under nutrition, anemia
and overweight or obesity may develop in them.3An
increasing trend of overweightedness and obesity in
combination with a high prevalence of
underweightedness is found to be common among
many countries4.The fundamental cause of nutritional
disorders are an increased consumption of more
energy dense, nutrient poor foods with high level of
sugar and saturated fats, poor choice of nutrient rich
food and consumption of inadequate quantity of food
which is due to ignorance, reduced physical activity
which is due to increased use of automated transport,
technology in the home and more leisure pursuits.
The economic growth in India and urbanization has
a remarkable impact on socioeconomic status, and
lifestyles; globalization and food markets are major
forces thought to underline the obesity epidemic5.
Adolescence is a unique intervention point in the
life cycle. It is a stage of receptivity to new ideas and
a point at which lifestyle choices may determine an
individuals life course. They are usually open to new
Effectiveness of Information Education Communication
(IEC) Package on Life Style Practices of Adolescents - A
Pilot Study
L Mendonca
1Prof (Vice Principal), Laxmi Memorial College of Nursing, A. J. Towers , Balmatta, Mangalore
ABSTRACT
Adolescents are those between the ages of 10 and 19 years old and are tomorrow's adults. Life style
factors related to eating behavior and physical activity play a major role in the prevention and treatment
of type 2 diabetes. However rapid changes in lifestyle may adversely affect the growth and maturation.
Some people lack adequate food while some people though have adequate amount of food yet make
its poor choices. Because of these reasons, nutritional problems not only affect their growth and
development but also in future would adversely affect their livelihood as adults.
Keywords: Adolescents, Physical Activity, Diet, Lifestyle Practices
DOI Number: 10.5958/j.0974-9357.5.2.054
ideas; they show curiosity and interest6. School – based
nutrition – physical activity education improves
dietary practices and physical activity level that affect
young persons’ health, growth and intellectual
development. School – based nutrition education is
particularly important because today’s children and
Adolescents frequently decide what to eat with little
adult supervision 7
Statement of the problem
Effectiveness of information education and
communication (IEC) package on lifestyle practices of
adolescents in selected high schools, Mangalore.
Objectives of study
1. To determine pre test and post test lifestyle
practices among adolescents in experimental and
control group.
2. To compare the pre test and post test lifestyle
practices among adolescents in experimental
group.
3. To compare the post test lifestyle practices between
experimental and control group.
Hypothesis
1. HO1: There is no significant difference between
mean post test life style practice score among
adolescents of experimental and control group.
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70 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
2. HO2: There is no significant difference in the mean
pre test and post-test lifestyle practice score among
adolescents of experimental group.
Research Methodology
Research approach: A experimental research approach
was used.
Research design: Pre test post test control group
design was adopted for the study
Setting of the study: The study was conducted in two
selected high schools of Mangalore city region.
Population: In this study Adolescents studying in high
school were the population of study.
Sample: The total sample consisted of 40 adolescents.
From each school twenty sample were selected.
Sampling technique Sampling technique adopted was
simple random sampling technique.
Development of the tool: The tool had 2 parts
Part I : demographic proforma
Part 2 : Structured questionnaire to assess the life
style practices of the adolescents.
Validity of the instrument: To ensure content validity
of the tool the tool was submitted to expect along with
the blueprint, objectives checklist and content
validation certificate.
Reliability: Test – retest method was used and
reliability coefficient was calculated by using Pearson
Correlation coefficient formula. The reliability
coefficient for the questionnaire found to be 0.94 which
was highly significant.
Preparation of IEC package: IEC package named as
information book on nutrition and physical activity
for adolescents was prepared based on review of
literature and discussion with the guide and other
experts.
Data collection procedure: Formal administrative
permission to conduct the study in the selected high
schools was obtained from the head of the institution.
The investigator visited the school on the given date.
The purpose of the study was explained to them. After
the pre-test teaching was given using power point
presentation and video show. Information book
containing the information regarding nutrition and
physical activity was given to the students along with
the letter to the parents; post test was conducted after
3 months.
RESULTS
Demographic characteristics
Higher percentages (40%) of them were in the age
group of 15-16 years in experimental group and control
group. Highest percentage (50%) were males in
experimental and in control group, 35% of them were
studying 9th slot 35% of them in 10th std and 30% of
them were studying in 8th standard.
Majority in experimental (65%) and in control
group (70%) were from nuclear families. Majority in
experimental (70%) and in control group (85%) were
non vegetarians. Highest percentage of them had
income in between Rs 10001-15000 (experimental
group 40% and control group 45%). Highest
percentage in the experimental group watching T.V.
for 2-4 hrs (60%) where as in the control group highest
percentage were watching T.V. for less than 2 hrs.
(55%). None of them in the experimental group and
control had any limitation to participate in the physical
activity.
Description of lifestyle practices
In the experimental group the mean pre test lifestyle
practice score was 95.70+16.93 and in the post it
increased to 110.10+15.51. Where as in the control
group the pretest mean was 94.70+12.92 and in the post
test it decreased to 92.50+12.08.
Effectiveness of IEC package on Lifestyle practices
of adolescents
There was significant difference in the post test
lifestyle practice scores between experimental and
control group (t=3.63, p<0.001). There was significant
difference between mean pre and post test lifestyle
practice scores among adolescents of experimental
group in the areas ‘dietary habits’ (t=2.191, p<0.001),
frequency and type of food ‘(t=0.006, p<0.001)’ amount
of food t=3.597, p<0.001) type and frequency of
physical activity’ (t=3.278, p<0.001).
Findings also revealed that there was significant
difference in the mean post test lifestyle practice scores
between experimental and control group. Significant
difference was found in the area’ diet area wise habits
(t=3.78, p<0.001) ‘frequency of food consumption
(t=2.18, p<0.001)’ ‘hygienic practices’ (t=3.63, p<0.001),
hence the research hypothesis accepted for these areas.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 71
There was no significant difference in the mean post
test lifestyle practice scores between experimental and
control group for the area ‘physical activity pattern’
‘and’ type of activity and’ Amount of food’.
Table 1. Mean, Median, Range and S.D of lifestyle practice scores in adolescents
Experimental (n=20) Control (n=20)
Range Mean Median S.D Range Mean Median S.D
Pre test 67-121 95.70 98.50 16.93 72-120 94.700 96.00 12.92
Post test 82-140 109.10 110.00 15.51 74.121 93.10 92.50 12.08
Table 2, significance of difference in the post test lifestyle practice scores between experimental group and control
group.
Life style practices Group N Mean Std. Deviation t
Experimental 20 109.10 15.51 3.63
Control 20 93.10 12.08 P<0.001 vhs
Table 3 area wise significant difference in the mean lifestyle practice scores of adolescents in experimental group.
Areas N Mean S.D tvalue P value
Dietary habitsPre testPost test 2020 19.1523.40 3.958.44 2.919 0.009 hs
Frequency and Type of foodPre testPost test 2020 48.9053.35 8.848.45 3.088 0.006 hs
Amount of foodPre testPost test 2020 13.0515.90 3.593.03 3.597 0.002 hs
Hygienic practicesPre testPost test 2020 3.503.70 1.000.732 0.777 0.447
Physical activity patternPre testPost test 2020 6.806.90 2.8392.712 0.2888 0.776
Type and frequency of physical activityPre testPost test 2020 4.305.85 2.252.13 3.278 0.004 hs
DISCUSSION
This study findings are supported by a study
conducted in Sousse, Tunisia to implement and
evaluate school based intervention to promote healthy
lifestyle and to prevent cardiovascular risk factors
among children pre-test – post test quasi experimental
study design with a control group was adopted.
Education was given regarding diet, physical activity
and tobacco use. The intervention programme lasted
for one year. The percentage of children who know
what they should eat on breakfast have been improved
significantly in the intervention group (15.4-40.5%,
there was significant improvement in students eating
fruits and vegetables, students who participate in more
than 30 minutes of physical activity after the
intervention increased significantly (_18.4%). The
findings of the study also suggested that intervention
can change the lifestyle knowledge and intention in
short period8
Another study supports the present study is an
experimental study conducted to evaluate the impact
of school based interdisciplinary intervention on diet
and physical activity among African American urban
primary school children. Student survey, food
frequency, activity measures and 24 hour recall of diet
and activity was assessed before the intervention as
well as after the intervention. The percentages of total
energy from fat and saturated fat were reduced among
students in intervention compared with control schools
(-1.4%; 95% confidence interval [CI], -2.8 to -0.04; P=.04
and -0.60%, 95% CI, -1.2 to -0.01; P=.05). There was an
increase in fruit and vegetable intake (0.36 servings/
4184kj; 95% CI, 0.10-0.62; P=.01), in vitamin C intake
(8.8 mg/4184 kJ; 95%CI, 2.0-16; P=.01), and in fiber
consumption (0.7g/4184kJ; 95% CI, 0.0-1.4;P=.05).
Television viewing was marginally reduced (-0.55h/
d; 95% CI, -1.04 to 0.04; P=.06). Analysis of longitudinal
and repeated cross sectional food frequency data
indicated similar significant decreases in the
percentages of total energy from fat and saturated fat9
CONCLUSION
Study resulted in substantial improvements
concerning behaviour in the intervention group. It is
concluded that the IEC package was found to be
effective in improving the lifestyle practices of
adolescents. It is Cost effective and nurses can utilize
all the opportunities to educate adolescents to improve
desired outcome and thus helping the adolescents to
prevent nutritional related disorders.
Ethical Clearance
Ethical clearance has been obtained from ethical
committee.
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72 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Source of funding: not received any financial
support from third party related to the submitted work.
Potential conflict of interest
I have no other relationship /condition /
circumstances that present a potential conflict of
interest.
ACKNOWLEDGEMENT
My sincere appreciation goes to all the participants
for being cooperated in the study
REFERENCES
1. Kapil U, Singh P, Pathak P, Dwivedi SN, Bhasin
S. Prevalence of Obesity amongst Affluent School
children in Delhi, Indian Pediatrics, May 2002;
39(5):449-452.
2. G.K. Mehdi, N.C. Hazarika, J. Mehanta.
Nutritional status of adolescents among tea
garden workers; Indian journal of paediatrics,
April 2007; 74(4):343-347
3. N. Gupta & G. Kochar. Role of Nutrition
Education in Improving the Nutritional
Awareness Among Adolescent Girls. The
Internet Journal of Nutrition and Wellness, 2009;
7(1). Available from;http://www.ispub.com/
journal/the internet journal of nutrition and
wellness/volume 7 number 121/article/role of
nutrition education in improving the nutritional
awareness among adolescent girls. Html.
4. Doak CM, Adair LS, Bentley M, Monterio C,
Popkin B.M. underweight and overweight coexist
within household in Brazil, China and Russia,
Nutrition Journal, 2000;130:29:1-5
5. WHO/FAO expert consultation. Diet, nutrition
and the prevention of chronic diseases, Geneva,
28 January -1 February 2002. (WHO technical
report series; 916). Available from http://
www.who.int/dietphysicalactivity/
publications/trs916/en/
6. Sheperd R, Dennison CM. Influences on
adolescent food choices. Proc Nutr Soc;
1996:55:345-57 available from
whqlibdoc.who.int/publications/2005/
9241593660_eng.pdf)
7. Ahmed F, Zareen M. Khan Mr. Dietary patterns,
nutrient intake and growth of adolescent school
girls in urban Bangladesh. Pub Health Nutr;
1998:1:83-92.
8. Imed Harrabi, et.alschool based intervention to
promote healthy lifestyles in sousse, Tunisia
Indian journal of community medicine vol.35/
issue 1/January 2010, 94-99.
9. Steven L. Gortmaker et.al Arch Pediatr Adolesc
Med. 1999;153:975-983.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 73
INTRODUCTION
Renal transplantation is the treatment of choice for
most patients with end-stage renal failure. According
to the World Health Organization, 66,000 kidney
transplants were performed in 83countries in the year
20053. Day by day it is increasing in number.
There is evidence that compliance to therapeutic
regimen is a critical requirement for the success of an
organ transplant. Noncompliance toward diet,
medications, exercise, and regular follow up and
different other recommendation is a real and common
problem in the transplant arena. Studies have shown
the prevalence of noncompliance among renal
transplant ranging from 2-68%4.
Patients who report noncompliance may get benefit
from the use of various intervention strategies. These
strategies need to target specific causes of
An Exploratory Study to Identify Factors Associated with
Noncompliance of Medications and Recommended
Lifestyle Behavior After Renal Transplantation- A Pilot
Study
Uma Rani Adhikari1, Abhijit Taraphder2, Tapas Das3, Avijit Hazra4
1Vice-Principal, Woodlands College of Nursing, Kolkata, 2Formerly Professor & Head, Dept of Nephrology, 3Formerly
Professor & Head, Dept of Medicine, 4Associate Professor, Dept of Pharmacology, I.P.G.M.E.R & S.S.K.M Hospital,
Kolkata
ABSTRACT
Introduction: Noncompliance to prescribed therapy has been found to be common in chronic diseases.
Therapeutic compliance not only includes patient compliance with medications but also with diet,
exercise or lifestyle changes. Therapeutic noncompliance after renal transplantation is a major risk
factor for acute rejection and graft loss. It is estimated that 1 in 10 deaths in transplant patients is due
to medication noncompliance1-2
Material and Method: This exploratory longitudinal study was performed in tertiary care teaching
and non-teaching hospitals in Kolkata. From 30 renal transplant patients data were collected through
interview, records & existing laboratory report. To get self-report structured questionnaire for interview
were prepared. For data collection clients were picked up from the period of pre-transplant work up
and they were followed up for 1 month.
Results: The extent of noncompliance after renal transplantation is 16.67 (95%CI 3.33-30%). The reason
for noncompliance is mainly forgetfulness and poor knowledge. This study also reveals that
noncompliance is significantly associated with dialysis duration and waiting time for transplant.
Keywords: Renal Transplant Patient, Noncompliance, Factors Influencing Noncompliance
DOI Number: 10.5958/j.0974-9357.5.2.054
noncompliance. However, an in-depth understanding
of factors associated with noncompliance of
medications and recommended lifestyle behavior is
essential prior to the development of any intervention.
Research question
i) How extensive is the noncompliance after renal
transplant?
ii) What are the factors influencing noncompliance
after renal transplant?
METHOD AND MATERIALS
This exploratory longitudinal study was performed
in tertiary care teaching and non-teaching hospitals
doing regular renal transplantation in Kolkata. With
consecutive sampling 30 adult renal transplant patients
who can read, speak & write were included in this
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74 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
study. Data were collected through interview, records
& existing laboratory report. To get self-report
structured questionnaire for interview were prepared.
The questionnaires consisted of open & closed ended
questions. Validity & reliability of the tool was
established before data collection. For data collection
clients were picked up from the period of pre-
transplant work up and they were followed up for 1
month (Pilot study). The study was approved by the
institutions ethics committee.
STATISTICAL METHOD
Descriptive and inferential statistical methods were
used. Data were summarized using frequency, means
and standard deviation. Pearson’s chi-square for all
categorical variables and Mann-Whitney U test for
numerical variables were used. A probability of less
than 0.05 was accepted as significant. Data were
analyzed by using SPSS-14th version.
RESULTS
Table 1: Socio-demographic characteristics of the subjects
Variables N (30) %
Age (Mean) 34.1±10.07
Gender
• Male 20 66.7
• Female 10 33.3
Marital status
• Married 19 63.3
• Unmarried 11 36.7
Types of family
• Nuclear 18 60
• Joint 12 40
Educational status
• Graduate & above 17 56.6
• Higher secondary 4 13.3
• Secondary 7 23.3
• Primary 2 6.7
Religion
• Hindu 23 76.7
• Muslim 5 16.6
• Christian 2 6.6
Belief in God
• Yes 24 80
•No 620
Employment
• Student 5 16.6
• Service 13 43.3
• Housewife 310
• Business 620
• Unemployment 310
Income (Mean) 26300±16269.60
Support person
• Spouse 17 56.6
• Parent 7 23.3
• Siblings 5 16.6
• Son/daughter 1 3.3
Insurance coverage
Yes 0 0
No 30 100
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 75
Table 2: Therapy related characteristics of the subjects
Variables N (30) %
Post-operative complications (Before discharge)
•Yes 8 26.66
•No 22 73.33
Duration of dialysis 8.1±3.46 (months)
Types of transplant
• Related 17 56.66
• Unrelated 13 43.33
Immunosuppressive regimen
• Pred+TAC+MMF* 930
• Pred+TAC+AZA* 21 70
Pill burden (Mean) 14.8±2.22 (number)
Hospital stay after transplant (Mean) 16.7±4.48(days)
*-TAC-Tacrolimus, MMF-Mycophenolate Mofitil, AZA-Azathioprin, Pred-Prednisolone.
Table 3: Health care system related characteristics of the subjects
Variables N(30) %
Health information
• Satisfied 16 53.3
• Not satisfied 14 46.7
Availability of health care facility
• Present 18 60
• Not present 12 40
Waiting time (Mean) 7.18±3.37 (months)
Medication knowledge (44.66 ± 17.95)%
Table 4: Patient & condition related characteristics of the subjects
Variables N(30) %
No of side effects of immunosuppressant
· No side effects
· 1 “ “ 1 3.3
· 2 “ “ 620
· 3 “ “ 7 23.3
· 4 “ “ 15 50
1 3.3
Comorbidity
· HTN 28 93.33
· DM 310
· Anemia 8 26.66
· Hepatitis 2 6.6
· Others 2 6.6
Depression
· Yes 24 80
· No 620
I. The extent of noncompliance after renal transplantation is = Mean ± 1.96 X SEM
= 16.67 (95%CI 3.33-30%).
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76 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Table 5: Reasons for Noncompliance
Reasons Frequency
Forgetfulness 3
Lack of information/poor knowledge 2
II. Relationship between selected variables
Table 6: Relationship between the selected variables with the compliance status
Sample characteristics Compliant Fisher’s exact
status test P value
Compliant Noncompliant
Types of family
Joint 10 2 0.364
Nuclear 15 3
Gender
Male 15 5 0.486
Female 10 0
Marital status
Married 14 5 0.129
Unmarried 11 0
Belief in God
Yes 21 2 0.256
No 33
Health information
Positive 13 3 1
Negative 12 2
Table 7: Relationship between the selected variables with the compliance status
Sample characteristics Compliant Fisher’s exact
status test P value
Compliant Noncompliant
Employment
Student 5 0 0.778
Service 11 2
Housewife 30
Business 60
Unemployment 03
Education 17 2
• Graduate & above 4 0 0.532
• Higher secondary 7 3
• Secondary 20
• Primary
No of Comorbidities
One 12 2 0.801
Two 10 3
Three 30
Table 8: Relationship between the selected variables with the compliance status
Aspect Compliant( Noncompliant P value from
Mean Rank) (Mean Rank) Mann-Whitney
U test
Age 14.56 20.20 .190
Income 16.38 11.10 .220
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 77
Table 8: Relationship between the selected variables with the compliance status (Contd.)
Aspect Compliant( Noncompliant P value from
Mean Rank) (Mean Rank) Mann-Whitney
U test
Waiting period 13.60 24.90 .007*
Dialysis duration 13.68 24.60 .010*
Pill burden 15.44 15.80 .933
Hospital stay 15.88 13.60 .592
* P < 0.05
DISCUSSION
In this study the incidence of noncompliance is
16.66% and it is supported by many other studies
where incidence of noncompliance ranges from 13-
36%5, overall compliant 23.8%6. Many other studies 6-9
reported that noncompliance among transplant patient
ranges from 5-43%. The present study reveals that
reason for noncompliance is mainly forgetfulness and
poor knowledge which is also supported by W.J.Liew
study10. This study also reveals that noncompliance is
significantly associated with dialysis duration and
waiting time. W J. Liew10 also found in her studies that
waiting time for transplant was significant predictor’s
of noncompliance. So dialysis duration & waiting time
for transplant are very good predictors of
noncompliance after renal transplantation. In the
present study other factors like-age, sex ,education,
income, knowledge, type of transplant, pill burden,
numbers of comorbidities, belief in god are not
significantly associated with noncompliance. This may
be because of small number of subjects included in
this study and short time follow up.
Implication for practice & future research: This
study raises several important questions to address in
future research. Before doing study on interventional
strategies to minimize noncompliance we need to
consider factors associated with noncompliance in
order to maximize long-term renal allograft survival
and it requires addressing larger studies in future.
Health care professional needs to stress the importance
of compliance with their post-transplant treatment.
This includes complying with follow-up visits,
medicine intake, investigation etc. It is also necessary
to stress the benefits of their treatment and their risks
of developing complications, and consequences of
non-compliance.
CONCLUSION
This study provides a framework for identifying
patients at risk for non-compliance and for developing
compliance-enhancing interventions from Indian
Context. Future strategies to improve compliance,
including increased vigilance in high-risk patient
groups, frequent medication review, and laboratory
testing, should be encouraged. So, we need to do this
sort of study from different parts of India for better
understanding regarding predictors of non-
compliance among renal transplant patient from
Indian sociocultural context.
ACKNOWLEDGEMENT
I am thankful to Head of the Dept. of Nephrology
& director of I.P.G.M.E.R & S.S.K.M Hospital, Kolkata
for providing support to carryout this work. I am also
thankful to The West Bengal University of Health
Sciences, Kolkata.
Source of Funding: Investigator is utilizing her own
income for the purpose of this research study.
Conflict of Interest: None
REFERENCE
1. WHO. Adherence to Long-term Therapies:
Evidence for Action. World Health Organisation;
2003.
2. Butler JA, Roderick P, Mullee M, Mason JC,
Peveler RC. Frequency and impact of non-
adherence to immunosuppressants following
renal transplantation: a systematic review.
Transplantation 2004; 77: 769–776
3. WHO-Fact sheet. Kuwalt Medical Jounal 2007 ;
39(2) : 203-208.
4. Chisholm MA. Issues of adherence to
immunosuppressant therapy after solid-organ
transplantation. Drugs 2002; 62(4): 567-575.
5. Mahmoud Loghman-Adham, Am J Manag Care.
2003 Feb; 9 (2):155-71,
6. Kiley DJ, Lam CS, Pallak R. A study of treatment
compliance following kidney transplantation.
Transplantation 1993 Jan; 55(1): 51-56.
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78 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
7. Royal Pharmaceutical Society of Great Britain:
From Compliance to Concordance. London,
Official Brochure, 1997.
8. Pullar T, Birtwell A, Wiles P, Hay A, Feely M: Use
of a pharmacologic indicator to compare
compliance with tablets prescribed to be taken
once, twice or three times daily. Clinical
Pharmacology and Therapeutics (1988) 44,
540–545;
9. Raynor DK: Patient compliance. The pharmacist’s
role. Pharm Pract 1992; 1:126–135.
10. W.J.Liew. Medication compliance among Renal
Transplant Patients. Med J Malaysia December
2004; Vol 59 (5):
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 79
INTRODUCTION
Working in community surely exposes one to the
practical primary care issues like maternal and child
health care, infectious diseases, water problem and
sanitation. This article presents a case scenario
encountered by the primary author, as part of her field
work primarily focused on clinical teaching.
CASE STUDY
The root cause behind many problems is scarcity
of resources and education. I came across this situation
when I was facilitating my students at clinical in one
of the slum areas of Karachi. In the very first week, we
encountered a 28 year old lady sitting outside her
house. Whenever I used to facilitate my students in
the locality, she used to come closer and actively listen
to my conversation with my students. In the last week
Intimate Partner Violence an Evil of Society with
Integration of Ecological Model a New Perspectiv
Yasmin Mithani RM1, Zahra Shaheen Premani2, Zohra Kurji3
1Senior Instructor, 2Chief Operating Officer, 3Senior Instructor/Curriculum Chair, The Aga Khan University School of
Nursing and Midwifery, Pakistan
ABSTRACT
Intimate partner violence (IPV) is the abuse that occurs between two people in a close relationship.
WHO report highlights that intimate partner violence has a damaging impact on physical, mental
reproductive and sexual health of victims, with consequences such as physical injuries, depression,
post-traumatic stress disorder, suicidal attempts, substance abuse, unwanted pregnancies,
gynecological disorders, increased risk of sexually transmitted infections including HIV/AIDS, and
others.6, 7.
The ecological model of Hesis for intimate partner violence states that there is no one cause behind
violence and it has multifaceted factors. If we understand how each factor is related, we can prevent
and intervene for IPV in our society.
Keywords: Intimate Partner Violence, Ecological Model of Hesis, Damaging Impact
DOI Number: 10.5958/j.0974-9357.5.2.054
Corresponding author:
Yasmin Mithani
Senior Instructor
Year 1 and 2 Coordinator, The Aga Khan University
School of Nursing and Midwifery
Ph: +92-300-2177250
Yasmin.mithani@aku.edu
of my rotation, the lady showed me a prescription of
anti-fungal medications. She had complaints of itching,
burning in vagina, heavy curd like discharge and
constant backache. When she shared these complaints,
I reinforced her to comply with the medication
regimen. After a week she reported that her problem
got worse. She was having excruciating pain and heavy
vaginal discharge, which was very uncomfortable for
her. Upon exploration, she quietly told me to send my
students away as she wanted to share a secret matter
with me. In order to maintain her privacy, I visited
her home to discuss the matter. She showed her
prescription again and said that the main cause of her
illness is her husband and due to this, the doctor has
advised her to refrain from sex. It surprised me when
she said that she cannot refrain from sex as it is her
duty to perform sexual activity every night, despite
her prevailing condition, and this is why this infection
is persistent. Stating this, she started crying, and told
me that even in her post natal days, she could not take
rest. If she refused, her husband would have put
allegations on her that she has fulfilled her needs
elsewhere when he went for fishing for one month.
He would also insist her to have sex with him using
different positions, which she did not like. She further
stated that she is unable to give more details as she
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80 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
was feeling embarrassed. Furthermore, she stated that
she was not alone and many other women in the
community were in the same plight. This is a common
primary health problem in the community. While
hearing this situation, I felt helpless as I was not able
to utter a word and just listened.
Subjective point of view
I was very angry listening to this entire scenario, I
asked myself when these women will be heard, and
why does the society always make norms to oblige
husbands? Why do women feel insecure after
marriage? Why are women still suppressed and
submissive? When will women be empowered? These
questions evoked frustration in me. I felt very sad
because this is not the story of one woman, but a very
prevalent primary care problem in Pakistani
community.
Objective point of view
The above mentioned situation illustrates
multifaceted areas where we can relate many factors
and many themes. I will now address the issue of
sexual violence by integrating epidemiology and
sociology into the situation.
Analysis with epidemiological and sociological
perspective
Epidemiological Perspective
According to a factsheet by Center for Disease
Control and Prevention (CDC):
‘Intimate partner violence (IPV) is the abuse that
occurs between two people in a close relationship. The
term “intimate partner” includes current and former
spouses and dating partners’.3
‘The World Health Organization (WHO)
Characterizes domestic violence as a pattern of
coercive behavior designed to extend power and
control over a person in an intimate relationship
through the use of intimidation, threats, and harmful
or harassing behaviors.’6 According to an estimate
“.Various forms of domestic violence in the country
include physical, mental and emotional abuse. Some
common types include honor killing, spousal abuse
including marital rape, acid attacks and being burned
by family members.”4
A similar report by the Centre of Disease Control
(CDC) on violence prevention reports that every year,
around 1.5 million women are victims of raped and/
or physical by an intimate partner.5 They also validate
that sexual violence is very common problem all over
Pakistan and many women accept this form of violence
as their fate. It is a pandemic problem. According to
WHO report, 1.4% women go through sexual violence
in La Paz, Bolivia, 0.8 % in Gaborone, Botswana, 1.6%
in Beijing, China, 0.3% in Manila, Philippines, 5% or
more in Tirana, Albania, 6% in Buenos Aires, 5.8% in
Argentina, 8% in Rio de Janeiro, Brazil and Bogota,
and 5% in Colombia. It also shows that in three
provinces of South Africa, 1.3% of women had been
forced physically or by means of verbal threats, to have
non-consensual sex in the previous year.6 WHO report
highlights that intimate partner violence and sexual
violence have a damaging impact on physical, mental
and reproductive and sexual health, with
consequences such as physical injuries, depression,
post-traumatic stress disorder, suicide attempts,
substance abuse, unwanted pregnancies,
gynecological disorders, sexually transmitted
infections, risk of increased HIV/AIDS, and others.6 7
Based on interviews with more than 24, 000 women
from rural and urban areas in 10 countries, the study
by Azam and Irma also found that lifetime prevalence
of sexual violence by an intimate partner ranged from
6% to 59%, with the prevalence in the majority of study
sites falling between 10% and 50%. 4
A similar study by Karmaliani et al done in Pakistan
also endorsed that “one in three women are victims of
IPV in Pakistan and a review of more than 50
population-based studies indicated that between 10%
and 52% of women from 35 countries around the world
report lifetime physical abused by an intimate partner,
and between 10% and 30% had experienced sexual
violence by an intimate partner.”8
Therefore, this means that IPV is a serious matter
and is prevalent worldwide with the above mentioned
data validating this concern.
Sociological Perspective
Sociologist will always focused circumstances with
society ,or how societal culture enable or become
impeding factors for a individual at micro or macro
level .like for example how does a individual behave
with family or peers .the main aim of sociologist is to
observe always with the lens of social situation .
Thus keeping in view the above mentioned role of
sociologist, many researchers have endorsed various
theories for violence for e.g. feminist theory ,exchange
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 81
theory, Bandura theory and many more. However, if
we analyze this case study with the ecological model,
it will facilitate in understanding the issue with a
broader perspective and will assist in preventing IPV
and intervening accordingly. It is very pertinent to
analyze sociological perspective while planning
intervention for prevention in the society.
Discussion: The Ecological Model and Its
Integration with the Case
As mentioned by Hesis, ‘understanding these
situations and manifold causes creates opportunities
to intervene before the violent act occurs, and provides
policy makers with concrete options to prevent
violence’.10 The ecological model of Hesis for intimate
partner violence depicts four major dimensions such
as individual, relationship, community and society
that influence an individual’s behavior. If we integrate
the client’s situation with this theory, she had no
education at individual level. At relationship level, she
was experiencing marital conflict, Furthermore, the
client expressed that it was not only her, but the
neighbors also faced similar problem. This means that
this problem was a sociological issue; Pakistan is a
male dominant society and women here are expected
not to raise their voice even if they are experiencing
violence.
The ecological model of Hesis for intimate partner
violence states that there is no one cause behind
violence and it has multifaceted factors. If we
understand how each factor is related, we can provide
interventional as well as preventive care to the
society.4 6 10
Individual
This level identifies the vulnerable characteristic
of a victim or perpetrator like client and her husband
who had no education. The biological circumstances
of ecological model includes low education, habit of
substance abuse and child hood aggression if we
integrate client situation with this model.
Relationship
The second level of this model identifies how close
social relationships contribute to IPV. In the case of
my client, I could integrate that daily she was sexually
abused by her husband and whenever he did not go
for fishing, he demanded sex from her, even when
she was undergoing infection or was postnatal. She
could not rest and she was bound in marital relation
with him, and even after so much violence when she
was beaten by him she was willing to continue the
relationship. This is a major issue as the emotional
attachment was lost in the relationship subsequent to
the violence, and the continuation of the relationship
was a mere obligation for her.
COMMUNITY
The third level of the ecological model elucidates
the community level causes such as schools,
workplaces and neighborhoods. As mentioned, my
client expressed that it was not only her but the other
women were also experiencing same problem. This
means that this problem is a social issue. At community
level, the woman was not empowered enough to raise
her voice against the violence, as it is considered
unusual in the community.
Society
The fourth level of the ecological model appraises
the societal factors that cause violence. For example,
in my client’s situation, she was not empowered but
was suppressed and she herself was accepting
violence as a norm. This acceptance of violence by
women not only prevails in certain communities, rather
it’s a bigger issue at society level, where women are
considered sub ordinates to men, and therefore are
expected to obey their husbands in all circumstances.
In conclusion, this frame work demonstrated various
causes of IPV and their significance at different levels.
CONCLUSION
Keeping this theory in view, I will resolve my
client’s issue with the help of the following strategies
at all levels. At individual level, I will resolve this issue
by counseling the victim and the abuser. Lack of
education is a very dominant factor for my client and I
think that by providing awareness sessions on
empowerment, women rights etc. might improve their
confidence level. Ali & Gavino have also highlighted
significance of practical intervention to improve the
relationship at individual, community and society
levels.4 I feel from now onwards, I can facilitate my
students to educate the community on the concept of
family dynamics via role plays, dramas or arranging
cultural shows and programs to create family harmony.
Couple of sessions on various topics like harmony on
family, and husband’s role in family can be arranged.
Moreover, if the concept of community as a partner is
applied and stake holders from the community and
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82 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
the institution are involved from the very beginning,
preventive strategies can be planned .Hence the client
can be prevented become productive member of
society.
ACKNOWLEDGEMENTS
I would like to acknowledge my faculty of
university of London ,Friends, and Family.
Source of Funding: None
Conflict of Interest: None
Ethical Clearance: Not required
REFERENCES
1 World Health Organization Health action in
crises: Pakistan. 2008. August. Available from:
http://www.who.int/hac/crises/pak/
Pakistan_Aug08.pdf. [Accessed 29 October 2009].
2 Urban health programme, community health
sciences Aga Khan university.[on line]. Karachi:
Available from: http://www.aku.edu/chs/chs-
uhpfield.shtml#rehri. [Accessed 28 September
2009].
3 Center for Disease Control and Prevention.
Understanding intimate partner violence. Fact
sheet [online].2006. Available from: http://
www.cdc.gov/violenceprevention/pdf/IPV-
FactSheet.pdf . [Accessed 29 0ctober 2009].
4Ali
PA, Gavino MRI . Violence against women in
Pakistan: a framework for analysis. Journal of
Pakistan Medical Association 2008; 58:
5 Center for Disease Control and Prevention.
Intimate partner violence prevention: preventing
violence against women: program activities
guide. [on line]. 2009. Available from: http://
www.cdc.gov/violenceprevention/pub/
PreventingVAW.html. [Accessed 28 0ctober 2009].
6 Editors Krug, EG, Dahlberg, LL, Mercy, JA, Zwi,
AB and Lozano, R. World report on violence and
health. [online]. 2002. Available from:
www.who.int/violence_injury.../violence/
world_report/en/. [Accessed 26 October 2009].
7 Campbell JC. Health consequences of intimate
partner violence. The Lancet 2002; 359:1331.
8 Karmaliani, R, Irfan, F, Bann, CM, Mcclure, EM,
Moss, N, Pasha, O, Goldenberg, RL. Domestic
violence prior to and during pregnancy among
Pakistani women. Acta Obstetricia et
Gynecologica. [online]. 2008. p. 1-8. Available
from:
9 Greenhalgh, T. The ‘ologies’ (underpinning
academic disciplines) of primary health care.
Primary health care: Theory and practice. Chapter
2. 2007. Blackwell Publishing. p.34.
10. Heise LL. Violence against women: an integrated,
ecological framework. Violence Against Women
1998; 4: 262-90.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 83
INTRODUCTION
Literature search revealed that though resource
allocation of funds is an extremely crucial process,
there is lack of local literature in Pakistan regarding
how the resources were allocated for various
programs8. The below-mentioned resource allocation
process is used for all healthcare programs in Pakistan
and is described here under8.
Resource allocation process in Pakistan
Resources in healthcare are allocated by evaluating
the cost-effectiveness of the interventions for high
burden diseases and the resources, usually scarce, are
allocated for selective, cost-effective interventions to
promote equitable healthcare among population1,3.
In Pakistan, the Five Year Plan is the main policy
document through which the Planning Commission
allocates recurrent and development budgets for the
next 5 years22. The proposal of a new program or project
needs to be submitted by the Ministry of Health to the
Planning Commission in the form of Planning
Commission Document 1 (PC-1). The PC-1 document
is a form that provides information regarding type of
project, related activities and annual funding. The
document is reviewed and deliberated by the Planning
Commission and the Ministries of Finance and Health
Are Health Care Resources Allocated Equitably in
Pakistan?
Zahra Shaheen1, Zohra Kurji2, Yasmin Mithani1
1Chief Operating Officer, Catco Kids, 2Instructor, The Aga Khan University School of Nursing and Midwifery,
Affiliation: University of London; the Aga Khan University School of Nursing and Midwifery
ABSTRACT
In countries such as Pakistan where there is paucity of resources, just allocation of resources becomes
more critical8. Resource allocation is informal12,22, centralized12,22 and based on personal and
political influences and donor wishes22 rather than national interests8.. The health policy making
process in Pakistan is explicit yet there is lack of coordination between the Planning Commission
and the planning and implementation partners, the Ministries that leads to inefficient decision-making
as shown by the broken lines12,22. This paper will, therefore, discuss if health resources are allocated
justly in Pakistan, using EPI program as an example.
Keywords: Resource Allocation, Health Care System
DOI Number: 10.5958/j.0974-9357.5.2.054
for its technical and financial feasibility. The committee
evaluates the strengths and weaknesses of the program
and approval is given by the Provincial or the Federal
Ministries based on the financial value of the project8.
Analysis of resource allocation in Pakistan
In countries such as Pakistan where there is paucity
of resources, just allocation of resources becomes more
critical8. Resource allocation is informal12,22,
centralized12,22 and based on personal and political
influences and donor wishes22 rather than national
interests8. As shown in figure 1, the health policy
making process in Pakistan is explicit yet there is lack
of coordination between the Planning Commission and
the planning and implementation partners, the
Ministries that leads to inefficient decision-making as
shown by the broken lines12,22. As there is lack of
scientific mechanisms, the definition of health needs
and priorities are reliant on decision makers and the
budget is allocated based on common knowledge,
intuition and allocations of previous year8,13,22. A
pioneer study done to identify the perceptions of
decision makers regarding resource allocation for the
Enhanced National Aids Program also revealed that
though the Planning Commission and Ministries of
Health and Finance have defined roles, the process of
resource allocation is “highly bureaucratic” thereby
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84 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
causing delays in the approval of the project. Most
importantly, the study demonstrated that individual
motivation and personal goals of the decision makers
were pre-dominant factors for resource allocation
rather than the national interests. Sadly, local evidence-
based data is not used to evaluate the cost-effectiveness
of the interventions in the process and the decisions
were based on “gut feeling”. Surprisingly, most of the
decision makers were unaware of the cost-effectiveness
tools and resource allocation was described by a
participant as “a political decision”. Moreover, donor
agency influence was also identified as an important
factor and the principles of equity and efficiency were
described by the participants as mere “slogans and
jargons”8.
Financing EPI
EPI service is free of cost for the population17 and
is funded partly by the Government of Pakistan and
by the donors. Government of Pakistan’s share of
funding for the Routine EPI in 2007 was 31% of total
program funding17. GAVI, which is the biggest EPI
donor, has committed US $313 million for the year
2001-20125. The allocation of budget for 2009-10 is Rs.
6000 million to improve health of mothers and
children9.
Analysis of EPI program: EPI is a justified program
though resource allocation for EPI is not sufficient and
appropriately utilized. Statistics reveal that EPI
vaccinates 5 million children under one year age and
pregnant women per year. A positive trend of 71%
overall coverage has been reported with DPT 3 at 69%,
Hepatitis B at 65%, measles at 68%5and BCG at 80%16.
In 2004, TT 2 was reported to be 43%5, which has now
increased to 57%16. Though not completely eradicated,
reduction of polio cases has been seen with 58%
coverage of Polio 3 in 2000. Likewise, the coverage of
DPT 3 was only 30% in the districts, which increased
drastically to 61% in 20095.
The goal of EPI program is to eradicate polio by
the end of 2005 and increase Routine Immunization
coverage to 80% by 20085. Conversely, the rate of fully
immunized children is only half of what was aimed
for 2008 with polio cases still emerging. Most of the
surveys in Pakistan reveal that the coverage of fully
immunized child, as per EPI Routine Immunization
schedule, is between 47% and 57% with highest rates
observed in Punjab while lowest rates seen in
Balochistan5.
If we analyze the utilization of costs against the
outcomes, the immunization cost was $ 104 million in
20085, yet, the country has not achieved its target of
80% overall coverage with financial resources being
wasted. For instance, it is estimated that if all children
had been vaccinated against DPT 3, the cost of per child
would have been US$ 17.83. On the contrary,
2008 baseline data of the EPI Comprehensive
Multiyear Plan 2011-2015 showed that the actual
expenditure was US $ 24.51, which is 37% higher and
lead to a total loss of US $ 28, 164,7745 (as shown in
table 1). Thus, though EPI is a justified program, it still
requires efforts in scaling up and utilizing the costs
effectively.
Resource Allocation for Expanded Program of
Immunization (EPI): Pakistan economic survey 2004-
05 indicates that the Infant Mortality Rate in Pakistan
is 74 per 1000 live births and the Under 5 Mortality
rate is 98 per 1000 live births, most of the deaths occur
due to preventable diseases,6. Similarly, Maternal
Mortality Rate ranges from 350 to 450 per 1000 live
births, which is one of the highest in the region mostly
occurring due to Tetanus during delivery45.
EPI is considered as the most cost-effective public
health intervention in reducing the communicable high
burden diseases14. Being one of the vertical service
delivery programs, EPI has played a pivotal role in
improving the health outcomes in Pakistan21.
Fig. 1. Pakistan’s current health policy framework12
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 85
Table 1: Comparison of per child vaccination cost and loss of annual expenditure5
Cost per child US $
Expenditure Categories Total At actual If 80% If 85% If 90% If 100 %
Expenditure coverage coverage coverage coverage coverage
in 2008 (US $) (73%) achieved achieved achieved achieved
Vaccines 57714408 13.56 12.37 11.64 11.00 9.90
Injection equipment 3894360 0.92 0.83 0.79 0.74 0.67
Operations 42705209 10.03 9.16 8.62 8.14 7.32
Total 104313977 24.51 22.36 21.05 19.88 17.89
Loss of value of annual 28.16 20.86 15.65 10.43 Nil
expenditure due to low
coverage (US $ million)
Conclusion/Discussion/Recommendation: Proposed
Changes
Health sector reforms are intended to bring about
a positive change through re-allocation of resources
to improve equity, efficiency and access to quality
healthcare services23. The strengths of Pakistani
healthcare system are health service delivery programs
and expansion of resources that have helped enhance
access of population to primary healthcare services.
In contrast, the weaknesses are lack of governance,
planning and surveillance along with lack of access,
equity and utilization of primary healthcare services.
Moreover, lack of planning and governance is also a
major factor that is affecting the resource allocation
and quality of services resulting in poor health
outcomes28.
Figure 2: PHC reforms towards health for all23
Figure 2 shows the four sets of integrated policy
reforms required to divert health system towards
Primary Health Care, which are universal coverage
reform, leadership reform, service delivery reforms
and public policy reforms23.
Universal coverage reforms: Healthcare services
should be such that reduce inequalities and exclusion
of the patients23. Hence, organizing primary care
networks so that the services are accessible and
affordable becomes vital23. In Pakistan, primary care
services that are accessible, unfragmented and efficient
are critical factors towards utilization of the services26.
An estimate reveals that only 15% of the budget is
spent on primary care which is utilized by the majority
(85%) of the population25. This in turn, increases usage
of tertiary care services and increases out-of-pocket
costs. Moreover, out of the $17 per capita spent on
health by the Government, out-of-pocket expenditure
is $13, which becomes a biggest barrier to accessing
healthcare services making it inequitable for the
population25. Hence, the health system of Pakistan
requires a serious paradigm shift25.
It is suggested that a Government-regulated social
health insurance, which is not currently common in
Pakistan, be progressively rolled out25. Studies done
to evaluate effects of contracting out on equity in access
and financial equity demonstrated that there was
remarkable improvement in both29. Insurance
programs rolled out in Malaysia, Thailand, Costa Rico
and Mexico are a few success stories23. A healthcare
basket of essential primary health care services could
also be offered as part of the insurance schemes19.
Nevertheless, this approach would limit the use of
services for those who require out-of-the-basket
services10.
Leadership reforms: Fragmentation of the health
system is mainly due to poor planning by the Federal
and Provincial Ministries that lacks integration,
participation and flexibility while implementation is
being done at the District level28. It is a known fact that
planning is a two-way process and plans are only
successful if there is feedback from the healthcare
providers working on the grass root level and their
recommendations incorporated28. This should be
overcome through decentralization of the system28.
Studies reveal that decentralization, which is the
transfer of power, is implemented in its true sense, has
positive impact on such as improvement in efficiency,
patient care, enhanced regional and local authority,
ownership19 and accountability19, improved
implementation of healthcare strategies and cost-
consciousness30. It is therefore, suggested that the
decision making power related to all primary
healthcare services should be handed over to the
District Office that is currently responsible for only
implementation of health policies. The District Health
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86 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Officer should be the supervisory body under the
provincial set-up to bridge the gap between planning
and implementation of the programs25. Conversely,
previous experience of decentralization in Pakistan
produced mixed results28. For instance, the
Government of Punjab has tried to decentralize the
system since 1990’s. The results of the recent
decentralized project of Rahim Yar Khan project
highlighted that lack of efficient policy formulation and
implementation systems was a major barrier in the
implementation28. Political manipulation of
decentralization, hindrances by the bureaucracy to
unleash their powers and possibility of increasing cost
and fragmentation is also various concerns with
decentralization. Therefore, it can be proposed that a
system of monitoring and surveillance be developed
and implemented alongside. Finally, strengthening the
core functions of the Ministry of Health and
department of health along with their capacity
building through on-going trainings is critical in
promoting strong stewardship role12. Setting of
standards through participative decision-making,
financial controls and providing performance-based
incentives would also assist in monitoring and
surveillance12.
ACKNOWLEDGEMENTS
I would like to acknowledge everyone who have
assisted me in writing this article; including my tutors,
friends, family, and my dear husband and children.
This would not have been possible without their
unconditional love and support!
Conflict of Interest: None
Ethical Clearance: Not required
Source of Funding: None
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17. Zahara Shaheen--83-88.pmd 1/6/2014, 9:30 AM88
International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 89
INTRODUCTION
India is one of the largest and most populated
countries in the world, with over one billion
inhabitants. Of this number, it is estimated that around
2.4 million people are currently living with HIV. HIV
emerged later in India than it did in many other
countries. Infection rates soared throughout the 1990s,
and today the epidemic affects all sectors of Indian
society. In a country where poverty, illiteracy and poor
health are rife, the spread of HIV presents a daunting
challenge. AIDS education for young people plays a
vital role in global efforts to end the AIDS epidemic.
Effectiveness of an Empowering Programme on Student
Nurses' Understanding and Beliefs about HIV/AIDS
Smriti Arora1, Sarin Jyoti2, Sujana Chakravarty3
1Assistant Professor, Rufaida College of Nursing, Hamdard Nagar, New Delhi, 2Principal, MM College of Nursing,
Haryana, 3Principal, Rufaida College of Nursing, New Delhi
ABSTRACT
Context: Recent research has shown inadequate knowledge, understanding and unfavorable attitude
towards HIV/AIDS amongst the youth. Many young people across India are still not receiving
information about HIV/AIDS.
Aim: The main aim of the study was to assess the effectiveness of an empowering programme on
student nurses' understanding and beliefs related to HIV/AIDS in a selected college of nursing in
Delhi.
Settings and Design: This true experimental study following pretest post design was conducted in
Rufaida College of Nursing, Jamia Hamdard, New Delhi.
Method and Material: The study was conducted among 65 student nurses pursuing third year BSc
nursing and General nursing during Aug 2011- March 2012. The students were randomized into
experimental and control group using a computer generated table of random numbers. There were
33 students in experimental group who received five days empowering programme and 32 students
in the control group who were not exposed to the empowering programme.
Statistical analysis used: Analysis was done using SPSS 16 using appropriate descriptive and
inferential statistics. Student t test was used to compare the understanding and beliefs between the
groups. Level of significance (p value) was kept at .05.
Results: Empowering programme was highly effective in increasing the understanding of student
nurses about HIV/AIDS and modifying their beliefs related to the same.
Conclusion: Empowering program facilitated the understanding and bringing about positive change
in the student nurses' beliefs about HIV/AIDS. More such programs can be planned and executed to
enable our youngsters to fight with the modern day epidemic i.e. HIV/AIDS.
Keywords: Empowering Programme, Understanding, Beliefs, HIV/AIDS
DOI Number: 10.5958/j.0974-9357.5.2.054
Yadav SB et al (1) conducted a community based study
among youths aged 15-24 years in rural areas of the
Saurashtra region of Gujarat, India and found that
basic knowledge of HIV/AIDS is still lacking in two
fifths of the rural youth. P Lal et al (2) in his study
reported that only 51.4% of the students were able to
write the full form of AIDS and 19.9% were able to
write the full form of HIV. Providing young people
with basic AIDS education enables them to protect
themselves from becoming infected. AIDS education
also helps to reduce stigma and discrimination, by
dispelling false information that can lead to fear and
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90 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
blame. It is crucial that young people learn about AIDS
in areas with a low prevalence so that the prevalence
stays low. The investigator undertook the present
study to investigate the understanding and beliefs of
nursing students related to HIV/AIDS and to assess
the effectiveness of an empowering programme on
HIV/AIDS.
SUBJECTS AND METHOD
In order to achieve the objective of the study the
following hypothesis was prepared;
H1: There will be a significant difference in the
mean posttest understanding and belief scores of
adolescents exposed to empowering programme on
HIV/AIDS and control group as measured by the
structured questionnaire at 0.05 level of significance.
The primary outcome variables were
understanding and beliefs of nursing students towards
HIV/AIDS.
In order to test the hypothesis the data was collected
from 65 student nurses after obtaining formal
permission from the institutional head. Verbal assent
was taken from the students after explaining them the
purpose of the study. The study was conducted among
65 female student nurses studying in third year of BSc
nursing and General nursing in Rufaida College of
Nursing, during Aug. 11 – March 2012. There were 34
students in BSc nursing and 31 students in General
nursing group, thus a total of 65 students. A sampling
frame of 65 student nurses was prepared from the
attendance register of first year B.Sc. and General
nursing students. The nursing students were
randomized into experimental and control group using
computer generated table of random numbers. There
were 33 students in experimental group and 32
students in control group. In each group there was a
mix of BSc and general nursing students. Students in
the experimental group were exposed to the
empowering programme. Intervention: The five day
empowering programme was prepared in consultation
with eight experts from community medicine and
nursing field with an objective to expand the
understanding of student nurses and modify their
beliefs related to HIV/AIDS. First two days focused
on the magnitude, basic dynamics, mode of
transmission and prevention of HIV/AIDS. Next two
days were dedicated to alter the beliefs of student
nurses about HIV infection and AIDS. Lecture, group
discussion and role play were used to impart correct
information to the students about AIDS. Case based
scenarios were used in the role plays to bring about a
change in the thought process of students. Tools: Two
parallel structured questionnaires were prepared to
assess understanding and beliefs of students related
to HIV/AIDS. Each questionnaire was pretested on a
group of ten students to ensure the clarity of items.
The content validity for the questionnaire was obtained
from ten experts in medical, nursing and education
field. Each questionnaire was divided into two parts ;
Part A and Part B. In part A, information about
demographic data and understanding of students
about HIV/AIDS was elicited. In the demographic
data information was obtained related to age, religion,
parents’ education, occupation and monthly family
income. To assess the understanding of nursing
students towards HIV/AIDS, 52 objective items were
framed. It contained 29 MCQs and 23 true false items.
Each MCQ contained a statement followed by four
options. There was only one correct response. Every
correct response was given one score. The 23 true false
items contained statements having possible choices of
“True, False, and Don’t Know”. The “Don’t Know” as
an option was included to reduce the probability of
guessing, as guessing causes some variation in
performance from item to item, which tends to lower
the test reliability. Each correct response had one score.
The items were prepared under the following heads:
magnitude of HIV/AIDS, mode of transmission,
management and prevention. The maximum score for
understanding domain was 52. The reliability was
assessed using KR 20 and it was found to be .84. The
test retest reliability was done within a gap of 10 days
to assess the stability of the tool. The value of pearson’s
r was .85. Difficulty level and discrimination index
were also calculated for the 52 items in understanding
domain.
In part B, the beliefs of the students towards HIV/
AIDS was assessed using a five point rating scale
containing 33 statements. The beliefs of the students
were assessed towards PLWHA, HIV infection and
safe sex. Students were asked to indicate the degree to
which they agree or disagree with the opinion
expressed by the statement. This tool consisted of 33
items. There were 16 positively worded and 17
negatively worded statements. Cronbach alpha was
used to assess the reliability of five point structured
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 91
rating scale containing 33 items. Its value was .79. The
value of pearson’s r obtained by test retest method
for rating scale within a gap of 10 days was .80. It took
around 45-60 minutes to complete the questionnaire.
Data collection technique: The data was collected
from 65 female nursing students selected conveniently
studying in Rufaida College of Nursing, Jamia
Hamdard. A list of all 65 students was obtained from
the attendance register of third year BSc nursing and
third year general students and the sampling frame
was prepared. These 65 students were randomised in
either experimental or control group using a computer
generated table of random numbers. First the data
was collected from the students in control group and
then from experimental group in order to avoid the
contamination between the groups. Structured
questionnaire I (pretest) was administered to the
students in control group on day 1 and parallel form
structured questionnaire II (posttest) was
administered on day 30 without administration of any
empowering programme. Then the data was collected
from the students in experimental group. A structured
questionnaire I( pretest) was administered to the
student nurses before initiation of the programme on
day 1. Following the empowering programme of five
days duration, the structured questionnaire II
(posttest) was administered on day 30 to the nursing
students to evaluate their understanding and beliefs
about AIDS.
RESULTS
The data was entered in MS excel and analyzed
using SPSS 16. The significance level was kept at 0.05.
The results were analyzed for 65 student nurses.
The mean age of the student nurses was 17.5 years.
Majority of the students were Hindus (87.6%). Most of
the fathers (73.8%) and 64.6% of mothers of the students
had studied till tenth standard. All the students had
heard about HIV/AIDS either from textbooks (90.7%)
or media (80%).
The pretest and posttest understanding and belief
scores within the group were compared using paired t
test. As shown in table 1, there was a significant increase
in mean understanding and belief scores after the
administration of empowering programme on HIV/
AIDS in the experimental group but no significant
difference was observed in the mean scores among the
students in the control group. After the implementation
of the empowering programme to the experimental
group, there was 48.9% increase in the mean scores
related to mode of transmission and 47.5% increase in
mean scores in the items related to prevention against
HIV infection. There was a significant difference
observed in the mean posttest understanding and belief
scores between the experimental and control group as
seen in table 2.
Table 1. Comparison of pretest and posttest scores of experimental and control group. N=65
Pretest Posttest t p
Mean (SD) Mean (SD)
Experiment group(n=33)
Understanding 15.09(5.4) 30.39 (7.6) 12.2 .00*
Belief 103.36(4.17) 129.12(13.5) 10.5 .00*
Control group(n=32)
Understanding 17.5(12.1) 22.94(9.5) 1.8 .06
Belief 104.1(7.5) 112.22(32.9) 1.3 .18
*significant at .05 level
Table 2. Comparison of posttest understanding and belief scores between the experimental and control group.
N=65
Experimental Control t p
group Mean group Mean
(SD)n=33 (SD)n=32
Understanding 30.39 (7.6) 22.94(9.5) 3.5 .001*
Belief 129.12(13.5) 112.22(32.9) 2.7 .01*
*significant at .05 level
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92 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Thus the hypothesis H1 is accepted that the
empowerment programme was effective in bringing
about a positive change in the understanding of
student nurses about HIV/AIDS and modifying their
beliefs towards the same.
There was no significant relationship observed
between mean posttest understanding and belief
scores (r=.06, p=.6) suggesting that understanding and
beliefs are independent of each other. The acceptability
of the empowerment programme was assessed using
an opinionnaire in which majority of the students
(90%) expressed that the programme was informative;
information was provided in simple and sensitive
manner which helped them to clarify their doubts
about HIV/AIDS and change their beliefs regarding
the same.
DISCUSSION
In the present study, with regard to the sources of
information about HIV/AIDS, majority of the students
mentioned that textbooks (90.7%) and television (80%)
were the main sources of information to them.
Likewise, a majority (62.7%) of senior secondary
students belonging to a government school in
Chandigarh reported that they derived most of the
information from TV and radio.(3) In Kuwait the 69 %
participants acquired information about AIDS from the
mass media. (4) Television as a source of information
was revealed by 72.1% students in a study by Li S,
Huang H, Xu G, Cai Y et al in China (5). These findings
imply promoting television as a significant source of
information. Low levels of knowledge about general
aspects and transmission of HIV/AIDS have been
observed in the current study which is congruent to
the findings amongst secondary school students in
Kolkata. (6)
The findings of the study are compatible with the
study conducted by Jahanfar S, Lim AW, Loh MA,
Yeoh AG and Charles A (7) who measured the
effectiveness of two hours talk on sex education offered
by a non governmental organization in improving
youngsters’ knowledge and perception towards HIV
and AIDS and found that there was a significant
increase in participants’ knowledge and perception
after the intervention (p = 0.000). Jahanfar S, Lye MS
and Rampal L (8) conducted a randomised controlled
trial of peer-adult-led intervention on improvement
of knowledge, attitudes and behaviour of university
students regarding HIV/AIDS in Malaysia and
concluded that the educational programmes for youth
using various interactional activities, such as small
group discussions, poster activity and empathy
exercises, can be successful in changing the prevailing
youth perceptions of AIDS and HIV. Similar
interactional activities like group discussion and role
play were used in the present study.
The present study was conducted only among girl
students, further studies may be carried out among
both the genders. Conclusion: Empowering program
facilitated the understanding and bringing about
positive change in the student nurses’ beliefs about
HIV/AIDS. More such programs can be planned and
executed to enable our youngsters to fight with the
modern day epidemic i.e. HIV/AIDS.
ACKNOWLEDGEMENT
The authors would like to thank the student nurses
who participated in the study without which this study
would not have been possible and the experts like late
Dr. Bir Singh, and Ms. Madhavi Verma for validating
the tool.
Interest of Conflict: None
Ethical Clearance: The permission was taken from the
HOD, Rufaida College of Nursing prior to conduct
the study.
Source of Funding Nil
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2. P Lal, Anita Nath, S Badhan, Gopal K Ingle. A
study of awareness about HIV/AIDS among
senior secondary school children of Delhi. Indian
J Community Med. 2008 July-September ;33(3):
190-192.
3. Sodhi S, Mehta S. Level of Awareness about AIDS:
a comparative study of girls of two senior
secondary schools of Chandigarh. Man India.
1997;77:259–66.
4. Rashed A. Al-Owaish et al. Knowledge, attitudes,
beliefs and practices of the population in Kuwait
about AIDS—a pilot study Eastern
Mediterranean Health Journa 1995: 1(2);235-240.
5. Li S, Huang H, Xu G et al. HIV/AIDS-related
knowledge, sources and perceived need among
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senior high school students: a cross-sectional
study in China.Int J STD AIDS 2009;20:561-565.
6. Chatterjee C, Baur B, Ram R, Dhar G,
Sandhukhan S, Dan A. A study on awareness of
AIDS among school students and teachers of
higher secondary schools in north Calcutta.
Indian J Public Health. 2001;45:27–30.
7. Jahanfar S, Lim AW, Loh MA, Yeoh AG, Charles
A. Improvements of knowledge and perception
towards HIV/AIDS among secondary school
students after two hours talk. Med J Malaysia.
2008 Oct;63(4):288-92
8. Jahanfar S, Lye MS, Rampal L. A randomised
controlled trial of peer-adult-led intervention on
improvement of knowledge, attitudes and
behaviour of university students regarding HIV/
AIDS in Malaysia. Singapore Med J. 2009
Feb;50(2):173-80.
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94 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
The most important factor in a child’s healthy
development is to have at least one strong relationship
(attachment) with a caring adult who values the well-
being of the child. A father is an involved father if his
relationship with his child can be described as being
sensitive, warm, close, friendly, supportive, intimate,
nurturing, affectionate, encouraging, comforting, and
accepting. In addition, fathers are classified as being
involved if their child has developed a strong, secure
attachment to them. The role of the father in child
rearing is limited, whereas mothers assume primary
responsibility for childcare duties However, recent
social and demographic changes as well as increasing
full time employment of wives increase pressure for
fathers to become more actively involved in child
rearing.1
A Study to assess the Knowledge and Involvement in
Child Rearing Practices among Fathers of Hospitalised
Children of 1-6 Years of Age, in Kasturba Hospital,
Manipal
Sreeram A1, D' Souza A2, Margaret B E2
1MSc Nursing, 2Assistant Professor, Department of Child Health Nursing; Manipal College of Nursing; Manipal
University, Karnataka, India
ABSTRACT
Objective: To assess the knowledge and involvement in child rearing practices among fathers of
hospitalised children of 1-6 years of age.
Materials and method: A descriptive correlational survey was done among conveniently selected
150 fathers of hospitalised children of 1-6 years of age at Kasturba Hospital, Manipal. The knowledge
and involvement in childrearing practices were assessed using a demographic proforma, knowledge
questionnaire and involvement rating scale.
Result: The findings showed that fathers had satisfactory knowledge and satisfactory involvement
in childrearing practices. However there was no relationship between knowledge and child rearing
practices. The study also revealed that there was a significant association between knowledge and
type of family ( p= 0.015ï) and that there was no association between involvement in childrearing
practices and demographic variables.
Conclusion: The study concluded that there is no relationship between knowledge and involvement
among fathers in child rearing practices and fathers had satisfactory knowledge and satisfactory
involvement in childrearing practices.
Keywords: Knowledge, Involvement, Child Rearing Practices, Hospitalised Children
DOI Number: 10.5958/j.0974-9357.5.2.054
A comparative study was conducted by Rodolfo
in 2005 about parenting knowledge in a sample of 70
married Brazilian couples in Rio De Janeiro. Snowball
sampling technique was used to select the participants.
Knowledge on infant development inventory was
collected and a sociodemographic questionnaire was
distributed and hierarchial regression analysis was
used to know whether gender, education status
predicted the knowledge scores. The study found out
that the average knowledge scores in mothers was
found to be significantly higher than that of father’s
knowledge scores and that in mothers, the education
[F(1,69) - 15.13] and child’s age[F(2,69)-3.92] predicted
knowledge score, that is older mothers with more
education and older children had higher knowledge
scores but for fathers only education predicted
knowledge score. 2
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 95
Palkovitz (1997) broadened the conceptualization
of childrearing with reference to 15 categories of
paternal involvement that included: Communication
(listening, talking, showing love); Teaching (role
modeling, encouraging activities and interests);
Monitoring (friends, homework); Cognitive processes
(worrying, planning, praying); Errands; Caregiving,
(feeding, bathing); Shared interests (reading together);
Availability; Planning (activities, birthdays); Shared
activities (shopping, playing together); Providing
(food, clothing); Affection; Protection; and Supporting
emotionality (encouraging the child).3
A survey done by Jessica and Mohammed Khan
in Bangladesh in 2010 sought to initiate dialogue about
fathering and fatherhood within the contexts of
cultural continuities and shifts, labor migration, and
geopolitical disturbances that are affecting families and
communities throughout South Asia. The findings
revealed that rural fathers appear to spend much more
time with their children, especially boys; fathers and
sons work together in the fields and factories, bathe
together in ponds, and gather firewood and food
together and they also may walk their children to
and from school whereas urban fathers generally have
much less time to spend with children as a result of
long work and commuting hours. The findings also
indicated that a parent education program in
Bangladesh should focus on providing fathers with
appropriate information about child health, safety,
nutrition, and development, and encourage them to
share ideas about how they can enhance and sustain
their care giving roles, even across changing
circumstances, such as temporary out-migration.4
A comparative survey done by Taiwanese
professors in child education surveyed the parental
involvement through a questionnaire in 2009. The
survey included instruments regarding parental
engagement activities and parental role beliefs. Among
the specific activities examined in the study (e.g.,
reading stories; practicing Chinese characters; teaching
songs; and visiting libraries, museums, and zoos),
Taiwanese mothers typically participated more in these
events compared to Taiwanese fathers. The study
indicated that the rapid changes to Taiwan’s social and
economic conditions and the resulting shift from a
traditional to a progressive society have contributed
to fathers becoming more involved with the everyday
lives of their children and to mothers and fathers
sharing more liberal beliefs about parenting roles.5
Although fathers became a topic of interest and
research, few Indian studies have specifically
examined fathers knowledge and attitude in child
rearing. Understanding the parent–child relationship
is fundamental to nursing of children and families.
Fathers have a key role in the development of a child
and their attitude and involvement in child rearing
brings about sociopsychological changes in the child’s
growing periods .
The investigator’s clinical and personal experience
provided rich insight into the problem. Studies
regarding paternal attitude in childrearing are studied
less in Indian population. This study is undertaken
since studies on paternal knowledge, attitude and
perceived paternal involvement in childrearing are few
in number.
The purpose of the study was to assess the
knowledge and involvement of fathers in
childrearing practices. The findings of the study would
help to identify the ways to improve the role of the
father in childrearing .The information gained will help
the health care personnel in planning educational
activities for the father in the future.
MATERIALS AND METHOD
Participants
After obtaining the ethical approval from the
institutional ethical committee, a total of 150 fathers
were conveniently selected from Paediatric medicine
wards whose children between the age of 1-6years
were admitted with minor conditions such as fever,
respiratory infections, urinary problems, etc and or
those who came for routine immunisation visits in
Paediatric outpatient department of Kasturba Hospital
Manipal.
MATERIALS
A demographic proforma was used which had ten
items that were divided into two sections namely;
data related to the father such as age, religion, type of
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96 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
family ,number of children, monthly income of family,
education and occupation and data related to the child
such as age , gender and birth order.
The knowledge questionnaire had thirty items
under different areas of child rearing practices namely
nutrition, health, milestone development,
immunization, accidents and toilet training with four
response options for each question and the correct
response was assigned a score of one and the incorrect
item was assigned a score of zero. According to the
scores obtained, the fathers were categorized into
having poor knowledge with scores between (1-10),
satisfactory knowledge with scores between (11-20)
and good knowledge with scores between (21-30).
The involvement rating scale had twenty items.
There were four responses to each item ranging from
always, sometimes, rarely and never. According to the
scores obtained, the fathers were categorized into
having poor involvement with scores between (20-40),
satisfactory involvement with scores between (41-60)
and good involvement with scores between (61-80).
METHOD
A descriptive correlational survey was done among
conveniently selected 150 fathers of hospitalised
children of 1-6 years of age from the Paediatric out
patient department and Paediatric medicine wards of
Kasturba Hospital, Manipal. The subject information
sheet about the study and informed consent were
given to the fathers. After obtaining informed consent,
the four tools were administered. The fathers were
asked to read the instructions of each tool and complete
each item accordingly.
FINDINGS
The data was categorized based on the objectives
and hypotheses of the study using descriptive and
inferential statistics. The SPSS ( 16.0 version) statistical
package was used for the analysis of data.
Table 1. Demographic characteristics of fathers of hospitalized children (n=150)
Demographic variable Category Frequency Percentage (%)
Age (in years ) 24- 29 39 26
30- 35 79 52.7
36-42 32 21.3
Religion Hindu 114 76
Muslim 20 13.3
Christian 16 10.7
Type of family Nuclear 117 78
Joint 33 22
Number of children One 76 50.7
Two 6 6 44
Three 8 5.3
Monthly family income (in rupees) 3000-5000 11 7.3
5000-7000 32 21.3
7001-9000 63 42
>9001 44 29.3
Education Upper primary 14 9.3
Secondary 42 28
Higher secondary 40 26.7
Diploma 27 18
Graduate 23 15.3
Postgraduate 4 2.7
Professional 15 10
Non professional 24 16
Occupation Skilled 50 33.3
Semiskilled 22 14.7
Unskilled 39 26
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 97
Table 2:Demographic characteristics of children (n=150)
Demographic variable Category Frequency Percentage (%)
Age (in years) 3-Jan 97 64.7
>3-6 53 35.3
Gender Female 90 60
Male 60 40
Birth order First 93 62
Second 50 33.3
Third 7 4.7
It was observed that majority 79 (52.7 %) of the
fathers belonged to the age group of 30-36 years,
belonged to Hindu religion 114 (76 %) and nuclear
family 117 (78 %) .Majority 76 ( 50.7 % ) of the fathers
had only one child . Regarding the family income, 63
(42%) had income between Rs 7001-9000. The study
results showed that 42 (28%) of the fathers had
secondary level of education and 50 (33.3% ) were
employed as skilled workers . It was also observed
that the majority 97 ( 64.7%) of the children were
between the age of 1-3 years , 90 ( 60%) of the children
were girls whereas 60 (40%) were boys and majority
93 (62%) of the children were first born.
Table 3: Mean, Median, Standard deviation of knowledge, attitude and involvement scores of fathers (n=150)
Variables Mean Median Standard
deviation
Knowledge 19.34 19 2.471
Involvement 66.98 67 5.183
The mean knowledge score on childrearing
practices was 19.34 +/- 2.471 and the mean
involvement score in child rearing practices was
66.98+/- 5.183.
Table 4: Correlation between knowledge and involvement in child rearing practices (n=150)
Variable Correlation coefficient p-value
Knowledge 0.070 0.397
Involvement
The data presented in table 4 shows that the p value
obtained is more than 0.05. Therefore, the null
hypothesis is accepted stating that there is no
significant relationship between knowledge and
involvement in child rearing practices among fathers
of children of 1-6 years of age.
Table 5: Association between knowledge in child rearing practices and selected demographic variables. (n=150)
Demographic variables Knowledge χχ
χχ
χ2df p-value Significance
< 19 >19
Age
24-29 19 20
30-35 42 37 1.391 2 0.499 Not significant
36-42 20 12
Religion
Hindu 62 52
Muslim 10 10 0.168 2 0.919 Not significant
Christian 9 7
Type of family
Nuclear 57 60
Joint 24 9 5.973 1 0.015ï Significant
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98 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Table 5: Association between knowledge in child rearing practices and selected demographic variables. (n=150)
(Contd.)
Demographic variables Knowledge χχ
χχ
χ2df p-value Significance
< 19 >19
Number of children
One 41 35
Two 36 30 0.06 2 0.971 Not significant
Three 4 4
Monthly family income
Below 7000 (in rupees) 23 20
Above 7000 (in rupees) 58 49 0.006 1 0.936 Not significant
Education
Below Diploma 56 40
Above Diploma 25 29 2.016 1 0.156 Not significant
Occupation
Skilled 46 43
Unskilled 35 26 0.472 1 0.492 Not significant
Age of the child
Below 3 years 52 45
Above 3 years 29 24 0.017 1 0.896 Not significant
Birth order
First 49 44
Second 29 21 0.736 2 0.692 Not significant
Third 3 4
The data presented in table 5 revealed that there is
significant association between knowledge and type
of family ( c2
(1 ) = 5.973, p= 0.015ï). Thus it can be
interpreted that knowledge is dependent on type of
family and independent of other variables. Hence the
researcher rejected the null hypothesis with regard to
type of family and accepted the null hypothesis with
regard to other remaining variables
Table 6: Association between involvement in child rearing practices and selected demographic variables (n=150)
Demographic variables Involvement χχ
χχ
χ22
22
2df p-value Significance
Satisfactory Good
Type of family
Nuclear 10 107
Joint 6 27 2.508 1 0.113 Not significant
Number of children
One 8 68
Two 8 58 1.103 2 0.576 Not significant
Three 0 8
Education
Below Diploma 8 88
Above Diploma 8 46 1.524 1 0.791 Not significant
Occupation
Skilled 9 80
Unskilled 7 54 0.071 1 0.217 Not significant
Gender
Female 8 82
Male 8 52 0.746 1 0.388 Not significant
Birth order
First 10 83
Second 6 44 0.93 2 0.628 Not significant
Third 0 7
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 99
The data from table 6 showed that the p- value
obtained for the association between involvement and
demographic variables is more than 0.05 stating that
the null hypothesis is accepted, therefore there is no
significant association between involvement in child
rearing practices and selected demographic variables.
knowledge in a sample 70 married brazilian couples
in Rio De Janeiro found out that the average
knowledge scores in mothers (M= 0.69, SD= 0.09) was
found to be significantly higher than that of father’s
knowledge scores(M= 0.64, SD= 0.09).
IMPLICATIONS
The practical implications of the study is that the
findings would help the nurses to understand the level
of knowledge, attitude and involvement of fathers in
childrearing practices. The awareness on the important
areas of child development like nutrition, health,
milestone development, immunisation, toilet training,
and the prevention of home accidents should be a
part of health teaching both in the hospital and in the
community. Nurses must focus on to the full
participation of each parent in the care of their child
by educating them about aspects of child rearing.
Different A. V aids can be used in imparting
knowledge to various categories of people. From the
present study, the investigator as a nurse felt the need
that nurse should act as a facilitator to educate fathers
regarding child rearing practices. Nursing
administration should implement outreach
programmes in the rural areas to make the fathers
aware about child rearing practices both within and
outside the hospital.
CONCLUSION
The present study shows that majority (66.1%) of
the fathers had satisfactory knowledge in childrearing
practices and The study also shows that there is
significant association between knowledge and type
of family ( χ2
(1 ) = 5.973, p=0.015ï). From this study it
can be inferred that as there is no relationship between
knowledge and involvement , fathers have got
satisfactory knowledge and satisfactory involvement
in childrearing practices.
ACKNOWLEDGEMENT
I extend my gratitude to Dr. Anice George, Dean,
Manipal College of Nursing for providing an
opportunity to undertake the study and for her
valuable ideas and suggestions in the initial part of
my study.
My heartfelt gratitude to Dr. Baby S. Nayak, HOD,
Department of Child Health Nursing, Manipal College
of Nursing for her valuable guidance and concern
during the entire period of my study.
Fig. 1. Pie diagram showing the percentage distribution of fathers
in each knowledge category. n=150
The data presented in figure 1 showed that a
majority 100 (66.7%) of the fathers had satisfactory
knowledge in child rearing practices whereas 50 (33.3
%) fathers had good knowledge in child rearing
practices
Fig. 2. Pie diagram showing the percentage distribution of fathers
in each involvement category. n=150
The data presented in figure 2 showed that a
majority 134 (89.3%) of the fathers had satisfactory
involvement in childrearing practices whereas 16
(10.7%) fathers had good involvement in child rearing
practices.
DISCUSSION
The present study shows that a majority 100
(66.1%) of the fathers had satisfactory knowledge in
child rearing practices with a mean knowledge score
on childrearing practices of 19.34 +/- 2.471. Similar
to the present findings, a comparative study
conducted by Rodolfo in 2005 about parenting
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100 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Conflict of interest : Nil
Funding : Nil
REFERENCES
1. Retrived from http://en.wikipedia.org/wiki/
Scientific Child Rearing.
2. Castro R. Parenting knowledge, similarities and
differences in Brazilian mothers and fathers.
InterAmerican Journal of Psychology.2005 Mar;
39(1):5-12.
3. Palkovitz R. Reconstructing involvement:
Expanding conceptualizations of mens caring in
contemporary families.1997. Retrieved from
URL: http://udel.edu/~robp/downloads/
reconstructing%20involvement.pdf.
4. Ball J, Khan M O. Exploring fatherhood in
Bangladesh. International Focus Issue. 2010.
5. Parental involvement in Taiwanese families:
father-mother differences. Childhood
Education. Association for Childhood Education
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 101
INTRODUCTION
The diagnostic and statistical manual of mental
disorders (DSM-IV) defines post-natal depression
(PND) as a major depressive episode occurring within
four weeks of childbirth1.This debilitating illness has
been described by mothers as “going to gates of hell
and back”, “your worst possible nightmare”2.
Annually approximately 400,000 mothers in the
United States are diagnosed with postnatal depression.
Identify Risk Factors For Postnatal Depression Among
Antenatal Mothers - A Hospital Based Study
Alma Juliet Lakra1, Salomi Thomas2
1Lecturer, Department of Fundamentals of Nursing, Manipal College of Nursing, Manipal University, Manipal,
Karnataka, 2Associate Professor, OBG Nursing Department, St. John's College of Nursing, Bangalore
ABSTRACT
Aim: Identify the risk factors associated with postnatal depression among pregnant women and its
outcome in a selected urban hospital in Bangalore.
Method: A cross sectional study design was used with sample consisting of hundred pregnant women
selected at convenience. The study was based on the conceptual framework of Pender's health
promotion model. The risk factors of low self esteem, prenatal anxiety and depression, lack of social
support, life stress and poor family relationship were measured using modified postpartum predictors
inventory.
Findings: Most prevalent risk factor for postnatal depression among pregnant women was prenatal
anxiety and depression (81%) and the least prevalent risk factor was poor family relationships. The
outcome area most affected was sleeping eating disturbances (mean %=40.5) and physical appearance
(mean %= 22.23). Significant associations were noted between family income with life stress (p=0.013)
and poor family relationships (p=0.017).
Conclusion: Presence of certain risk factors in the antenatal period places the mother at a higher risk
of developing postnatal depression and nurses should assess mothers at each contact for signs and
symptoms of depression.
Keywords: Prevalence, Pregnant Women Risk Factors, Postnatal Depression
DOI Number: 10.5958/j.0974-9357.5.2.054
Corresponding author:
Alma Juliet Lakra
Lecturer
Department of Fundamentals of Nursing, Manipal
College of Nursing, Manipal University, Manipal,
Karnataka-576104
E mail: alma.lakra@manipal.edu
Mob:+ 9731076474
The recent enquiries have reported prevalence rates
for postpartum depression of 15.8 % in Arab women,
16% in Zimbabwean women, 34.7% in South African
women, 17% in Japanese women, 23% in Goan women
and 30% in Bangalorean women, India3.However as
much as 50% of all cases are undetected, and the
incidence and prevalence rates of postnatal depression
are misleading and thought to be underreported.
The immediate and long term consequences of
postpartum depression are far reaching, affecting not
only the mother but her infant and their
relationships4.Many obstetric care providers fail to ask
mothers explicitly about symptoms of depression and
may not schedule visits until 6 weeks after delivery
when symptoms may already have led to adverse
consequences5. Heneghan and Chaudron have
reported that clinical discomfort with psychiatric
disorders, time constraints, low belief in maternal
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102 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
health having an important effect on child
development, and lack of knowledge about resources
are some of the barriers to clinical screening for
psychiatric disorders in medical settings6.
A systematic review examining antenatal risk
factors for postnatal depression of over 14,000 subjects,
found that the following factors were the strongest
predictors of postpartum depression: depression
during pregnancy, anxiety during pregnancy, stressful
life events experienced during pregnancy or the early
puerperium, poor social support, and a previous
history of depression7. There is no perfect time for the
assessment of a woman with signs of postpartum
depression but it needs to be continuous. Nurses do
not look for postnatal depression as a part of their
assessment and this is an aspect that has been
neglected due to early discharge and lack of time.
Keeping in mind the seriousness of the disease and to
make prevention of postpartum depression as the
primary nursing goal this study was taken up with
the aim of identifying the risk factors of postnatal
depression among pregnant women are able to
provide adequate referral services.
METHODOLOGY
A cross sectional descriptive survey design was
selected and study was carried out at the OBG
outpatient, antenatal and postnatal units of a selected
tertiary care hospital. The study was based on Revised
Pender’s model of health promotion (2002). Informed
consent was taken from participants consisting of 100
pregnant women attending the outpatient department
as well as those admitted in the inpatient antenatal
unit. Pregnant women at or beyond 36 weeks of
gestation and willing to come for deliveries in the same
hospital were included in the study. Pregnant women
who developed pregnancy related complications like
metabolic, endocrine disorders and eclampsia and
with previous history of psychiatric illness were
excluded from the study owing to the reason that
literature review has shown that these mothers are at
a potential risk of developing PND due to the effect of
these conditions. A non probability convenient
sampling technique was used.
After the sample selection, modified post partum
predictors inventory was administered to the mother
in a separate counseling room in the OPD, for samples
identified in the inpatient area the inventory was
administered in the class room. Investigator kept a
track of the patients till delivery. After the delivery
three participatory observations were made using an
observational checklist at 24 hrs and 48 hrs of delivery,
the last observation was done at the time of discharge
along with a structured questionnaire answered by the
samples.
Findings of the study
Out of the 100 pregnant women, majority (58%) of
the antenatal mothers were less than 25 years of age,
about 55 % had received education upto high school
and majority (74%) of the mothers were semi skilled
workers. 60% belonged to nuclear families, family
history of psychiatric illness was present in 6%, 65%
had their family income more than Rs.10, 000 and
majority (89%) had undergone vaginal delivery.
Table 1: Participants demographic characteristics
n=100
Baseline variables Frequency Percentage (%)
Age (in years)
<25 52 52
≥25 48 48
Education
High school 44 44
Pre degree 19 19
Graduate 37 37
Occupation
Professional 19 19
Skilled 7 7
Semi skilled 74 74
Type of family
Nuclear 60 60
Joint 40 40
Family history of psychiatric illness
Absent 94 94
Present 6 6
Family income
<Rs.10,000 35 35
≥Rs.10,000 65 65
Type of delivery
Vaginal delivery 89 89
Caesarean section 11 11
Fig. 1. Distribution of antenatal mothers based on the prevalence
of risk factors of postpartum depression.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 103
The risk factor of post partum depression most
prevalent among pregnant women was prenatal
anxiety & depression and the least prevalent risk factor
was family relationships.
Postnatal outcome areas of subjects most affected
were sleeping eating disturbances (mean %= 40.5) with
the least affected area being suicidal thoughts (mean%=
26.33) .
Table 2: Range, mean and standard deviation based on the outcome among postnatal mothers n=100
Sl No Outcome Maximum score Range Mean Mean % Standard deviation
1 Sleeping eating disturbances 20 5-14 8.10 40.5 2.51
2 Anxiety and insecurity 12 3-7 4.52 37.6 1.27
3 Emotional stability 20 5-10 5.79 28.9 1.28
4 Mental confusion 12 3-7 3.75 31.25 1.04
5 Loss of self 8 2-5 2.19 27.37 0.58
6 Guilt and shame 16 4-12 4.51 28.18 1.38
7 Suicidal thoughts 12 3-7 3.16 26.33 0.66
There was no association of risk factors with age,
education, type of family and occupation. Significant
associations were observed between family income
with life stress (p=0.013) and poor family relationships
(p=0.017) at 0.05 level of significance.
DISCUSSION
The most prevalent risk factor in this study was
identified as prenatal anxiety and depression (n=81).
A longitudinal study by the University of Reading
have implicated that there is paucity of evidence on
the relationship between the various forms of anxiety
and postnatal depression8, after accounting for the
presence of other antenatal anxiety disorders,
antenatal depression, maternal age at child’s birth,
socio-economic status and ethnicity, antenatal
generalised anxiety disorder independently predicted
depression at all time points after delivery. The study
carried out in Italy also supports that the most
prevalent risk factor for the occurrence of PPD at 6-8
weeks was antenatal anxiety9 ,in another cohort study
conducted in Tamil Nadu, the risk factors for postnatal
depression identified were low income, an adverse life
stress, poor relationship with in laws, birth of a
daughter and lack of physical help at home3, a meta-
analysis conducted in North America found the
following risk factors of stressful life events during
pregnancy, poor social support and previous history
of depression7.
Findings of the current study state that outcome
area of sleeping eating disturbances (mean= 8.10) and
physical appearance (mean=0.697) was most affected.
Similar conclusions were drawn from a study using
the DSSI-D (Delusions-Symptoms-States Inventory),
which states that having difficulty sleeping, feeling
inactive and depressed without knowing why were
some of the common symptoms reported10.According
to this study, there was an association between family
income with life stress (p=0.013) and with poor family
relationships (p=0.017). The presence of low family
income increases life stress and poor family
relationships placing the mother at a higher risk for
developing postnatal depression. Significant
associations were also reported in a study carried out
in Turkey between the risk factors of postnatal
depression and poor socio-economic status. Women
with very poor economic status had more than a six
times higher risk of depression than those with good
economic status. Women with poor family
relationships have a fivefold higher risk of depression.
The risk of depression was almost two times higher
among women with three or more daughters.6
LIMITATIONS
Convenient sampling technique which was used for
this study and small sample size, which may limit the
generalizability to the population under study. Follow
up of the study samples was not done.
CONCLUSION
The present study shows that there is higher
prevalence of risk factor prenatal anxiety and
depression during the antenatal period. Hence there
is an urgent need for early identification of high risk
mothers in order to prevent the occurrence of postnatal
depression during puerperium. Nurses as health
professionals play a very important role by making
family members aware of this phenomena and taking
active steps to screen mothers during puerperium. The
study findings will help to think and implement several
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104 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
possible practical measures in the fields of nursing
education, nursing practice, and nursing research.
ACKNOWLEDGEMENTS
The authors are extremely grateful to the mothers
who participated in the study.
Conflict of Interest: Nil
Source of Funding: Nil
Ethical Clearance: Institutional ethical committee
clearance was sought before conducting the study.
REFERENCE
1. Sobey, WS. 2002. Barriers to postpartum
depression prevention and treatment: A policy
analysis. Journal of Midwifery and women’s
health (5):331-336.
2. Beck, TC. 1998. A checklist to identify women at
risk for developing postpartum depression.
Journal of Obstetrics and Gynaecologic nursing
(27)39-46.
3. Chandran, M. Tharyan, P. Muliyet, J. Abraham,
S. 2002. Postpartum depression in a cohort of
women from rural area of Tamilnadu, India.
British journal of psychiatry http://
www.rchpsy.org/full/content/html.
4. Bronwyn, L. Jeannette, M. 2008. Risk factors for
antenatal depression, postnatal depression and
parenting stress. http://
www.biomedcentral.com/1471-244x/8/24.
5. Noreen CF. Lawrence, F. 2006. Psychiatry health
nursing. Sanat, Haryana.
6. Pearlstein,T. Margaret, H. Amy, S. Caran, Z. 2009.
Postpartum depression. American Journal of
Obstetrics and gynaecology (55)357-362.
7. Kizilay, PE. 1992. Prediction of depression in
women. Nursing clinics of North America (4):983-
992.
8. Milgrom, J. Gemmill, AW. Bilszta, JL. Hayes, B.
Barnett, B. Brooks, J. Ericksen, J. Ellwood, D.
Buist, A. 2008. Antenatal risk factors for postnatal
depression: a large prospective study. Journal of
affective disorders (1-2):147-57.
9. Bhachech, H. Bhargava, A. 2000 . Postpartum
psychiatric disorder. Indian Journal of paediatrics
(1):241-244.
10. Vikram,P. Merlyn,R. Nandita,D. 2002. Gender,
Poverty and postnatal depression: A study of
mothers in Goa. American Journal of psychiatry
(1):43-47.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 105
INTRODUCTION
Despite the several local and international
initiatives taken, eradication campaigns and
immunization programmes, communicable diseases
such as tuberculosis, measles and polio remain the
leading cause of mortality and morbidity in developing
countries. 1 These communicable diseases may affect
children and adults badly; as a result they either are
disabled or lose the important time of their life
including loosing schooling and employments. 2
Pakistan is one of the high risk countries where
infectious/communicable diseases account for almost
41 percent disease burden 3. Each year Tuberculosis
kills 68000 people in Pakistan. 4 Although polio has
Accessing Community Through A Nursing Course:
Evidence Based Practice
Amina Aijaz Khowaja1, Lubna Ghazal1, Fatima Jawad1, Naveeda Haq2
1Senior Instructor, School of Nursing and Midwifery, 2Instructor, Institute of Education Develpment, Aga Khan
University, Stadium road, PO Box 3500, Karachi 74800, Pakistan
ABSTRACT
Back ground: Despite several initiatives taken communicable diseases such as Tuberculosis, measles,
and polio remain the leading cause of mortality in developing countries but also severely affect both
children and adults. Therefore, it is necessary to prevent them on mass scale by raising awareness
among public by health care professionals.
Method: Nursing faculty in one of the private health institutions in Karachi Pakistan conceptualized,
designed, and operationalized a course for students to address the issue of communicable diseases
in general public within the course. One of the assessment strategies "Teaching Learning Aids
Assignment" was designed in step by step approach that involved: community assessment;
prioritization of problems; health awareness session planning; budgeting; session delivery; and the
evaluation.
Results: The designed strategy was successful in engaging students in learning as well it served the
dual purpose of health awareness in communities, especially among children, parents and teachers
in school and community settings. The course also left a positive impact on some school policies and
sensitized communities to take pertinent actions against communicable diseases.
Conclusion: The innovative nursing course helped the nursing students and nursing faculty to access
communities in providing health awareness sessions during the course implementation and also
provided opportunity for students to acquire skills of a health educator in health promotion and
disease prevention. This teaching learning strategy also had positive impact on the community.
Keywords: Communicable and Tropical Diseases, Nursing Education, Teaching Learning Strategy, Health
Promotion
DOI Number: 10.5958/j.0974-9357.5.2.054
been eradicated from most of the countries, Pakistan
reported 58 cases of polio in 2012.5 Moreover, from
January 2012 to February 2013 measles epidemic in
Pakistan affected 19,048 with 463 deaths of children.6
This disastrous situation calls for local health
professionals to take personal interest and work
collaboratively to save lives of the people. Such
initiatives could be taken by focusing on public
awareness at mass scale through community
involvement. The Health Sciences University or
Schools of Nursing can also help developing in public
awareness programmes to promote health and prevent
illness as they can use innovative teaching learning
strategies to address the prevalent communicable
diseases.
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106 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
This paper will share one of the initiatives taken
by the faculty of a private university- School of Nursing
and Midwifery that accessed communities through
their course, in which the community was involved
and mobilized to eradicate tropical and communicable
diseases. Moreover, the nursing students also availed
an opportunity to learn and practice the role of
community health nurse, as a health educator.
Course conceptualization and design (background)
In this process the “Tropical and Communicable
Diseases” course was redesigned and integrated in the
curriculum. Previously, the concepts of tropical and
communicable diseases were scattered in different
courses i.e. child health nursing, adult health nursing
and community health nursing in the existing nursing
curriculum. However, looking at the epidemics of
communicable diseases in the country, a need for a
separate course was identified by the faculty.
Moreover, the objective of separating this course was
to develop the competence of nursing students, once
they graduate to deal patients with communicable
diseases as well as to educate general public regarding
the prevalent communicable disease. Therefore, for the
purpose of emphasis, all the topics of major
communicable diseases were extracted from different
nursing courses and were put together to make a
separate course. In addition, keeping in mind the
objective of this newly developed course, it was
important to assess the nurses’ knowledge and their
teaching learning skills regarding tropical and
communicable diseases (in past it was paper and pencil
test) . Therefore, it was decided to include one of the
assessment criteria that is “low cost teachings aids
assignment” cum “health education project” to
evaluate both the above mentioned competencies
(knowledge and teaching skills) in students. Thus this
assignment was conceptualized and planned to
operationalize after the curriculum committee, which
approved it and allowed to implement it in the
diploma and baccalaureate nursing programmes after
several vigilant reviews.
Course Planning and Budgeting
It is important to share that this community based
project helped the students to access the actual
community in need for the health education sessions.
However, this step required intense planning for the
implementation of the project with students, targeted
community and the School of nursing administration
by the course faculty. This course is offered twice a
year.
Once the course faculty identifies and approaches
second partner i.e. target groups where the project is
supposed to be implemented. , she prepares course
budget, which includes transport to reach community,
students’ lunch and gets approval of the budget by
AKUSONAM administration. Next, faculty
collaborates with target population heads (community,
school administration, or hospital heads) and the year
coordinator AKUSONAM to decide the day and
timings for the project implementation, according to
the availability of the target groups.
Community assessment and involvement
The major emphasis of the tropical and
communicable diseases course is that the students
learn the theoretical concepts related to the spread of
communicable diseases in hospital and community
and apply their concepts through health awareness
sessions in hospital/ community, as literature suggests
that bridging theoretical knowledge of students to
practice is an important pedagogy in nursing
education. 7 To implement this project, in the initial
classes the course faculty survey current epidemics
through newspapers and other media. This strategy
helps the faculty as well as students to prioritize and
select one of the highly communicable diseases at the
time of offering this course. Faculty shares this
prioritized list with the students and makes small
groups of students 6 weeks prior to the implementation
of the project. Student grouping is randomly (4-6
students in one group) made and the topics for the
propjet are also randomly assigned to them from
prioritized list.
Students conduct meetings and keep a record of
their process of working and work load of 6 weeks of
the class timings .In their study time, they search recent
literature regarding diseases and thoroughly educate
themselves on their assigned topics. Next, they plan
to prepare health education material, by collecting old
or low cost material such as empty box (insert picture
TV made from Empty boxes), old socks, old clothes,
empty bottles to puppets and environmental hygiene
models. The special focus is on how to prepare low
cost and sustainable teaching aids. While preparing
materials students keep the knowledge of target
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 107
population such as language, gender and age.
Moreover, students in their group use creative
approaches to develop teaching aids, which are based
on teaching learning principles as well are culturally
acceptable. Faculty meets individual student groups
time to time to facilitate them
Project implementation
To bring the theory into practice students are
expected to develop a project to deliver health
education to community through arranging a Health
Mela 8 in school, community health centers, and
hospitals or boarding houses. On the day of the
implementation of the project, students reach project
site in the morning with their cost faculty to set their
stalls in a camp or in a hall set by school or community
administration. Once people start coming on the given
time , nursing students provide health education to
them by using their low cost teaching materials. The
student activities are evaluated by community
representatives, course faculty and one neutral faculty
expert in content. They evaluate students by using set
criteria and their feedback students are graded for the
project.
Impact of course on students and community
Both the student and the agency benefit from the
experience of this course assignment as it helps
students to develop sense of social responsibility 9
towards preventable communicable disease, as well
as to enhances their interest in learning and their
critical thinking abilities. The Health Mela cum
teaching learning aids assignment” is successful in
engaging and empowering communities, especially
to parents and teachers in the schools; as this project
impacted on some school policies that emphasized
health of children at school. In one of the schools after
running this project, school administration developed
an strategy to keep soap outside washroom in the
school (rare practice in many schools of Pakistan) and
assigned one worker to oversee and make sure
children wash hands after coming from washroom,
same school asked parents to sent their child with their
own boiled water bottles, simultaneously, started
keeping boiled water in the school. In one of the
boarding houses where similar project was
implemented, they arranged typhoid vaccines for
children. Moreover, one of the communities after this
project developed “Kuta bahgao scheme (Street dog
eradication to prevent rabies) with help of city
municipal cooperation after this project.
Furthermore, at the end of health festival (health
Mela) evaluation of the participants attending this
course were encouraging as they were able to discuss
the causes of the diseases and ways to protect from
these deadly but preventable diseases.
In addition, through this course students learn to
work collaboratively and cooperatively to complete
their assignments in groups outside classroom. From
this cooperative learning they develop skills to create
their own teaching aids and learn how to work in a
team. The real essence of application of theory in to
practice is noted when students display and use these
handmade teaching in the implementation phase of the
project.
CONCLUSION
In conclusion, this innovative nursing course about
tropical and communicable diseases helped the nursing
students and nursing faculty to access community to
provide health awareness session during the course.
The course assisted the students to develop skills to
get involved in the community, and conduct health
awareness sessions, to prevent the communicable
diseases. It also provided them an opportunity to learn
the skills, required for a health educator and practice
this role. They also learned to prepared low cost and
culturally acceptable teaching material to deliver the
session. This course not only developed nursing
students skills as health educators, but also brought
many positive impact on targeted communities.
ACKNOWLEDGEMENTS
We acknowledge all our students, faculty,
community leaders, and residents, all administrative
personnel within and outside AKUSONAM efforts in
providing their support to operationalize this course.
Their active participation at all levels made it possible
to bring our course to benefit the public and raised
awareness on such deadly diseases.
Conflict of Interest: We do not have any Conflict of
interest
Source of Funding: Aga Khan University School of
nursing and midwifery
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108 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Ethical Clearance: Course is approved by Curriculum
committee of the school of nursing Karachi Pakistan.
REFERENCES
1. Gupta I, Guin P. Communicable diseases in the
South-East Asia Region of the World Health
Organization: towards a more effective response
Bulletin of the World Health Organization 2010;
88:199-205. doi: 10.2471/BLT.09.065540
http://www.who.int/bulletin/volumes/88/3/
09-065540/en/
2. Communicable disease prevention, control and
eradication. WHO regional office for
Africa. http://www.afro.who.int/en/ethiopia/
country-programmes/communicable
diseases.html.
3. Non communicable diseases Pakistan’s next
major challenge. NCD’s Policy Brief (February
2011). The World Bank south Asia, Human
Development Health, Nutrition and Population.
http://siteresources.worldbank.org.
4. Sabir SA, Naseem U, Abideen Z, Chisti MJ.
Assessment of “Tuberculosis Preventive
Knowledge “in Persons Taking Care of TB-
Patients. Journal of Rawalpindi Medical College;
2012; 16(1):62-64.
5. The Global Polio Eradication Initiative: Every
Last Child: copyright 2010. http://
www.polioeradication.org/AboutUs.aspx
6. Report on Measles Outbreak in Pakistan (2013).
Wafaqi Mohtasib (Ombudsman)’s Secretariat
Islamabad. http://202.83.164.28//Mohtasib/
reports/Measles Report.pdf
7. Armstrong MA, PieranunziV. Interpretive
Approaches to Teaching/Learning in the
Psychiatric/Mental Health Practicum. Journal of
Nursing Education. 2000; 39(6), 274- 277.
8. Gupta R, Vaidyab A, Campbell R, Gupta A,
Rajbhandari, S. Health Mela: a novel way o f
health promotion. British Journal of Healthcare
Management 2011; 17(4): 165-167.
9. Narsavage GL, Batchelor H, Lindell D, Chen Y.
Developing Personal and Community
Learning in Graduate Nursing Education
through Community Engagement. Nursing
Education Perspectives. 2003; 24(6), 300-305.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 109
INTRODUCTION
My workplace: The organization I work in is an
American organization that came to Pakistan in 2003.
It aims to open quality childcare/daycare centers in
Pakistan. The daycare centers include corporate
centers; which manage children of the employee’s
working in multinational organizations; community
centers, which are context-based models in the rural
areas of Karachi, Pakistan; Franchised centers, which
are Catco Kids franchises that are run as businesses
by trained individuals; and advocacy initiatives with
the stakeholders, including the Ministries.
Demographic Profile: The population that I serve
is from both urban and rural areas of Pakistan. There
are four provinces of Pakistan: Sindh, Punjab,
Balochistan and North West Frontier Province (NWFP).
Islamabad is its capital with Karachi being the most
populous city. According to the 2005 estimates by
Tourism department of the Government of Pakistan,
Pakistan’s population is 162,400,000. The ethnic group
of majority of people in Pakistan is Indo-Aryan with
sub-ethnic groups as Punjabis (44.68%) of the
population, Pashtuns (15.42%), Sindhis (14.1%),
Seraikis (10.53%), Muhajirs (7.57%), Balochis (3.57%)
and others (4.66%) such as Tajiks, Bengalis etc 1. The
national language of Pakistan is Urdu with the majority
of people being Muslims. Its major health problems
include high infant mortality rate (82/1000 live births),
high maternal mortality rate (500/100,000 births) 3, and
high fertility rate of 4 2(p.491-499). Its primary causes
of sickness and death include gastroenteritis,
The Threat of Domestic Violence: an Analysis through
'ology' Perspectives
Zahra Shaheen1, Yasmin Mithani2, Zohra Kurji2
1Chief Operating Officer, Catco Kids. Pakistan, 2Senior Instructor, the Aga Khan University School of Nursing and
Midwifery
ABSTRACT
Domestic Violence is a threat generally to females all around the world. It not only leaves a mark on
a person's physical state but has more serious consequences on the emotional, spiritual, sexual and
social states as well. Below is the case study of an employee, which I had encountered at my work
place. This case study will be analyzed with the help of epidemiological and sociological perspectives.
Keywords: Violence, Sociology, Epidemiology
DOI Number: 10.5958/j.0974-9357.5.2.054
respiratory infections, congenital abnormalities,
tuberculosis, malaria, and typhoid fever 4.
Significant Event:
This situation occurred in 2006 with one of our
female employees, Ms. XYZ, who had joined us as a
caregiver in 2004. She is a very happy-go-lucky person
with a pleasant personality. She does not have children
and has been married for 20 years. After she joined us,
she stated that her husband and in-laws physically
abused her when there were any quarrels between
them. Recently, they were having frequent arguments
and fights. Her husband insisted that she should give
consent for his second marriage to which she was
refusing. Based on the religion that she belonged to,
her consent was important. One day, her husband came
to the daycare center in the evening asking for her
identity card, saying that he wanted to cash his pay
cheque as it was first of the month. She willingly gave
her identity card to him. Next morning, she came to
the center crying. When we asked her what had
happened, she said that her husband has re-married
and that is why he had come to the center the day
before for her identity card, so that he could prove to
others that he had her consent. The husband moved
out of the house the same night and she started living
all alone.
After this incident, we observed that she usually
came to the center with bruises all over her body. One
day, we noticed that her face and eyes were swollen
and she was not in her usual happy mood. I called her
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110 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
in my office and asked her what had happened, she
started to cry profusely. I let her cry for a while. Then
she said that her father-in-law and husband had come
to her house in the evening and started quarrelling
with her. The husband picked up a cricket bat and
started hitting her. He then pulled her hair and bunch
of hair came out of her scalp. The father-in-law also
hit her. When the neighbour heard her screaming and
shouting, they came to her rescue and both of the
husband and father-in-law fled away.
I counseled her and tried to help her out but I felt
very helpless. I did not know w1hat to do. I also felt
like crying and felt very upset the whole day. Then I
called the head of my organization and explained the
situation to her. She asked me to bring Ms. XYZ to the
head office so that she could talk to her. I took her in
the evening and Ms. XYZ was again counseled. The
counseling helped her to ventilate her feelings and she
felt comfortable. As we were concerned about her
safety and security, we hired the services of a security
guard at Ms. XYZ’s residence for a few days to protect
her. We also discussed the option of divorce with her,
which she refused, as she loved her husband very
much. After that incident, the husband or her in-laws
did not come to her house and Ms. XYZ is still legally
his wife.
If I analyze this situation, the husband used
physical violence habitually, which increased in
frequency due to the wife’s refusal to divorce him and
to take on a new wife. As the supervisor, if I had not
explored why this staff was upset and if she hadn’t
told me, I would not been able to explore her life world
and she would have been left without any support.
As an organization, we could not do much regarding
Domestic Violence at a family or community level as
it is believed to be a private matter between a husband
and wife. Families believe that nobody can interfere
in this. People think that women are “their property”
and they can treat them in whichever way they like to.
Eastern women usually hide their marital problems.
In addition, there are very few Non-Governmental
Organizations working on this issue and women do
not approach them unless they are in a life-threatening
situation. We also encounter this primary care problem
at our health centers in rural area of Karachi where
women come with injuries and when asked, they
usually report a fall or an injury as the cause of those
injuries. After analyzing this situation, I would like to
explore the sociological and epidemiological
perspectives in order to prevent this problem through
our daycare centers.
How an academic perspective will help address
such issues problems at work place:
Epidemiological Perspective of Domestic
Violence: To have a holistic picture of the issue of
domestic violence, I would first like to describe the
epidemiological perspective. Domestic violence, as
defined by the World Health Organization (WHO) is:
“The intentional use of physical force or power,
threatened or actual, against oneself, another person,
or against a group or community, that either results in
or has a high likelihood of resulting in injury, death,
psychological harm, mal development or
deprivation.”5.
Violence is a preventable problem that entails use
of power and physical force 5. According to Karmaliani
et al, one out of every three women goes through some
sort of violence worldwide at some point in time 6 (p.1-
8). The epidemiological data mentioned by WHO,
reveals that 10 % of women are physically assaulted
by their intimate partners in Paraguay and Phillipines,
22.1% women in the United States of America, 29% in
Canada and 34.4% in Egypt 5. A study done in Karachi,
Pakistan to explore the attitude of Pakistani men
reveals that 49.4% women are physically abused, with
slapping, hitting or punching being the most common.
Another interesting data demonstrates that 55% men
were themselves beaten during their own childhood
and 65% had seen their mothers being beaten. Almost
half of them thought it was their right to hit their wives
7 (p. 49-58). A similar study from Pakistan shows that
the most common cause of violence includes societal
factors such as cultural norms of male dominance; use
of excessive force; health; education; economic and/
or social policies8 (p.23-28). Hence, the above
mentioned data reveals that violence is a universal and
preventable problem with the abuser having
experienced abuse during his own childhood.
Moreover, violence against women is viewed as a
cultural norm in Pakistan due to various factors.
Sociological Perspective: Sociology, as defined by
Greenhalgh, is ‘…the study of human society and the
relationships between its members, especially the
influence of social structures and norms on behaviors
and practices’ 9 (p.34). Hence, according to the above
situation, understanding the object relations theory
from the sociological perspective would explain why
some men are violent and some are not. If we integrate
this situation with the theory, it is an intra psychic
theory that understands the reasons for some people
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 111
to resort to violence while others do not10. Object
relations theory illustrates that Early Childhood
Development plays a vital role in an individual’s
psychological development. According to Zosky,
human beings form an attachment to relationships that
are termed as objects. If the relationship with the
primary caregivers, such as mothers is not healthy,
there is a strong possibility of problems in the child’s
future relationships. Hence, children who are exposed
to negative environment in their early childhood
period tend to demonstrate negative behaviors with
their objects when they grow up. The primary
caregiver must, therefore, build trust, develop the
child’s self-esteem and provide consistent, positive
nurture and care during the period of early
childhood10. A study cited by Zosky revealed that
children who did not receive nurture and care in their
childhood turned out to be violent towards their
intimate partners. (Kesner, Julian and McKenry,
1997).10 This theory further states that as these
children’s object constancy (separate identity of self
and others) has not developed during their childhood,
they are unable to manage love and anger towards
their partners and therefore, resort to violence on their
seemingly “all bad” partners10.
Hence, as Ms. XYZ was subjected to partner
violence, the above stated theory could be the cause
for her husband’s violent behavior although we did
not explore at that time whether her husband had
himself been a victim of violence during his own
childhood. It further explains that violent individuals
use power to suppress their partners. This means that
in the above situation, Ms. XYZ’s husband exerted
power on her by being violent and by hitting her. Not
only the husband, but the family was also involved in
this as hitting wives is sociologically agreeable. This
could be explained by WHO citation, that violence is
pre-determined by a culture. Therefore, wife battering
may not be viewed as a problem but as a norm10.
CONCLUSION
As I am working in the higher management and
am involved in developing policies for the
organization, this theory has helped me gain an insight
on how important it is to provide a healthy and
nurturing environment for children. I strongly believe
that being proactive is way better than being reactive.
Therefore, I would now oversee all our training
modules and inculcate “importance of nurturing
relationships” for our staff and teachers. Moreover, as
the children spend most of the day with us at the
center; it nevertheless becomes more important for us
to train the caregivers in this aspect. In addition, the
staffs are already trained in assessing the children’s
behavior for any changes in order to identify child
abuse, but this has to be re-enforced. As per our center’s
policies, these issues are reported in writing to the
higher management as soon as they are observed and
the parents or guardians are counseled.
ACKNOWLEDGEMENTS
I would like to acknowledge everyone who have
assisted me in writing this article; including my tutors,
friends, family, and my dear husband and children.
This would not have been possible without their
unconditional love and support!
Conflict of Interest: None
Ethical Clearance: Not required
Source of Funding: None
REFERENCES
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2005. Available from: http://
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pakistan.htm. [Accessed on 21-9-2009].
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AB and Lozano, R. World report on violence and
health. [online]. 2002. Available from:
www.who.int/violence_injury.../violence/
world_report/en/ [Accessed on 22-10-2009].
6. Karmaliani, R, Irfan, F, Bann, CM, Mcclure, EM,
Moss, N, Pasha, O, Goldenberg, RL. Domestic
violence prior to and during pregnancy among
Pakistani women. Acta Obstetricia et
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112 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Gynecologica. [online]. 2008. p. 1-8. Available
from: http://dx.doi.org/10.1080/
00016340802460263. [Accessed on 26-10-2009].
7. Fikree, FF, Razzak, JA, Durocher, J. Attitudes of
Pakistani men to domestic violence: a study from
Karachi, Pakistan.Top of Form [online]. Vol 2, no
1. March 2005. p. 49-58. Available from: http://
www.journals.elsevierhealth.com/periodicals/
jmhg/article/S1571-8913(05)00005-1/pdf.
Retrieved on 22-10-2009. [Accessed on 22-10-
2009].
8. Shaikh, MA. Is domestic violence endemic in
Pakistan: perspective from Pakistani wives?
Quarterly January. [online]. Pakistan Journal of
Medical Sciences. Vol 19, no 1. 2003. p. 23 – 28.
Available from: http://www.crescentlife.com/
psychstuff/is_domestic_violence_ endemic_in_
pakistan.htm. [Accessed on 22-10-2009].
9. Greenhalgh, T. The ‘ologies’ (underpinning
academic disciplines) of primary health care.
Primary health care: Theory and practice. Chapter
2. 2007. Blackwell Publishing. p.34.
10. Zosky, DL. The application of object relations
theory to Domestic Violence. [online]. Clinical
social work journal. Vol. 27, no. 1. Spring 1999.
Available from: ww.springerlink.com/index/
U0570115388333V2.pdf. [Accessed on 20-10-
2009].
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 113
INTRODUCTION
Breastfeeding is a mother’s privilege and a baby’s
right. Human milk contains a balance of nutrients that
closely matches infant requirements for brain
development, growth and a healthy immune system.
Though breast feeding is a pleasant experience it
can cause a lot of discomfort both to mother and the
newborn if the breast feeding positions and techniques
are not proper. If the mother is comfortable and pleased
with breastfeeding, her baby also will be comfortable
and enjoy being fed. So it is very important to provide
a proper position for breast feeding that minimizes the
discomfort of the mother during the early postnatal
period.
Comparison of Maternal Comfort between two
Breastfeeding Positions
Bency G1, Maria P2, Anusuya V P2
12nd Year MSc Nursing, 2Assistant Professor, Department of OBG Nursing, Manipal College of Nursing Manipal,
Manipal University, Manipa
ABSTRACT
Objectives: To compare the effectiveness of cradle hold versus football hold position of breast feeding
in terms of increased comfort of primiparous women and to find the association between comfort of
primiparous women and type of delivery.
Method and materials: An evaluative approach was used and the design selected for the study was
quasi experimental, two group post test only design. Samples comprised of 60 postnatal mothers (30
in each group) admitted in Kasturba Hospital, Manipal and Dr.TMA Pai Hospital, Udupi. Purposive
sampling technique was used to select samples. Data was collected using demographic proforma
and maternal comfort checklist
Results: The result of the study shows that, there was no significant difference in the mean post test
scores of comfort of primiparous women between cradle hold and football hold groups (p=0.411).
But there was improvement in the mean post test scores of comfort of primiparous women in
subsequent measures (three measures) in each group. There was no significant association between
comfort of primiparous women and type of delivery (P value- 0.589).
Conclusion: Cradle hold and football hold positions of breast feeding were equally effective in terms
of increased comfort of primiparous women. Mother can try either cradle hold or football hold position
for breast feeding and can adopt whichever is comfortable for her. The study also revealed that there
was no association between comfort of primiparous women and type of delivery in both cradle hold
and football hold positions of breast feeding. Mother can try either cradle hold or football hold position
for breast feeding irrespective of type of delivery.
Keywords: Breastfeeding Positions, Comfort, Primiparous Women
DOI Number: 10.5958/j.0974-9357.5.2.054
The most common breast feeding position involves
cradling the infant next to the breast from which he or
she will feed, with his or her head propped up by the
mother’s arm. Another holding position is the football
hold, in which the infant is cradled in the mother’s
arm with his or her head in the mother’s hand and the
feet oriented toward the mother’s elbow. Mothers
recovering from cesarean delivery may usually prefer
this position because less pressure is placed on her
abdomen.
Though breast feeding is a natural process it cannot
be done so instinctively. First time mothers needs lots
of help and guidance at the beginning of the breast
feeding especially after the caesarean section.
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114 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Indian women usually prefer the cradle hold
position of breast feeding. But literature describes some
other positions which are more or less equally effective
to cradle hold. So the researcher felt the need to identify
the position which promotes the comfort of
primiparous women by comparing two positions
(cradle hold and football hold position of breast
feeding).
Statement of the problem
“A comparative study of the effectiveness of two
breast feeding positions on comfort of primiparous
women in selected hospitals of Udupi District,
Karnataka”.
Objectives of the study
The objectives of the study were to
1. compare the effectiveness of cradle hold vs.
football hold position of breast feeding in terms of
increased comfort of primiparous women
2. find the association between comfort of
primiparous women and type of delivery.
Hypotheses
All hypotheses were tested at 0. 05 level of
significance
H1: There will be significant difference in the mean
post-test scores of comfort of primiparous women
between cradle hold group and football hold group.
H2: There will be significant association between
comfort of primiparous women and type of delivery
MATERIALS AND METHOD
Research Methodology
The research approach used in the study was
evaluative approach. Research design used was quasi
experimental, two group post test only design. The
population comprised of primiparous women
admitted at the Dr.TMA Pai Hospital, Udupi and
Kasturba Hospital, Manipal. In this study the sample
comprised 60 postnatal women with 30 each in group
one (cradle hold group) and group two (football hold
group). Samples for group one was taken from
Kasturba Hospital, Manipal and for group two was
taken from Dr.TMA Pai Hospital, Udupi. Allocation
of breast feeding positions have been done in two
hospitals (cradle hold position of breast feeding to
Kasturba Hospital, Manipal and football hold position
of breast feeding to Dr.TMA Pai hospital, Udupi) to
avoid the chance of contamination. Purposive
sampling technique was used to select samples in each
group.
Sampling criteria
Primiparous women
- aged 18-35years
- delivered after 37 weeks of gestation
- admitted to the postnatal ward of Kasturba
Hospital, Manipal and Dr.TMA Pai Hospital,
Udupi
- mothers with nipple abnormalities (flat, inverted
or cracked nipple) were excluded from the study.
Description of the tool
Tool 1: Demographic proforma
This tool was developed to gather information
about sample characteristics. It included six items
seeking information on the background of primiparous
woman such as age, education, occupation, religion,
type of family and mode of delivery.
Tool 2: Maternal comfort checklist
This tool was developed to determine the comfort
of primiparous women during breast feeding (self
reported checklist). The items of the checklist were
developed as per the blueprint and items covered were
the physiological and the psychological comfort of
primiparous women. Few items were taken from the
modified fatigue symptom checklist. The maternal
comfort checklist comprised of 18 items (‘yes’ and ‘no’
columns). Each ‘yes’ carried one score and ‘no carried
zero score except item numbers 14, 15 and 16 (reverse
scoring is done for these items). The maximum score
possible is 18 and minimum score is 0.
Data collection procedure
The main study was conducted in selected hospitals
of Udupi district (Kasturba Hospital, Manipal and
Dr.TMA Pai Hospital, Udupi). Allocation of breast
feeding positions had been done in two hospitals (
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 115
cradle hold position of breast feeding to Kasturba
Hospital, Manipal and football hold position of breast
feeding to Dr.TMA Pai hospital, Udupi ) to avoid the
chance of contamination. Equal number of mothers
with normal delivery and caesarean delivery were
taken in each group. Once the mother is able to sit
and give feeds by herself without anybody’s support
(normal delivery- six hours after being shifted to the
postnatal unit and operative delivery- twenty four hrs
after being shifted to the postnatal unit) the willingness
of the mothers were asked to participate in the study
and the consent was taken. After this, cradle hold
position of breast feeding was taught to one group
and football hold position of breast feeding to the
second group. Mothers were encouraged to assume
same position which was taught to them on
subsequent feeding. Comfort of primiparous women
was assessed in three repeated measures (fourth, sixth
and twenty fourth hours of breast feeding) after the
teaching session. Demographic background of the
mother and the neonates was collected during the first
measure.
OBSERVATION AND RESULTS
Section 1: Description of sample characteristics
- Majority of the samples i.e. 15 (50%) in cradle hold
group and 15 (50%) in football hold group belonged
to the age group of 26-30
- 25 (83.3%) in cradle hold group and 23 (76.7 %) in
football hold group were unemployed.
- Majority of the samples i.e. 25 (83.3%) in cradle hold
group and 27 (90%) in football hold group belonged
to the Hindu religion.
- Majority of the samples i.e. 21 (70%) in cradle hold
group and 16 (53.4%) in football hold group
belonged to nuclear families.
Section 2: comparison of comfort of primiparous
women between cradle hold and football hold position
of breast feeding
Section 2A: Scores of comfort of primiparous
women of group 1 (cradle hold) and group 2 (football
hold)
Table 1: Mean and standard deviation of subjects based on post test scores of comfort of primiparous women in
group 1 and 2. n=60(30+30)
O1 O2 O3
Mean SD Mean SD Mean SD
Comfort scores Group 1 11.17 1.341 12.47 1.332 14.83 0.986
Group 2 11.16 1.206 12.70 1.264 15.30 1.055
The data in the table 1 depicts that there was no
significant changes in the mean post test scores of
comfort of primiparous women in three repeated
measures between cradle hold group and football hold
group but there was improvement in the comfort
scores in subsequent measures in each group.
Section 2B: Difference between the post test scores
of comfort of primiparous women across two groups:
Repeated Measures ANOVA (RMANOVA) was
used to test post test scores of comfort of primiparous
women across two groups at three time points
(fourth, sixth and twenty fourth hours of breast
feeding).
Table 2: Repeated measure analysis of variance
between the subjects
F ratio df value P value
0.686 1, 58 0.411
*Significant at p<0.05
Table 2 and figure no 1 profile plot showed that there
was no significant difference in mean post test scores
of comfort of primiparous women between cradle hold
group and football hold group. So the null hypothesis
was accepted and the research hypothesis was rejected.
Therefore it could be concluded that both of the breast
feeding positions (cradle hold and football hold
position of breast feeding) were equally effective for
Fig.1. Profile plot showing RMANOVA for post test scores of
comfort of primiparous women.
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116 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
breast feeding in terms of increased comfort of
primiparous women.
Section 3: Association between comfort of
primiparous women and type of delivery
In order to find the association between comfort of
primiparous women and type of delivery, the
following hypothesis was stated
Ho3: There is no significant association between
comfort of primiparous women and type of delivery.
Two - way Repeated Measures ANOVA was used
to test the association between comfort of primiparous
women and type of delivery at three repeated
measures.
Table 3: Mean Standard deviation, F ratio and P value of post test scores of comfort of primiparous women on type
of delivery. n=60(30+30)
Group O1 O2 O3 F ratio P value
Mean SD Mean SD Mean SD
Cradle hold ND* 11.7 1.223 12.87 1.18 15.27 0.977
CD* 10.60 1.242 12.07 1.38 14.40 0.986 0.295 0.589
Football hold ND* 10.73 1.163 12.40 1.24 15.07 1.100
CD* 11.60 1.121 13.00 1.254 15.53 0.990
*Significant at p<0.05 *N D– Normal Delivery, *CD-Caesarean Delivery
Table 3 depicts that there was no significant
association between comfort of primiparous women
and type of delivery (P value- 0.589). So the null
hypothesis was accepted and research hypothesis was
rejected.
DISCUSSION
The current study revealed that there was no
significant difference in the comfort scores between
cradle hold and football hold position of breast feeding.
Both of the positions are equally effective for breast
feeding in terms of increased comfort of primiparous
women.
The current study finding is supported by the article
published by Wagner and Rosenkrantz on June 5, 2009
with the title of “Counseling the Breastfeeding
Mother”. The article described that positioning the
infant is one of the most fundamental components to
successful breastfeeding. If no maternal or neonatal
contraindications are present immediately after birth,
the mother should be helped into a comfortable
position. The most common position involves cradling
the infant next to the breast from which he or she will
feed, with his or her head propped up by the mother’s
arm. The infant should be placed with his or her
stomach flat against the mother’s upper abdomen, in
the same plane (cradle hold position of breast feeding).
This close contact also helps the infant maintain a
normal body temperature. Another holding position
is the football hold, in which the infant is cradled in
the mother’s arm with his or her head in the mother’s
hand and the feet oriented toward the mother’s elbow.
Mothers recovering from caesarean delivery may
prefer this position usually because less pressure is
placed on their abdomen. Mothers can adopt any one
of these position based on their comfort.7
The current study also reveals that there is no
significant association between comfort of primiparous
women and type of delivery in each group. Cradle hold
and football hold positions of breast feeding are equally
effective after normal and operative delivery.
This study finding contradicts the article published
in the Breastfeeding Answer Book .It described that
the football or clutch hold position is a very useful
position for mothers who have had a caesarean birth
than any other position. It helps keep the weight of
baby off mother’s incision. It is also a good position
for mothers with flat or inverted nipples and for babies
with latch-on or sucking problems because it offers
the mother a better view of the baby and breast and
offers her better control of the baby’s head. Though
there is no significant difference between normal and
operative delivery in football hold position, mean
scores of comfort of primiparous women is more in
operative delivery than normal delivery.
The limitations of the study were
• In the present study the primiparous women in
each group were selected using purposive
sampling, which limits the generalizibilty of the
study.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 117
• Controlling the extraneous variables like personal
characteristics of primiparous women and hours
of postnatal period was not possible.
ACKNOWLEDGEMENT
The authors are thankful to all administrators and
participants for providing necessary facilities and
information to carry out this project.
Conflicts of Interest
There were no situations which give rise to conflicts
of interest in present study. The study is done as a
partial fulfillment for the degree of MSc Nursing. Not
for an organization, any person, financial interest or
any significant position.
Ethical Clearance
For collecting data, following steps were taken in
terms of ethical clearance
• Formal administrative permission from the Dean,
Manipal College of Nursing, Manipal.
• Ethical clearance from the ethical clearance
committee of Kasturba Hospital, Manipal.
• Permission from Unit Heads of OBG department,
Kasturba Hospital, Manipal
• Permission from the Medical Superintendent of
Dr. TMA Pai Hospital, Udupi.
• Informed consent from the participants
Source of Funding
This research is not funded by any corporations,
organizations and universities.
REFERENCES
1. Eastman A. The mother baby dance: positioning
and latch on. LEAVEN 2000; 16(4):63-68 (Updated
2006 October15). Available from: http://
www.llli.org/llleaderweb/lvagusep00p63.html
2. Wagner C L, Rosenkrantz T. Counseling the
Breastfeeding Mother. American Academy of
Pediatrics 2009 (Updated 2012 February
2).Available from: http://
emedicine.medscape.com/article.html.
3. Polit FD, Hungler PB. Nursing Research
principles and Method. Philadelphia: Lippincott;
1999
4. Birth source.com, official site of Perinatal
Education Associates.inc.
5. Drucker, Peter F. The effective Executive
Definition Guide to Greeting the Right Things
Done. Newyork: Collins.2006
6. Polit FD, Hungler PB. Nursing Research
principles and Method. Philadelphia: Lippincott;
1999.
7. Stufflebeams B L. CIPP model. Annual conference
of the Oregon Programme Evaluators Network
(OPEN). Portland; 2003. Avialbe from: http://
www.wmich.edu/ evalctr/pubs/CIPP-Model
Oregon 10-03.pdf
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118 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
Auditory hallucinations are found most often in
patients with schizophrenia, with a prevalence of 75%
in that population. Hallucinations are pathognomonic
of no one mental illness. They may be experienced in
a range of mental disorders such as schizophrenia,
depression, mania, post-traumatic stress disorder as
well as drug withdrawal or intoxication, metabolic
disorders, and during periods of high stress,
deprivation of sleep or sensory stimulation. However,
auditory hallucinations have been described
inconjunction with many life circumstances and
diseases, including religious phenomena,
bereavement, drug intoxication, sensory deprivation,
and near-death experiences, as well as psychiatric or
neurological disorders. Auditory hallucinations have
been estimated to occur in 10%–15% of those without
neuropsychiatric illness1.
Patterns of Auditory Verbal Hallucination among Patients
Diagnosed with Chronic Schizophrenia
Bivin J B1, Sailaxmi Gandhi2, John P John3
1Lecturer in Psychiatric Nursing, Mar Baselios College of Nursing, Kothamangalam, Kerala, 2Asst. professor, Dept. of
Nursing, 3Associate professor, Dept. of Psychiatry National Inst. of Mental Health & Neurosciences, Bengaluru
ABSTRACT
Background: Presence of auditory hallucination is considered to be the frontline diagnostic criteria
for schizophrenia. The present study aimed to evaluate the pattern of auditory verbal hallucinations
(AVH) among patients diagnosed with chronic schizophrenia.
Materials and method: Consented patients (N=52) were asked individually to detail about their
experience of persistent auditory hallucinations using a semi-structured interview schedule. Data
was pooled and analyzed using Microsoft Excel-2007.
Results: Mean age at first hearing voices was 26 years, and 50% of them reported to hear voices for
about a few minutes a day. 11.5% of them reported that their voices were hostile and many (69.2%) of
them heard voices of more than one person talking at a time. Commenting type of AVH was more
(84.6%), voices more (61.5%) frequently heard during evening time. Majority (57.7%) of them reported
to hear voices which are of both male and female and 50% of them it was not from anyone they
known before. 88% reported that the intensity of AVH was more when they are alone and 65.4% of
them reported to be relieved when they started doing something interesting. 50% them reported that
the medications have no effect over AVH.
Discussion: The result of the study may be used to increase understanding of the pattern of AVH
among chronic schizophrenia and to be more empathetic in formulating nursing care plans to help
those troubled voice hearers by incorporating more adaptive self help strategies to deal with it.
Keywords: Auditory Verbal Hallucinations, Schizophrenia
DOI Number: 10.5958/j.0974-9357.5.2.054
Various psychological explanations have been
offered for the phenomenon of hallucinations.
Auditory hallucinations found to vary considerably
in their frequency, duration, severity, intrusiveness,
content, loudness, clarity, tone of voice, the degree of
affective reactions they elicit, and the extent to which
they are perceived as distressing or disabling by the
individual who experiencing them.2 The experience of
hallucinations can be influenced by the environmental
conditions such as sensory deprivation, or exposure
to white noise or other stimulations.3
Cultural attitudes towards hallucinations affect the
person’s emotional reaction, the degree of control over
the experience, and helpers should consider the
functional significance and meaning of hallucinations
as well as the social context and the stimuli associated
with them4
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 119
Experiencing auditory hallucination is distressing
and may often lead to various other problems such as
anxiety, depression, self harm and suicide. It also
causes disability in social and occupational
functioning.5 Even with the best pharmacological
treatments many people continue to experience
voices6. Most individuals with schizophrenia spectrum
disorders hear voices even when they adhere to
prescribed medications regimens.7 Many of them
report voices that are abusive, critical, and out of touch
with everyday reasoning and sense of self. These
troubled voice hearers often have a persistent paranoia,
abuse, and suicidal ideation, and occasionally, violent
acting out.8
“…understanding of psychotic problems may be
improved by taking more account of the patient’s
subjective experience of psychosis, and the ways in
which people with psychosis may try to make sense
of their subjective experiences, and then act to cope
with them”9. Nurses are in an ideal position to facilitate
coping with voices through teaching, coaching, and
counseling roles.
Attempts at helping the voice hearer must be by
an understanding of the experience, sensitivity to the
person’s distress, the person’s own usage of coping
strategies and the meaning the person attributes to the
experience. Without such knowledge, the nurse may
unwittingly hinder the person’s attempts to cope and
undermine their sense of self-efficacy. An
understanding of the biological processes underlying
the hallucinatory experience and theories of
hallucinations are required to provide some direction
to the nurses’ choice of intervention.
MATERIALS & METHOD
The study adopted a cross sectional descriptive
research design aimed at exploring the pattern of AVH
among patients diagnosed with Schizophrenia using
a semi structured interview schedule, Auditory
Hallucination Interview Guide- Inpatient version
(AHIG-IP). The study was conducted at inpatient
psychiatric units of National Inst. of Mental Health and
Neurosciences, Bengaluru, involving the patients who
have been diagnosed as schizophrenia (F20.0) by a
board certified psychiatrist based on the diagnostic
criteria outlined by ICD-10, including the subtypes of
schizophrenia. Consented subjects (n=52) who were
reported to hear AVH for a duration of not less than
one year persistently even with their psychotropic
medication. The subjects were informed about the
purpose of the study and duration of individualized
interview. The given information by the participants
were checked for its consistency with their primary
caregivers who present with them during their hospital
stay.
Auditory Hallucinations Interview Guide -
Inpatient Version (AHIG-IP) 10
The Auditory Hallucinations Interview Guide
(AHIG) 10 is a 30-item interview guide developed from
the literature and clinical experience that asks patients
for demographic and detailed information about
auditory hallucinations and command hallucinations
to harm, strategies they have found useful to manage
auditory hallucinations and command hallucinations
to harm, and their psychiatric medication regime.
Clinical utility has been established with the revised
and shortened inpatient version (AHIG-IP) 10
Inter-rater reliability has been reported to be very
high for AHIG-IP total scores. All items showed
adequate reliability when the scale was administered
within the context of interview guidelines. A
sufficiently high inter-rater reliability (Cohen kappa
>0.60) was reported for most of the AHIG-IP items and
the total score (Cohen kappa: 0.57–0.73) 10
The data was pooled and analyzed using Microsoft
Excel-2007 using descriptive statistics.
RESULTS
Demographic Profile of the subjects
Most of the study subjects were females (57.7%)
and unemployed (69.2%). 50% of the subjects were
below/ equal to the age of 35 years and were married.
38.5% of the study subjects have completed their Pre
University course, while 34.6% have no formal
education. 57.7% of the subjects were from the rural
background.
Clinical Profile of the subjects
61.5% of the subjects were diagnosed with paranoid
schizophrenia, 11.5% with disorganized schizophrenia,
and 27% with undifferentiated schizophrenia. Mean
age at hearing voices at first was 26 years. About the
psychotropic medications, most of them were on
typical antipsychotics (84.6%), 69.2% were on atypical
antipsychotics, 57.7% were on Sedatives or Anxiolytics
and 11.5% were on Antidepressants. All study subjects
were on Antiparkinsonian agent, Tab. Trihexyphenidyl.
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120 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Pattern of Auditory Hallucinations among the
Patients Diagnosed With Schizophrenia
Most (61.5%) of them reported the location of their
voices as just outside of their head, while 3.8% of them
could not locate their voices. 50% of the subjects were
hearing voices for a few minutes and 30.8% of them
were hearing long for hours. 57.7% of the subjects, the
voices were continuous monologues; whereas, 38.5%
of the subjects reported that the voices talks in
paragraphs. 11.5% of the subjects reported that the
voices were hostile; but, 88.5% of them reported that
the voices are different at different time, either hostile
or friendly. No one in the study population reported
the voices to be friendly.
Second person auditory verbal hallucination was
commonly (73.1%) reported among the subjects
compared to third person auditory verbal
hallucination (26.9%). 57.7% of the subjects reported
the voices that they heard were both female and male;
whereas 26.9% of them it was male voices alone and
15.4% of them it was female voices alone. Number of
voices that the subjects heard commonly (69.2%) was
2 or less than 2 in number.
Common (84.6%) content in the hallucinatory
voices was commands to do something. Voices that
comments on subject’s activities, about person, laughs
at the subject, talk about religion or god and talks
about sex constituted 38.5%, 23.1%, 30.8%, 19.2% and
7.7 % respectively. Only 3.8% of the subjects heard that
the voices command to harm self during the
preliminary assessment.
Subjective perception towards the hallucinatory
voices
69.2% of the subjects reported that they have
negative thoughts associated with the auditory
hallucinations. The voices were rather more distressing
(88.5%) than pleasant (11.5%) among the study
subjects.
61.5% of the subjects reported that they hear voices
most frequently during evening time, (5 PM –
bedtime), and 23.1% of them have frequent voices
during morning (till 12 noon). Most (61.5%) of the
subjects reported that they never heard voices while
asleep and 26.9% of them reported that they never
heard voices morning till 12PM. Two subjects (7.7%)
reported that they heard voices while they sleep, that
the voices awaken them from sleep. Three subjects
explained that they usually woke up by the voices in
the morning time.
Most of the subjects agreed that the voices are more
pronounced when they are alone (88.5%) and fewer
voices are associated with the activities that they are
engaged with (65.4%).
Table 1: Distribution of subjects based on coping
strategies on AVH N=52
Coping strategies and Effects of Medications f%
• Listening to music 8 15.4
• Reading aloud 4 7.7
• Watching television 22 42.3
• Doing something which is interesting 26 50
• Taking rest or relax 12 23.1
• Yell back at the voice 6 11.5
• Using extra dose of medications 6 11.5
• Praying 6 11.5
*Multiple response item; overall response score does not
correspond to 100%
50% of the subjects reported that doing something
which is interested could help them to cope with the
voices. The other common strategies reported by the
subjects were watching Television (42.23%), taking rest
or relax (23.1%) and listening to music (15.4%). 11.5%
of them reported that praying, using extra dose of
medications and yelling back the voices as the coping
strategies used. 7.7% reported that they preferred to
read aloud while they hear distressing voices.
50% of the subjects reported that the medications
have no effect on the hallucinatory experience and
dizziness and sleepiness was the main problem
associated with medications as the subjects stated. One
subject was concerned about her weight gain with the
psychotropic medication. 42.3% of the subject stated
medications do have effect on their hallucination. As
the subjects stated, the psychotropic medications are
helpful in getting sound sleep, and relaxation. 7.7% of
the subjects were not sure about the effect of
medications on the auditory hallucination.
DISCUSSION
50% of the study population was unmarried though
the Mean age was 35 years; this is possibly due to the
high stigma associated with the illness in India. 38.5%
of the subjects completed their pre university
education; the findings could be discussed in the light
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 121
of their age at onset of hearing AVHs, i.e. 26 years.
Unemployment among people diagnosed with
schizophrenia increased from 88% in 1990 to 96% in
1999 and increasing through years.11 This is reflected
in the present study where 69.2% of them were
unemployed.
Paranoid schizophrenia was the common (61.5%)
subtype among subjects as the literature stated.12 The
Mean age at hearing voices at first was 26 years and it
was similar in many other studies13,14 done among
schizophrenia patients who reported to have persistent
AVH.
73.1% of them reported to hear 2nd person AVH,
most of them reported the location of their voices from
outside of their head, 11.5% of them reported to hear
voices as continuous monologues; these findings were
similar to other studies15,16 done among similar
population. One subject in the present study reported
that the voices heard were more of animal sounds than
verbal forms. Commenting type of AVH was
commonly reported as similar to other studies15,16,17
CONCLUSION
Voice hearing refers to a subset of auditory
hallucinations representing the linguistic, dialogical,
properties of “hearing” and reacting to intersubjective
voice events. The phenomenon is tied to a variety of
normal or abnormal organic, physiological,
psychological, and bioelectrical processes.
Experiencing auditory hallucination is distressing and
may often lead to various other problems such as
anxiety, depression, self harm and suicide. It also
causes disability in social and occupational
functioning.
Central to assisting people to cope with auditory
hallucinations is an understanding of the experience
from the point of view of the individual. Attempts at
helping the voice hearer must be by an understanding
of the experience, sensitivity to the person’s distress,
the person’s own usage of coping strategies and the
meaning the person attributes to the experience.18
Without such knowledge, the nurse may unwittingly
hinder the person’s attempts to cope and undermine
their sense of self-efficacy. An understanding of the
biological processes underlying the hallucinatory
experience and theories of hallucinations are required
to provide some direction to the nurses’ choice of
intervention.
ACKNOWLEDGEMENT
This study was greatly supported by Prof. Robin
Kay Buccheri, DNSc, RN, PMHNP, and Louise Neigh
Trygstad, DNSc., RN, CNS, (Professor Emeritus)
University of San Francisco, School of Nursing, Fulton
St., San Francisco, California, USA. It is our pleasure
to express our profound gratitude and indebtedness
to them for introducing us to a highly stimulating
study topic and for the expert guidance and the
invaluable support given.
Conflict of Interest: Nil
Source of Support: Nil
Ethical Clearance: Ethical clearance was obtained from
the Institutional Ethics Committee, National Inst. of
Mental Health and Neurosciences, Bangalore, and the
subjects were informed about the study and a signed
consent was obtained prior to the data collection
procedure.
REFERENCES
1. Nayani, T.H & David, A.S. The auditory
hallucinations: A phenomenological survey,
Psychol Med.1996; 26(1):177-89.
2. Al-Issa, I. The illusion of reality or the reality of
illusion; Hallucinations and culture, British
Journal of Psychiatry. 1995; 166 (3): 368–373.
3. Prasada Rao. Cognitive Behavioral Therapy in
Hallucinations, Indian Journal of Psychology.
2000; 27: 189-201.
4. Margo, A., Hemsley, D.R., & Slade P.D. The Effect
of Varying Auditory Input on Schizophrenic
Hallucinations, British Journal of Psychiatry.
1981; 139: 122-127
5. Westacott, M. Strategies for managing auditory
hallucinations. Nursing Times. 1995; 91 (3): 35–
37.
6. Lindenmayer, J. Treatment of refractory
schizophrenia. Psychiatry Quarterly. 2000; 71(4):
373-384.
7. Morrison, A.P., Nothard, S., Bowe, S., & Wells, A.
Interpretation of voices in patients with
hallucinations and non patient controls: A
comparison and predictors of distress in patient.
Behavior Research &Therapy. 2004; 42(11): 1315-
1323.
8. Hardy, A., Fowler, D., Freeman, D., Smith, B.,
Steel, C., & Evans, J. Trauma and hallucinatory
experience in psychiatric clients. Journal of
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Nervous and Mental health Diseases. 2005; 193(8):
501-507
9. Fowler, D., Garety, P. & Kuipers, E. Cognitive
Behaviour Therapy for Psychosis: Theory and
Practice. Chichester, UK, Wiley. 1995; 25.
10. Buccheri, R., Trygstad, L., Kanas, N., Wal-dron,
B., & Dowling G. Audi-tory hallucinations in
schizophrenia: Group experience in examining
symp-tom management and behavioral
strat-egies. Journal of Psychosocial Nursing and
Mental Health Services. 1996; 34(2): 12-26.
11. Rachel Perkins & Mils Rinaldi. Unemployment
rates among patients with long term illness.
Psychiatric Bulletin. 2002; 26: 295-298.
12. Ahuja, N. A short Textbook of Psychiatry. 6th ed.,
New Delhi, Jaypee Brothers Medical Publications
(P) Ltd. 2006; 57.
13. Sreevani, R. A Guide to Mental Health and
Psychiatric Nursing. 2nd ed., New Delhi, Jaypee
Brothers Medical Publications (P) Ltd. 2007; 80.
14. J.C. González, E.J. Aguilar, V. Berenguer, C. Leal
& J. Sanjuan. Persistent Auditory Hallucinations.
Psychopathology. 2006; 39: 12-125.
15. Buccheri, R., Trygstad, L., & Dowling G.
Behavioral management of command
hallucinations to harm in schizophrenia. Journal
of Psychosocial Nursing and Mental Health
Services. 2007; 45(9): 46-54.
16. Romme, M.A., Honing. A., Noorthroon & Escher.
Coping with Hearing Voices: An Emancipator
Approach. British Journal of Psychiatry. 1992;
16(1): 99-103.
17. Morrison, A.P., Nothard, S., Bowe, S., & Wells, A.
Interpretation of voices in patients with
hallucinations and non patient controls: A
comparison and predictors of distress in patient.
Behavior Research &Therapy. 2004; 42(11):
1315-1323.
18. Bivin, J.B & Sailaxmi Gandhi. Strengthening self
symptom management strategies in auditory
hallucinations among patients diagnosed with
schizophrenia. Souvenir, Third International
Conference of ISPN- Bhilai, Chattisgarh. 2011;
41-44.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 123
INTRODUCTION
The World Health Organization has defined
“Adolescents” as persons in `the age group of 10 to 19
years1. About22 % of India’s population is adolescents1
which are among the largest in the world2. This is the
generation which will shape India’s future. One of
the most important commitment a country can make
for its future economic, social, and political progress
and stability is to address the health and development
related needs of adolescents3.
Depressive disorders are prevalent and serious in
children and adolescents, often causing substantial
difficulties in social, personal, family and academic
Health Risk Behaviour and Depression among
Adolescents
Dayananda B C1, Meera K Pillai2
1Lecturer, HOD of Psychiatric Nursing, Apex College of Nursing, Varanasi, Utter Pradesh, 2Principal, Sree Gokulam
College of Nursing, Trivandrum, Kerala
ABSTRACT
Adolescent health is particularly an important issue in India, due to very high population growth,
wide socioeconomic and health disparities among its population.
Objectives of the study
The study objectives were to:
1. Assess the occurrence of health risk behaviours among adolescents.
2. Assess the occurrence of depression among adolescents.
3. Study the correlation between health risk behaviours and depression
4. Determine the association between depression and selected demographic variables.
Materials and Method: A quantitative research approach with descriptive correlative design was
used for study. A sample of 500 high school students in the age group of 13-16 years were drawn
through purposive sampling. Tools: structured Health Risk Beaviour (HRB) rating scale and Beck
Depression Inventory (BDI).
Result: There was significant occurrence of health risk behavior and depression among adolescents
aged 13-16 years. There was positive correlation between health risk beahviour and depression. Here
was association between depression and age, father's educational status and academic grades.
Conclusion: A very high number of high school children had one or the other health risk behavior
calls for more attention in this area by school authorities for early intervention.
Keywords: Health Risk behavior, Depression, Adolescents
DOI Number: 10.5958/j.0974-9357.5.2.054
functioning. Increased depressive symptoms are one
of the most prevalent mental health problems among
adolescents4. Various risk behaviors, such as engaging
in physical fights, violence ,smoking, alcohol and drug
use, consuming a high fat diet, suicidal thoughts and
attempts and depression are often adopted in young
adolescence. In India 70% of mortality in adulthood is
linked to habits picked up during adolescence. 24% of
drug abusers are in the age group of 12-18 years1.
METHODOLOGY
The research approach adopted for the study was
quantitative research with descriptive correlation
design. The independent variables in the study
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124 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
included health risk behaviours and depression. The
extraneous variables were age, gender, parental
support, educational status of father, academic grades,
type of family, total family income per month and BMI.
The study was conducted in one selected high
school from Mangalore. The population under the
study consisted of all the high school students between
13- 16 years of age from all the high schools in
Mangalore. Purposive sampling technique was used
to select an urban English medium high school in
Mangalore for easy access to the sample under study.
500 samples who met the inclusion criteria were
selected by purposive sampling method for assessing
health risk behavior and depression among
adolescence.
Health risk behaviour 5 point rating scale contained
20 items in 4 different areas. They were 6 behavioural
practices under risk for violence, 3 behavioural
practices under risk for suicide, 6 behavioural practices
under risk for substance abuse and 3 behavioural
practices under risk for obesity (weight gain).5- point
scale as never, rarely, sometimes, most of the time and
always. The total score ranged between 31 and 100.
Beck Depression Inventory consist of 21-question
multiple-choice self-report inventory, one of the most
widely used instruments for measuring the severity
of depression. Screening ranges from, 0 to 3 for each
item. Total score is compared to a key to assess the
severity of depression. Selected cut-offs are as follows:
0–15 indicates minimal depression and these minimal
ups and downs are considered to be normal,16–30
indicates mild depression, 31–40 indicates moderate
depression and more than 40 indicates severe
depression. Higher total scores indicate more severe
depressive symptoms.
Validity of procedure and tool was determined on
the basis of expert’s opinion for clarity,
appropriateness, adequacy and relevance of the items.
A try- out study was conducted in order to finalise the
tool. Reliability was established by test and retest
method. There was 24 hour gap between test and retest
in collecting the data. Reliability for health risk
behaviour rating scale was found to be 0.891. Data was
collected by personally administering the tool to 500
sample subjects of selected high school.
The data was tabulated, organised, analysed, and
interpreted using descriptive and inferential statistics
on the basis of objectives and hypothesis of the study.
Parameters used were mean, median, mode, standard
deviation, chi-square, Karl Pearson’s Test and
regression method.
RESULTS
Demographic characteristics
Table 1: Distribution of samples according to baseline
characteristics. n = 500
Sl. Sample Frequency Percentage
No characteristics (%)
1 Age (in years)
13 167 33.4
14 166 33.2
15 154 30.8
16 13 2.6
2 Gender
Male 400 80
Female 100 20
3 Standard
8th 180 36
9th 160 32
10th 160 32
4 Religion
Hindu 230 46
Muslim 44 8.8
Christian 219 43.8
Others 7 1.4
5 Parents
Both parents alive 471 94.2
Single parent 21 4.2
Lost both parents 1 0.2
Parents are divorced 2 0.4
Parents are separated 5 1
6 Educational status of father
Illiterate 0 0
Primary level education 3 0.6
High school education 37 7.4
PUC education 94 18.8
Graduate 258 51.6
Postgraduate/ professionals 108 21.6
7 Father ’s occupation
Unemployed 2 0.4
Laborer 9 1.8
Private employee 252 50.4
Government employee 139 27.8
Any other 98 19.6
8 Mother ’s education
Illiterate 1 0.2
Primary education 0 0
High school education 47 9.4
PUC education 147 29.4
Graduate 242 48.4
Postgraduate/ professional 63 12.6
9 Mother ’s Occupation
House wife 310 62
Laborer 3 0.6
Private Employee 84 16.8
Government employee 83 16.6
Any others 20 4
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 125
Table 1: Distribution of samples according to baseline
characteristics. n = 500 (Contd.)
Sl. Sample Frequency Percentage
No characteristics (%)
10 Academic grades
< 35 % 14 2.8
35- 50% 41 8.2
50-60 % 63 12.6
60-70 % 131 26.2
> 70 % 251 50.2
11 Type of family
Nuclear family 412 82.4
Joint family 69 13.8
Extended family 19 3.8
12 Total family income per
month in Rupees
< 5000 23 4.6
5001-10,000 47 9.4
10,001- 15,000 60 12
15,001-20,000 91 18.2
>20,000 279 55.8
13 BMI
Normal( >18.5 - < 25) 384 76.8
Over weight (> 25 - <30) 72 14.4
Obese (?30) 14 2.8
Under weight (< 18.5) 30 6
Table 1: depicts that 33.4% of the subjects were in
the age of 13 years. Majority (80%) of subjects were
males. 36% of the subjects were from 8th standard. 46%
of the subjects were belonged to Hindu religion 43.8%
of subjects were Christians. Majority (94.2%) of the
subjects reported that their both parents were alive and
live with them. Majority (51.6%) of the subject’s fathers
were graduates. Majority (50.4%) of the subject’s
fathers were private employees. 48.4% of the subject’s
mothers were graduates. Majority (62 %) of the
subject’s mothers were housewife. Majority (50.2%)
of the subject’s academic grades in school was above
70%. Majority (82.4%) of the subjects were from
nuclear family. Majority (55.8%) of the subject’s family
income was above Rs.20, 000. Majority (76.8%) of the
subject’s BMI was normal.
Occurrence of health risk behavior
Table 2: Occurrence of health risk behavior.
Hrb Range of Frequency Percentage
Scores (%)
Violence
No risk for violence 20 %-30 % 172 34.4
Mild risk for violence 31%-55% 301 60.2
Moderate risk for violence 56%-78% 25 5
High risk for violence 79%-100% 2 0.4
Table 2: Occurrence of health risk behavior. (Contd.)
Hrb Range of Frequency Percentage
Scores (%)
Suicide
No risk for suicide 20 %-30 % 299 59.8
Mild risk for suicide 31%-55% 172 34.4
Moderate risk for suicide 56%-78% 20 4
High risk for suicide. 79%-100% 9 1.8
Substance Abuse
No risk for substance abuse 20 %-30 % 478 95.6
Mild risk for substance abuse 31%-55% 20 4
Moderate risk for 56%-78% 2 0.4
substance abuse
High risk for substance abuse 79%-100% 0 0
Obesity (Weight Gain)
No risk for obesity 20 %-30 % 68 13.6
(weight gain)
Mildrisk for obesity 31%-55% 346 69.2
(weight gain)
Moderaterisk for obesity 56%-78% 86 17.2
(weight gain)
High risk for obesity 79%-100% 0 0
(weight gain)
Over all HRB
No HRB 20-30 225 45
Mild 31-55 273 54.6
Moderate 56-78 2 0.4
High 79-100 0 0
Table2- shows that Occurrence of health risk
behavior among adolescents (as measured by
structured health risk behavior rating scale) was found
to be 55%. Majority of subjects (60.2 %) reported mild
risk for violence, 5% had moderate risk for violence,
0.4% had high risk for violence and 34.4% had no risk
for violence. Identified risk for suicide revealed that
(59.8% had no risk for suicide) 34.4% had mild risk for
suicide, 4% had moderate risk for suicide and 1.8 %
had high risk for suicide. Identified risk for substance
abuse revealed that (95.6% had no risk for substance
abuse ) minor 4% had mild risk for substance abuse
and 0.4% had moderate risk for substance abuse.
Identified risk for obesity (weight gain tendency)
revealed that [13.6% had no risk for obesity (weight
gain tendency)] major 69.2% had mild risk for weight
gain and 17.2% had moderate risk for weight gain.
Occurrence of depression
Table:3 Occurrence of depression
Scores Depression Frequency Percentage
(%)
0-15 No depression 361 72.2
16-30 Mild 127 25.4
31-40 Moderate 10 2
>40 Severe 2 0.4
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126 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
The table 3 indicates that 72.2% had no depression,
where as 25.4% of the subjects had mild depression,
2.0% had moderate depression and 0.4% had severe
depression.
Correlation between health risk behavior and depression
Table 4 : Correlation between health risk behaviour and depression. = 500
Variables Pearsons Value d.f Table value
Depression score Risk for Violence 0.304 498 0.19
Risk for Suicide 0.614 498 0.19
Risk for Substance abuse 0.18 498 0.19
Risk for Obesity 0.301 498 0.19
Over all health risk behaviour 0.509 498 0.19
Table 5: Regression analysis to evaluate the most contributing health risk behaviour factor to
depression
Model Unstandardized Standardized t p-value
Coefficients Coefficients
B Std.Error Beta
(Constant) -3.803 1.757 2.165 0.031
Risk for Violence 0.289 0.109 0.106 2.65 0.008
Risk for Suicide 0.344 0.024 0.553 14.279 0
Risk for Substance Abuse -0.101 0.221 -0.018 -0.459 0.646
Risk for Obesity 0.076 0.03 0.096 2.557 0.011
The table 4 shows there was positive correlation
between the health risk behavior and depression.
Which indicates that, health risk behavior increases
with increase in symptoms of depression. Regression
analysis, table 5 revealed that risk for suicide, risk for
violence, risk for obesity had significant contributing
role in depression. HRB -q risk for suicide was found
to be more of a contributing factor to depression in
comparison to risk for violence, risk for obesity and
risk for substance abuse (standardized beta to risk for,
suicide= 0.553, violence=0.106, obesity=0.096 and
substance abuse= -0.018).
Association between depression and selected
demographic variables
Chi-square is used in order to find out the
significance association between depression and
selected demographic variables. There was significant
association between depression, and age(χ2
cal = 22.597,
p<0.05), father’s educational status (χ2
cal = 10.283,
p<0.05) and academic grades (χ2
cal = 26.791, p<0.05) .
There was no significant association between
depression and other variables like gender, parental
support, type of family, total income per month, BMI.
INTERPRETATION AND CONCLUSION
Findings of the study show that majority of the
subjects had one or the other health risk behavior.
There was a positive correlation between health risk
behavior and depression. Depression was found to be
27.8% out of only 2.0% had moderate level of
depression and 0.4% had severe depression. This
indicates that majority had (25.4%) mild depression,
which may be due to depressive feelings, related to
environmental factors and subjective well being. These
points towards the scope for possible beneficial effects
by interventions like alternative and complimentary
therapy for life style modification.
ACKNOWLEDGEMENT
We acknowledge our thanks to high school students
who participated in the study , authorities who
provided permission to conduct study and statistician
Mrs. Sucharita, Fr Mullers Medical College,
Mangalore.
Ethical approval: Ethical approval to conduct the
study was obtained from the ethical committee of Nitte
Usha Institute of Nursing Sciences (Nitte Deemed
University), India. Permission was obtained from the
Block Education Officer of urban area and the principal
of St.Aloysius high school, little hill road, Mangalore,
India, to conduct study. Written consent obtained from
the high school students whoever participated in the
study.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 127
Source of Funding: Self.
Interest of Conflict : None
REFERENCE
1. Overview of Adolescent Health in India.
Retrieved on 2009 Aug14. Available from: URL
http://www.indmedica.com/journals/xhtml/
13_overview_adol_chopra.htm
2. World’s Teen Capital. Retrieved on 2012 Oct 17.
Available from: http://articles. timesofindia.
indiatimes.com/2011-02-26/india/28636628_1_
urban-girls-rural-girls-adolescent-girls
3. Adolescents In India A profile Retrived .Retrieved
on 2012 Oct 17. Available from: http://
web.unfpa.org/focus/india/facetoface/docs/
adolescentsprofile.pdf
4. Eszter Kovacs, Bettina F Piko, ‘Depressive youth’
– Adolescent’s depressive symptomatology in
relation to their social support in Hungary, 1089
Budapest, VIII. Nagyvárad Square 4. Hungary.
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128 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
“If accident is a disease, education is its vaccine”1
Road traffic crashes are routine occurrences
throughout the world. Thousands of people lose their
lives on the roads every day. Many more left with
An Experimental Study to assess the effectiveness of the
Structured Teaching Programme on Knowledge of Traffic
Safety among School Children at Selected Urban Schools
in Ludhiana, Punjab
Gaurav Kohli
Assistant Professor, Department of Community Health Nursing, M.M Institute of Nursing M.M university, Ambala
ABSTRACT
Objectives:
1. To assess the pretest knowledge of Traffic Safety among school children of control and experimental
group.
2. To assess the post test knowledge of Traffic Safety among school children of control and
experimental group.
3. To compare the pretest and posttest knowledge of Traffic Safety among school children of control
and experimental group.
4. To ascertain the relationship of structured teaching on knowledge of Traffic Safety among school
children with selected variables such as age, gender, academic standard, father's education,
exposure to mass media, type of vehicles use.
Material and Method: Experimental approach, true experimental design was used and the study
conducted in Sargodha National public senior secondary school, field ganj and Shivalik Vidya Mandir
School, Jamalpur. & Shivalik Vidya Mandir School Jamalpur, Ludhiana (Pb.) 64 school children were
chosen by Non proportionate stratified random sampling. The data collected through self structured
questionnaire. The data was analyzed by descriptive statistics (mean, median & mode) & inferential
statistics (Chi square, F test, Correlation of coefficient & t test).
Results: The pretest mean knowledge score of experimental group was 19.66 and in post test 31.94
after carrying out the structured teaching programme. On other side control group mean knowledge
score of pretest was 19.91 & in post test 21.41. Horizontal't' test findings between pre test and post
test of experimental group was18.065 is highly significant at the level of P<0.001 & vertical't' test
value between post tests of control and experimental group was 198.677 also highly significant at the
level of P<0.001. it has shown that structured teaching brought valuable change in the knowledge of
school children regarding traffic safety. Recommendations: the findings of the study shown that
there is need to carry out the interventions to increase the knowledge of school children regarding
traffic safety which further will help to reduce the accidents & secure the school children on the
roads.
Keywords: Experimental Study, Structured Teaching Programme, Traffic Safety, School Children
DOI Number: 10.5958/j.0974-9357.5.2.054
disabilities or emotional scars that they will carry for
the rest of their lives.2 Children and young adults are
more vulnerable. Every hour of every day, forty
youngsters die as a result of road traffic crashes. This
means that every day another one thousand families
have to cope with the unexpected loss of a loved one.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 129
Losing a child is never easy. Knowing that a child was
lost to a preventable incident may add to the pain and
suffering, and can leave families and communities with
emotional wounds that take decades to heal.3
It is estimated that more than a quarter of injury-
related deaths in the world occurred in the South-East
Asia Region in 2000.4 In fact, road traffic injuries alone
ranked as the number one cause of the burden of
disease among children between 5-15years. This
portion of population comprises 17.5 % of world’s total
number of accidents. Which cause 15.6 deaths per 1,
00,000 population of this age group. This heavy burden
at such an early age has long-term implications on the
quality of life and economy of the nations.5
METHODS AND MATERIAL:
Objectives
• To assess the pretest knowledge of Traffic Safety
among school children of control and experimental
group.
• To assess the post test knowledge of Traffic Safety
among school children of control and experimental
group.
• To compare the pretest and posttest knowledge of
Traffic Safety among school children of control and
experimental group.
• To ascertain the relationship of structured teaching
on knowledge of Traffic Safety among school
children with selected variables such as age,
gender, academic standard, father’s education,
exposure to mass media, type of vehicles use.
Hypothesis
•H
1 The posttest mean knowledge score of traffic
safety among school children in the experimental
group will be significantly higher than those of the
control group school children as measured by
structured questionnaire at 0.05 levels.
• Rationale: Researcher reported the improved
crossing behaviors from pre-test to post-testing
conditions after conducting walk safe education
programme. A total of 2,987 tests were collected
during the three different testing times. Significant
differences were observed (p value <0.05) between
pre- and post testing.6
•H
0 There will not be statistically significant
difference in posttest mean knowledge score of
traffic safety among school children in control and
experimental group as measured by structured
questionnaire.
Research Approach and Rationale
An experimental research approach was adopted
to accomplish the objective of the study to assess the
effectiveness of structured teaching programme on
traffic safety among school children in selected schools
of Ludhiana Punjab. Experimental study is found
appropriate for the study, this approach involves all
three properties of these are control, manipulation and
randomization. 7
Research Design
An experimental design was prepared to develop
a plan of strategy that would guide the collection and
analysis of data.
Experimental group 01X0
2
Control group 0102
O1 –Pretest
X – Manipulation
O2 - Posttest
Selection and Description of Setting
The present study was conducted in two schools
i.e Sargodha National public senior secondary school,
field ganj and Shivalik Vidya Mandir School, Jamalpur.
Sargodha National Public Senior Secondary School is
near college of nursing C.M.C & hospital. It was
established in 1972. It is a co education school. The
total strength of school is 1200. The total numbers of
school children in age group of 12-15 years are 412.
The Shivalik Vidya Mandir School was located at a
distance of 5 kilometer from college of nursing C.M.C
& hospital. Sargodha National Public Senior Secondary
School is 6 km away from the Shivalik Vidya Mandir
School. It was established in 1998. The total strength
of school is 1000 students. The total number of school
children in age group of 12-15 years is 221. It is a co
education school. The experimental group was selected
from Sargodha National Public Senior Secondary
School, Field Ganj and control group from Shivalik
Vidya Mandir School Jamalpur.
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130 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Sample and Sampling Technique The questions were related to following aspects
Area Items Score
Introduction 3 3
Causes 4 4
Traffic Safety 12 12
Safety actions 21 21
Total Items 40
Maximum score 40
Minimum score 0
Plan of Analysis
Analysis and interpretation of data was done by
using descriptive and inferential statistics such as
Percentage, Mean, Mean Percentage, Standard
Deviation, Coefficient of Correlation, Chi Square Test,
T Test and Anova. Bar diagrams were used to depict
the findings.
Conceptual Framework
Conceptual model of the present study based on
general system’s theory by Ludwig Von Bertalanffy
(1968). General system theory serve as a model for
viewing man as interacting with the environment. One
of the first theorists to develop systems theory was
Ludwig Von Bertalanffy (1968). A system theory
consists of interacting components within a boundary
that exchange with the environment. Refers to the
arrangements of parts at a given time and function is
process of continuous exchange in system. The system
uses input to maintain the system’s equilibrium. (See
Fig. No: 2)8
RESULTS
Mean post test knowledge score of school children
was significantly higher than the mean pre-test
knowledge score of school children in experimental
group. There was significant relationship of structured
teaching among school children with age, father’s
education, type of vehicle used & mass media
exposure.
Fig. 1. (sample size & classification into control & experimental
group)
Two schools were confirmed to conduct study.
These schools were divided into control and
experimental group with help of lottery method. Lists
of names of all school children under the age of 12-15
year were taken from the school attendance register
and age was confirmed by asking orally before making
the lists. A total of 221, 412 school children of 12-15
year in control and experimental group considered as
accessible population using defined inclusion criteria.
The total 64 school children were selected from both
groups by using stratified random sampling technique.
Description of tool
The tool consisted of two parts
Part1: Sample characteristics
This part consisted of 8 items for obtaining personal
information i.e. age in year, gender, academic standard,
family income, father’s education, mother’s education,
channel of mass media exposure and type of
conveyance used.
Part2: Questionnaire
This part consists of multiple choice questions on
all aspects of school children regarding traffic safety.
This questionnaire consisted of 40 multiple choice
items, each item consist of one correct answer among
the four choices and each correct answer carry one
mark.
Table No. 1 Comparison for effectiveness of teaching by calculating Pretest and Posttest mean, SD, horizontal &
vertical t test of Knowledge Scores among School Children Regarding Traffic Safety N=64
Group Knowledge Score
Pretest Posttest
N Mean SD Mean SD Df T
Control Group 32 a19.91 3.622 c21.41 4.047 31 2.585NS
ExperimentalGroup 32 b19.66 3.543 d31.94 3.426 31 18.065***
Df t Df t
62 2.441NS 62 198.677***
Maximum Score=40 *** at P<0.001
Minimum Score=0 NS Non Significant
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 131
Table 2 Text is ct (Txt YTC)
are thankful to invaluable guide Associate Prof. (Mrs.)
Reena Jairus, co-supervisor Asstt. Prof. Mrs. Malini
Singh & family for their guidance and support
throughout the research work.
Interest of Conflict: Financial budget of study was
borne by me and I did not find any financial difficulty
to carry out this research study. There was not any
hindrance to write an article and its publication.
Study Funded By: Self
Ethical Consideration: Though it was a knowledge
study so it was not required.
REFERENCES
1. National Safety Council. International Accident
Facts. 3rd edition, Itasca & Co.2002.
2. McKeena Frank.The international Hand Book Of
Traffic Accidents and Psychological Trauma. 1st
edition. Philadelphia, Pergamon publishers 2000.
3. Jha N and Agrawal CS., Epidemiological Study
of Road Traffic Accident Cases. Regional Health
Forum WHO South-East Asia Region 2004;
8(1):15-22.
4. Swami H.M., Puri S., Bhatia V., Road Safety
Awareness and Practices among School Children
of Chandigarh. Indian Journal of Community
Medicine 2006:31(3):199-200.
5. Jha N and Agrawal CS., Epidemiological Study
of Road Traffic Accident Cases. gional Health
Forum WHO South-East Asia Region 2004;
8(1):15-22.
6. Hotz G, Cohn S, Castelblanco A, ColstonS, Nelson
J, Dunun R. Walk Safe: a school-based pedestrian
safety intervention program. Traffic Injury
prevention 2004; 5 (1), 382-389.
7. Polit and Hungler, Nursing Research, Principles
and Methods, 2nd Edition, Philadelphia,
Lippincott. Co. 1987.
8. Braziller G., General System Theory, 1st edition,
New York, Grouce Beckfeller Co. 1968.
Fig. 1. Conceptual Framework Modified and Based on General
System Model (Ludwig Von Bertalanffy,1968) Key Studied, —
Not studied
DISCUSSION
Findings shows that structured teaching
programme had excellent level of improvement in
experimental group of school children as in control
group it was average or below average. There is no
relation between structured teaching programme &
gender, academic standard, family income, mother’s
education, use of vehicles and type of vehicles but
significant relationship has revealed with age, father’s
education, type of vehicle used and mass media
exposure.
ACKNOWLEDGEMENT
First and foremost I praise and thank ‘Lord Radhe
Krishna’ for His abundant grace, which enabled me
to complete this thesis work successfully The authors
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132 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
Sleep-related disorders are common in the general
adult population, and as the population ages, the
prevalence of these disorders increases. A common
misconception among clinicians and the public is that
this increased prevalence of sleep problems are a
normal and expected phenomenon of aging. However,
this higher prevalence of sleep disruption is often the
result of the increased presence of medical and
psychosocial co-morbidities in this population. The
complicated multi-factorial interactions that generate
sleep disorders in older individuals pose important
challenges health care personnel.1
Therapeutic massage is an ideal way to deal with
stress and health disorders naturally. A massage
provides both physical and emotional wellness. The
massage sessions can vary from single sessions to a
regular massage for a short span, over a period of time.
Therapeutic massage is usually rendered to treat
certain health conditions, boost overall immunity or
A Study to Determine the effectiveness of Therapeutic
Back Massage on Quality of Sleep among Elderly in
Selected old Age Homes at Mangalore
Gayathri J Nair1, Swapna Dennis2, Babu Dharmarajan3
1II Year M. Sc Nursing, 2Lecturer, 3Head of the Department, Yenepoya Nursing College, Yenepoya University,
Mangalore
ABSTRACT
Sleep-related disorders are common in the general adult population; Therapeutic massage is an ideal
way to deal with the health disorders naturally. A quasi experimental study has been carried out to
determine the effectiveness of therapeutic back massage on quality of sleep among 60 elderly people
in the selected old age homes, in Mangalore, Karnataka, India , found that there was significant
difference 6.23 (p<0.05) and improvement (F = 80.463, p<0.05) in the quality of sleep of elderly
among experimental and control group. The study concluded that therapeutic back massage was
effective to promote the quality of sleep among elderly population.
Keywords: Therapeutic Back Massage, Quality of Sleep, Elderly, Old Age Homes
DOI Number: 10.5958/j.0974-9357.5.2.054
Corresponding author:
Swapna Dennis
Lecturer
Dept of Medical Surgical Nursing, Yenepoya Nursing
College, Yenepoya University, Mangalore
E - Mail id - gjmsc2013@gmail.com
as a distressing mechanism. It provides varied benefits
such as improved blood circulation, release of
endorphins that reduce pain, speedy recovery from
injuries or chronic illness and improvement in sleep.2
A study was done to examine the physiological and
psychological effects of slow-stroke back massage and
hand massage on relaxation in older people and
identifies effective protocols for massage. All studies
using slow-stroke back massage and hand massage
showed statistically significant improvements on
physiological or psychological indicators of relaxation.
The most common protocols were three-minute slow-
stroke back massage and 10-minute hand massage.
Results of the review show the effectiveness of slow-
stroke back massage and hand massage in promoting
relaxation across all settings. It was concluded that
studies are needed to analyze the feasibility and cost
effectiveness of massage to develop best practices for
massage interventions in older people.3
MATERIALS AND METHOD
The research design selected for this study was
quasi experimental design. The independent variable
of this study was therapeutic back massage and the
dependent variable is quality of sleep. Setting for the
present study was St Ann’s poor homes, Mangalore,
Karnataka. Subjects were selected by purposive
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 133
sampling technique and randomly assigned to
experimental and control group (30 samples each).
After obtaining consent from the subjects pre-test
quality of sleep was assessed by using developed scale,
after referring the standardized scales. The validity of
the tool was assessed by 13 experts; nine experts from
the field of Medical Surgical nursing, two doctors, and
two masseurs. The reliability coefficient calculated by
using Karl Pearson’s correlation coefficient and the
value obtained was 0.9 which indicated that the
developed tool was reliable.
The experimental group is provided with
therapeutic back massage. Therapeutic back massage
means, systematic manipulation (eg. Lubrication,
friction, fulling, kneading, compression, percussion,
and stroking) of back muscles and soft tissues, 2-3
hours prior to sleep for 10 – 15 minutes per day for 6
consecutive days for an elderly person in prone
position (with forehead resting upon the crossed
hands). Post-test quality of sleep was assessed in all
subjects on 4th day, 5th day, and 6th day during
intervention period.
FINDINGS
Post test level of sleep score in experimental and
control group
The Sixth day’s post test level of sleep score in
experimental group in terms of mean, median and
mean percentage was 25.33 ± 2.86, 25 and 51.05% and
in the control group it was 30.63 ± 3.76, 31, and 51.03%
respectively. The mean post tests score of elderly in
experimental group (25.33 ± 2.86) was much less than
the elderly in control group (30.63 ± 3.76). It shows
that there was significant difference in the quality of
sleep between experimental group and control group.
Assessment of improvement of quality of sleep
among experimental group
Table 1: Assessment of improvement of quality of
sleep among experimental group N= 30
Sum of Mean F ratio
squares squares
Within the subject effects 649.067 216.356 80.463 F3,87 =
2.87P<0.05
From this table F value for the quality of sleep score,
with repeated measures, based on the tabled value
under the degree of freedoms 3 and 87 in 2.87.
Therefore the calculated value is greater than the tabled
value, and concludes that there is high significant
improvement in the quality of sleep from the 4th - 6th
day, in the elderly people of experimental group.
Effectiveness of therapeutic back massage on quality
of sleep
Independent‘t’ test was used to test the
effectiveness of therapeutic back massage on quality
of sleep.
Table 2: Effectiveness of therapeutic back massage on
quality of sleep among experimental and control
group N= 60
Group Mean t value Mean
difference
Experimental group 6.266 9.522 6.23t58 =
Control group 0.033 1.67, p < 0.05
The data presented in table shows that‘t’ value
computed between experimental and control group
quality of sleep score was statistically significant at 0.05
level of significance. The calculated value (t58= 9.522)
was greater than the tabled value (t58 = 1.67). Since the
calculated value was more than the table value the
research hypothesis stated that there was a significant
difference in the quality of sleep between the
experimental and control group was accepted.
The present study findings are consistent with the
study findings of Richard on effect of a back massage
and relaxation intervention on sleep in critically ill
older patients, who with 6 minutes back massage, in
which the back massage group slept more than 1 hour
long than the patients in the control group. However,
the variance was significantly different among the 3
groups, and, the reanalysis of data with only 17 subjects
in each group revealed no difference among groups
(p= 0.05). The authors concluded that back massage is
useful for promoting sleep.4
The present study findings are consistent with the
study findings of Cinar S (2005), on the effect on sleep
quality of back massage in older adults in rest homes,
in Turkey approves that, the older people who received
10 minutes of back massage prior to bedtime over 3
days had a significant effect on the quality of sleep. It
shows the subject’s Pittsburg Sleep quality Index scale
total mean scores were lower before back massage
(11.84 ± 2.11) than on the days when the massage (9.78
± 2.17) was done (t = 8.07, p= 0.000). It was found that
the massage increased the participant’s quality of
sleep.5
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134 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Association between pre test quality of sleep and
selected demographic variables.
The calculated values of Chi square test are less than
the tabled value in all the demographic variables. It
indicates that there was no association between
demographic variables like age, gender, marital status,
length of stay in old age home and pre test quality of
sleep among elderly.
CONCLUSION
This study was to examine the effects of back
massage on the quality of sleep of elderly in selected
old age homes. The result of the research showed that
back massage applied for 10minutes before bedtime
in older adults increased the quality of sleep in older
adults. Back massage results significantly better sleep
quality in the elderly people.
ACKNOWLEDGEMENTS
With sincere gratitude and humility I acknowledge
the Almighty God who has showered his blessings and
never ending support throughout my study, which has
helped me to overcome all difficulties with courage
and confidence. It is my pleasure and privilege to
record my deep sense of gratitude and sincere thanks
to the authorities of old age homes, Yenepoya
University and to the faculties of Yenepoya Nursing
College for the successful completion of this
endeavour.
Conflict of Interest: Nil
Source of Funding: Nil
Ethical Clearance: Ethical clearance was obtained prior
to the study from Yenepoya University ethics
committee to conduct the study.
REFERENCE
1. Richardson A, Crow W, Coqhill E. A comparison
of sleep assessment tools by nurses and patients
in critical care. J clinic nurse. 2007 Sep ;16(9) :
1660- 1668
2. Glew G.M, et all. Survey of the use of massage
therapy. Int J Ther Massage Bodywork. 2010; 3(4):
10-5.
3. Barnes PM, et all. Complementary and alternative
medicine use among adults. Massage therapy.
Unites states. 2004 Jan; 343(12): 1- 19
4. Richard, Su TP, Fang CL, Chang MY. Sleep quality
among community – dwelling elderly people
after back massage. JCMA. 2011 Taiwan ; 75(8):
75 – 80
5. Cinar S, Eser I. Effect on sleep quality of back
massage in older adults in rest homes. DEUHYO
ED. 2010 Turkey; 5(1): 2 – 7.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 135
INTRODUCTION
Malnutrition can be defined as a group of clinical
conditions that may result from varying degree of
protein deficiency and energy (calorie) inadequacy1.
Based on reports by the World Health Organization,
malnutrition has been recognized as creating the
highest burden of disease in the world. Lack of food;
however is not always the primary cause
for malnutrition. In many developing and
underdeveloped nations, diarrhoea is a major factor
in malnutrition. Additional factors are bottle-feeding
with poor sanitary condition, inadequate knowledge
of proper child care practice, parental illiteracy,
economic factors and lack of adequate food2.
Need for the study
In India 47 % of all children below 3 years of age
are undernourished. National Family Health Survey
(NFHS 1998) data highlights the critical period when
growth faltering occurs to be six months to 2 years.
About 50-60 % of children are reported to be
undernourished by another source. In India, regarding
malnutrition, majority of problems are related to
deficiency states rather than excess. The most
important for this is being poverty, ignorance and
illiteracy. Malnutrition is a major pediatric problem and
it is responsible for high rates of morbidity and
mortality 3-4.
Malnutrition among Underfive Children and Factors
Influencing it
Anumod S1, Aparna S V1, Ggayathri Devi A S1, Julie I S1, Lydia Ferry1, Shilpa Santhan1, Hepsibai J2
1IIIrd year BSc (N) Students, 2Lecturer, Department of Pediatric Nursing, Sree Gokulam Nursing College,
Venjaramoodu, Trivandrum
ABSTRACT
A descriptive study was conducted at Trivandrum District of Kerala among 108 children; aged 6
months to 5 years old were selected by consecutive sampling followed by total enumeration sampling
technique. A semi-structured questionnaire was used to collect information on factors influencing
malnutrition and nutritional status was assessed by measuring height, weight and mid upper arm
circumference (MUAC).Degree of malnutrition was calculated based in IAP classification and Arnold's
classification. Majority (86%) of the children are well nourished, (12%) had grade 1 malnutrition and
(3%) had grade 2 malnutrition none of the children had grade 3 and 4 level of malnutrition. It was
found socioeconomic factor, nutritional factor and health factor were strongly influenced child's
nutritional status (p<0.05)
Keywords: Malnutrition, Under Five Children, Factors Influencing
DOI Number: 10.5958/j.0974-9357.5.2.054
Statement of the problem
“A descriptive study to assess malnutrition among
under five children and factors influencing it in
selected community at Trivandrum District, Kerala.
OBJECTIVES
1) To determine the degree of malnutrition among
under 5 children
2) To identify the factors influencing malnutrition
among under 5 children
3) To determine the association between degree of the
malnutrition and factors influencing malnutrition.
METHODOLOGY
• Research design: Quantitative approach and
descriptive design.
• Settings: Kallara Panchayat at Trivandrum district.
•Population: 6 months to 5 year old children and
their parents in the selected wards of Kallara
Panchayat
•Sample and Sampling technique: 108 children
aged 6 months to 5 year old selected by consecutive
sampling followed by total enumeration sampling
technique.
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136 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
•Tools and techniques: Assessment of nutritional
status of the child including weight taken by
calibrated weighing machine, height and mid
upper arm circumference (MUAC) was measured
by an inch tape and degree of malnutrition was
calculated according to IAP classification and
Arnold’s classification. A semi-structured
questionnaire was used to collect information on
factors influencing malnutrition
Findings: (tables & figures attached in last page
Degree of malnutrition based on IAP classification
Figure (1) shows majorities (85%) of children were
well nourished, (12%) have 1st degree of malnutrition
(grade 1) and (3%) have 2nd degree of malnutrition
(grade 2).
Fig.1. Distribution of subjects according to IAP degree of
malnutrition (n= 108)
Fig. 2. Distribution of subjects according to Arnold’s degree of
malnutrition (n=108)
Figure (2) shows majorities (85%) of them were well
nourished, 13% have mild to moderate and only 2%
have severe malnutrition. (Based on Arnold’s
classification mid upper arm circumference)
Table 1: Association between the degree of malnutrition and factors influencing malnutrition (n=108)
Factors influencing malnutrition Well Malnourished Calculated Degree of Tabulated
Nourished (%) value freedom value
(%)
a) Birth Factor:
1. Birth weight 1 1 3.17 2 0.204
<1 kg &1.1 – 1.5 kg
1.6 – 2.5 kg 16 4
2.6 – 3.5 kg and above 1 – 1.5 kg 76 10
2. Gestational age at birth
Preterm & Term 17 2 0.001 1 0.977
Post Term 77 12
3. Antenatal complication
Yes 1 5 4
No 78 11 0.396 1 0.52
4. Intranatal complication
Yes 7 2
No 77 12 0.001 1 0.977
5. Post natal complication
Yes 9 1 1
No 1 15 0.168 1 0.68
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 137
Table 1: Association between the degree of malnutrition and factors influencing malnutrition (n=108) (Contd.)
Factors influencing malnutrition Well Malnourished Calculated Degree of Tabulated
Nourished (%) value freedom value
(%)
b) Nutritional Factor:
6. Exclusive breast feeding
<3 months 5 3 2 0.08
4 – 6 months 86 11 4.9
Above 6 months & Still continued 3 -
7. Duration of breast feeding
<6 months 3 -
6 months – 1 yr 19 2 3 0.82
1 year- 3 yrs 45 8 0.91
Above 3 yrs & still continued 29 4
8. Failure of breast feeding
Yes 3 2
No 91 12 1.34 1 0.24
9. Age at weaning started
3- 4 months 16 3
5 – 6 months 45 11
After 7 months 33 - 7.26 2 0.02*
10. First source of complimentary feed
Rice, Wheat 7 3 2 0.002**
Raggi 79 5 17.3
Others 8 6
12. Type of food
Vegetarian 32 8
Non - vegetarian 60 8 0.78 1 0.37
13. Cooking practice
Draining away the water at the end of 19 2 0.26 1 0.87
cooking & Prolonged boiling in open pan
Clean and pealing the vegetables 75 12
prior to cooking & none
c) Health Factor
14. Illness in family
Yes 31 4 1 0.981
No 64 10 0.001
15. Illness in child
Yes 4 6 11
No 48 3 4.18 1 0.04*
16. Immunized up-to age
Yes 77 28
No - -
17. De-worming 1.09 1 0.29
Yes 8 1 11
No 14 -
* p < 0.05 level of significance
Above table 1 shows that there was a association
between age at weaning started, first source of
complimentary feed, illness in child with degree of
malnutrition at p = 0.05 level of significance. There was
no association between other factors influencing
malnutrition and degree of malnutrition.
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138 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
• Majorities (86%) of the subjects were between 25 –
60 months of age and (14%) were between to 6 –
24 months. (57%) of the subjects were males and
(43%) were females.
• Majority (85%) of children were well nourished,
(12%) of them have 1st degree of malnutrition and
3% have 2nd degree of malnutrition based on IAP
classification. None of the children had 3rd and 4th
degree malnutrition.
• Majority (85%) of them were well nourished, 13%
had mild to moderate and only 2% had severe
malnutrition.(based on Arnold’s classification of
malnutrition)
• There was a significant association between
socioeconomic factor, nutritional factor and health
factor with degree of malnutrition at p< 0.05 level
DISCUSSION
Degree of malnutrition
Malnutrition is important in determining the status
of the child health in any country. In this study none
of the children has 3rd and 4th degree of malnutrition
and 85% were well nourished. This finding is par with
the survey done by UNICEF, 2004 regarding the
prevalence of malnutrition in India and stated that
malnutrition varies across the states, with Madhya
Pradesh recording the highest rate (55%) and Kerala
among the lowest (27%) 5 .
Factors influencing malnutrition
Socio demographic factor:
Children age group between 25- 60 months (2-5
years) are well nourished (85%) comparing to other
age group between 6 months to 24 months. Anita
Khokar et al in her study revealed that 60.7% of the
subjects were malnourished who were aged 6 months
to 24 months. In the present study male children (56%)
are well nourished than female children (36%) 6.
Sanghvi et al also assessed the potential risk factors
for child malnutrition in rural Kerala, and found that
female gender was found to be more strongly related
to childhood malnutrition. There was a significant
association between occupation of father and degree
of malnutrition (p = 0.002)7. Yasodha P also found that
a strong influence of socioeconomic status and parental
care on the control of infectious disease and food intake
which are the 2 major causes for malnutrition among
children8 .
Birth factor
Regarding birth factor, a large majority (82%) of
them is born between 38 - 42 weeks (term) of
gestational age and they are well nourished. Majority
(76%) of the children born with birth weight of 2.6 –
3.5 kg and they found to be well nourished. Most of
the mothers had no complication at antenatal period
(82%), intra-natal (82%) and postnatal (98%). Israt
Reyhan also found children with larger size at birth
and longer prior birth interval have lower risk of
malnutrition, children of nourished mother have lower
risk of being malnourished compared to children of
thin mother, the educational level of parent’s is
positively related to better nutritional and health status
of their children and type of housing, breastfeeding
status, vaccination coverage and mother’s education
are depicted to be significant factors affecting
morbidity among under five children 9.
Nutritional factor
Majority (80%) children started
weaning at age group between 5-6 months, and they
are well nourished (p =0.02). Majority (77%) mother
provided Raggi as a first source complimentary feed
and those children had good nutritional status (p =
0.002). Solomon A, Zemene T found that inappropriate
feeding practices have an association with severe
malnutrition. They concluded that to reduce childhood
malnutrition, emphasis should be given in improving
the knowledge and practice of parents on appropriate
infant and young child feeding practices including
exclusive breast feeding, weaning, complimentary
food etc 10.
Health factor
There is a significant association between illness
in children and child’s nutritional status (p = 0.04).
Yasoda P found that strong influence of socioeconomic
status and parental care on the control of infectious
disease and food intake which are the two major causes
for malnutrition among children 8.
SUMMARY
Malnutrition is important in determining the status
of the child health in any country. Present study was
conducted to assess the malnutrition status and factors
influencing malnutrition in a selected community at
Trivandrum and it was found large majority (85%) of
children was well nourished, and 12% are suffering
from mild to moderate grade 2malnutrition. The health
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 139
factor, socioeconomic factor, nutritional factors played
a vital role in reducing the grade of malnutrition.
IMPLICATIONS
Nursing Practice in the community
• Emphasis the importance of exclusive breast
feeding, weaning with cheap simple nutritious
food in prevention of malnutrition.
· Strengthen the child health services provided by
primary level health care providers in the
community.
Nursing Research
• This study shall be replicated in other parts of the
community coastal region and in large sample.
· An experimental study can be carried out to find
out the effectiveness of teaching programme to
prevent malnutrition.
Nursing Education
• Nursing curriculum should emphasis on factors
influencing malnutrition, importance of educating
the parents.
• Provide information to the public about different
facilities that provide health services and
encourage them to utilize those services.
Nursing administration
• Alternative modalities of health care should be
made available for the children who suffering from
malnutrition in the community.
· Health facilities should be strengthened to assess
the nutritional status of children in the coastal
region of the community.
CONCLUSION
Nurses play an important role in ensuring good
nutritional status and health of children. Though
various educational programme, both in the clinical
as well as in the community setting, efforts need to be
made to improve feeding practices of mothers and
thus, the nutritional status of their children can be
maintained.
Acknowledgement: None
Conflict of Interest: None
Source of Support: None
Ethical Clearance: Informed consent from parents and
asset from the child
REFERENCES
1. Parul Dutta “Text Book of Paediatic Nursing”,
2nd edition (2008): Jaypee Publishers
2. World Health Organization The World Health
Report Reducing Risks, Promoting Healthy Life.
(2005). Geneva, Switzerland: World Health
Organization;
3. National Family Health Survey II, Key Findings:
International Institute of Population Services,
Mumbai, India IIPS Press: 1998
4. Park K, Park’s Text Book of Preventive and Social
Medicine, 20th edition, Jabalpur Banarsidas
Bhahot Pub: 2010
5. United Nations Sub-Committee on Nutrition. 5th
Report on the World Nutrition Situation:
Nutrition for Improved Outcomes March 2004.
6. Khokar A, Singh .S, Talwar .R, Rasania SK,Badhan
SR, Mehra M Astudy of malnutrition among
children 6 months to 2 yrears from a resettlement
colony of Delhi, Ind J of Med Science 2004: 57
:286
7. Sanghvi U, Thankappan KR, Sarma PS, Sali N.
Assessing potential risk factors for child
malnutrition in rural Kerala, India. J Trop Pediatr.
2001;47:350–355.
8. Yasoda P. Geervani , Determinants of nutritional
status of rural preschool children in Andhra
pradesh, Indian Peditar 2010:39:207-209
9. Rayhan. I Factors Affecting Malnutrition,
Morbidity and Mortality among Under Five
Children of Bangladesh. Social Science and
Medicine, 2002 Vol 73, Is 4, Page 576-585.
10. Amsalu S, Tigabu Z. Protein Energy Malnutrition
in urban children: Prevalence and Determinants.
Ethiop Med J.1998;36 (3);153-165
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140 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
The World Health Organization defines
malnutrition as “the cellular imbalance between
supply of nutrients and energy and the body’s demand
for them to ensure growth, maintenance, and specific
functions.1 Worldwide, malnutrition accounts for 11%
of all diseases and causes long-term poor health and
disability.In developing countries 15 % (18 million) of
infants, or more than 1 in 7, weigh less than 2,500 grams
at birth. India, one of the countries with the highest
incidence, has the highest number of low-birth weight
babies each year: 7.5 million. UNICEF and the World
Health Organization have adjusted the under-
reporting and misreporting of birth weights with
results from household surveys (Multiple Indicator
Cluster Surveys and Demographic and Health
Surveys).2 Intra-uterine growth restriction (IUGR) is a
A Study to Compare the Nutritional Status Assessed by
CAN Score and Ponderal Index Against WHO Intrauterine
Growth Curves among Newborns at Birth in Selected
Hospital of Ambala, Haryana
Herbaksh Kaur1, Yogesh Kumar1, Jyoti Sarin2
1Assistant Professor, 2Director-Principal, M.M College of Nursing, Mullana Ambala
ABSTRACT
The neonatal morbidity and mortality is closely related to the nutritional status of newborn at birth
and early identification of malnutrition with appropriate tool and technique can reduce the mortality
rate. Descriptive and comparative survey design was used to assess and compare the Nutritional
status of newborns at birth by CAN Score and Ponderal Index against WHO Intrauterine growth
curves at MMIMS&R Hospital, Mullana Ambala. Sixty newborns were selected by purposive sampling
from NICU and postnatal wards. The data was collected by Performa for newborn and maternal
characteristics, WHO Intrauterine Growth Curves, Ponderal Index and observation sheet of CAN
Score. Findings revealed that Ponderal Index (48.4%) classified more newborns as malnourished as
compared to CAN Score (25%) with regard to WHO Intrauterine growth curves (21.6%). Ponderal
Index has higher Sensitivity (76.9%) and lower Specificity (59.5%) than CAN Score (38.4%, 78.7%)
respectively whereas Positive predictive value and Negative predictive value of Ponderal Index (34.4%,
90.3%) was higher than CAN Score (33.3%,82.2%). The likelihood ratio of Positive test of Ponderal
Index (1.89) was higher than CAN Score (1.80) and likelihood ratio of Negative test of Ponderal
Index (0.38) was lower than CAN Score (0.78) test indicating that Ponderal Index can act more sensitive
indicator of assessing malnutrition than CAN Score. The main conclusion of the study is that Ponderal
Index may be a simple clinical index but sensitive predictor for identifying malnutrition and for
prediction of neonatal morbidity associated with it, without the aid of any sophisticated equipments.
Keywords: : WHO Intrauterine Growth Curves, CAN Score, Ponderal Index, Nutritional Status
DOI Number: 10.5958/j.0974-9357.5.2.054
clinical definition and includes neonates with clinical
evidence of malnutrition. IUGR contributes to almost
two-thirds of LBW infants born in India. Even after
recovering from neonatal complications, they remain
more prone to poor physical growth, poor neuro
developmental outcome, recurrent infection and
chronic diseases in life later.3. Since neonatal morbidity
and mortality is more closely related to nutritional
status of newborns at birth than to the birth weight
for gestational age.4 The assessment of growth
parameters remain one of the most practical and
valuable tool to assess the nutritional status among
newborns by neonatal nurses in NICU.5 Various
methods are used in the early identification of
malnourishment among newborns at birth.6
Intrauterine growth always remains the gold standard
for comparing the nutritional status among newborns.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 141
WHO Intrauterine growth curves developed by
“Lubencho” have been widely used because the chart
is based on a reasonable sample size, provides curves
to monitor, weight, length and head circumference
,moreover it is easy to use and interpret.7 A
retrospective study was conducted to determine the
ratio of disproportionate versus proportionate Intra
uterine growth retardation among low birth weight
babies using the Ponderal Index. Ponderal Index in
full term babies was <2.2 in 54.3% and in pre-term <2.0
in 34.9%.Nearly 40% of low birth weight babies had
disproportionate body proportions. Ponderal Index is
an effective and simple measure to identify wasting.8
Fetal Malnutrition is a clinical state characterized by
obvious intrauterine loss or failure to acquire normal
amounts of subcutaneous fat and muscles. This state
may be present at almost all birth weights irrespective
of the classification of birth weight into AGA or SGA.
9 A study conducted on 473 newborns in Nigeria
showed that CAN Score was able to diagnose the Fetal
malnutrition more precisely than using Intrauterine
growth curves.10 A prospective comparative study
conducted on assessment of fetal malnutrition by CAN
Score from July 2008 to September 2010 in Wardha
Maharashtra in which total 1400 consecutive, live,
single, full term neonates delivered during this period
were studied. According to CAN Score, 519 (37.1%)
subjects were diagnosed as malnourished as compared
to Lubchenco (23%). On the other hand Ponderal Index
diagnosed 40.8% as malnourished, out of which only
297 (52%) were malnourished by CAN Score. Of
remaining 829 babies diagnosed as well nourished by
Ponderal Index, 222(26.8%) were malnourished by
CAN Score. Hence CAN Score is a practical, simple
method to diagnose fetal (neonatal) malnutrition. 1111
Preeti Waghmare, D N Balpande , Bhavana B
Lakhkar.Assessment of fetal malnutrition by CAN
Score Malnutrition in the newborns might be missed
if intrauterine growth curves only are used for
assessment. The main need of the study is prompt
identification of newborns with malnutrition at birth,
because newborns who are malnourished at birth are
known to have increased morbidity, mortality, and
long-term disabilities. So there is need, for early
recognization of features of malnutrition for ,
appropriately diagnosis and soon treatment in every
newborn at risk with the anticipatory management of
CAN score and Ponderal index at birth. Nurses should
be acquainted with different tools for assessing the
nutritional status. Nurses should not rely on one tool
for screening the malnourished among newborns.
OBJECTIVES
1. To assess the nutritional status by WHO
Intrauterine growth curves, CAN Score and
Ponderal Index among newborns at birth.
2. To compare nutritional status assessed by CAN
Score and Ponderal Index against WHO
Intrauterine growth curves among newborns at
birth.
3. To determine the association of nutritional status
of newborns assessed by WHO Intrauterine
growth curves, CAN Score and Ponderal Index
with selected variables.
METHODOLOGY
A non-experimental approach and Descriptive
Comparative Survey Design was used. The study was
conducted in Maharishi Markandeshwar Institute of
Medical Science and Research and Hospital, Mullana,
Ambala after obtaining Ethical approval from
Institutional Ethical Committee of M.M University,
Mullana. Total 60 Newborns ≥37 weeks of gestational
age were included as assessed by New Ballard score
within 24hrs of birth. Newborns with congenital
malformation, Multiple births, CPAP and Mechanical
Ventilators were excluded from the study.
Development of Tool
Newborn and Maternal characteristics: The
newborn (gestational age, gender, birth weight, length)
and maternal characteristics (age, educational status,
occupation, region, religion, place of living, total family
income, parity ,hemoglobin, type of delivery &
nutritional supplementation during pregnancy)
included in the study was derived from the extensive
literature review.
WHO Intrauterine growth curves: In present study
WHO Intrauterine growth curves has been taken as
golden standard. WHO12 Intrauterine growth curves
have been widely used because the chart is based on a
reasonable sample size, provides curves to monitor,
weight, length and head circumference ,moreover it is
easy to use and interpret.
CAN Score: Clinical assessment of nutritional
status score is a simple, practical, systematic, rapid and
quantifiable clinical method for the assessment of fetal
malnutrition in term new born developed by Jac
Metcoff. It comprise of nine superficial readily
detectable signs by inspection viz. hair, cheeks, neck
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142 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
& chin, arms, legs, back, buttocks, chest, abdomen to
differentiate between well nourished and
malnourished newborns. Maximum score of 4 is
awarded to each parameter with no evidence of
malnutrition and lowest of 1 is awarded to parameter
with the worse evidence of malnutrition. The CAN
Score ranges between 9 (lowest) and 36 (highest).
Newborns at birth with CAN Score having ≤25 is
considered as malnutrition and >25 considered as well
nourished.
Ponderal Index- Ponderal Index <2.2 is indicative
of malnourished newborns and PI ≥2.2 is indicative of
well nourished newborns.
Content Validity: To ensure content validity – tool
was given to nine experts which include two doctors
from Department of pediatrics, one neonatologist, four
experts from Department of Child Health Nursing, one
expert from Department of obstetrics and gynaecology
and one expert from Department of Medical Surgical
nursing.
Reliability: The tools used in the study were found
reliable i.e (WHO Intrauterine growth curves,Ponderal
Index and CANScore)
RESULTS
Frequency and percentage distribution of newborn
characteristics revealed that 35% newborns had 37
weeks of gestational age followed by 26.7% of
newborns in 39 weeks. 31 out of 60 (51.7%) newborns
were male .Majority of newborns (83.3%) had birth
weight of ≥2.5kg and 16.7% had birth weight of <2.5
kg. The length of all newborns was within normal
range i. e 48-52 cm whereas frequency and percentage
distribution of mothers indicated that most of mothers
of newborns (55%) were in age group of 21-25 years.
Maximum of them (88.3%) were Hindus. Majority of
mothers (90%) belonged to rural area. Most of mothers
(41.7%) were graduate. All of them were homemakers.
The family income ranged between 5001 to 10000 per
month in INR for 27 out of 60 (45%) mothers and equal
number of mothers had Hemoglobin status between
6-8g/dl. Most of mothers (58.3%) were Primigravida.
Majority of mothers (95%) had taken nutritional
supplements during antenatal period. The mode of
delivery of maximum of mothers (63.3%) was normal
vaginal delivery.
Table 1 Frequency and Percentage distribution of Well nourished (WN) and Malnourished (MN) newborns as
determined by WHO Intrauterine growth curves, CAN Score and Ponderal Index. N=60
Category WHO Intrauterine CAN Ponderal
growth curves Score Index
f (%) f (%) f (%)
Well nourished AGA/LGA 47(78.4) >25 45 (75) ≥2.2 31(51.6)
Malnourished SGA 13 (21.6) ≤25 15 (25) <2.2 29 (48.4)
Table 1 indicated that data WHO Intrauterine growth
curves classified 78.4% newborns as well nourished
while CAN Score classified 75% and Ponderal Index
categorized 51.6% newborns as well nourished. The
nutritional status assessed by WHO Intrauterine
growth curves classified 21.6% newborns as
malnourished while CAN Score categorized 25%
and Ponderal Index categorized 48.4% newborns as
malnourished.
Table 2. Sensitivity, Specificity, Positive Predictive Value and Negative Predictive Value of CAN Score and
Ponderal Index against WHO Intrauterine growth curves. N=60
Parameter WHO Intrauterine Sensitivity Specificity Positive Negative
growth curves (%) (%) Predictive Predictive
Value (%) Value (%)
M.N (47) W.N (13)
CAN Score ≤25 05(38%) 10 (21.3%) 38.4 78.7 33.3 82.2
>25 08(62%) 37(78.7%)
PI <2.2 10(77%) 19(40.4%) 76.9 59.5 34.4 90.3
≥2.2 03(23%) 28(59.6%)
Findings of table 2 inferred that Sensitivity (76.9%)
of Ponderal Index was higher and Specificity of
Ponderal Index was lower (59.5%) than the CAN Score
(38.4%, 78.7%) respectively. Positive Predictive Value,
Negative Predictive Value of Ponderal Index was
higher (34.4%, 90.3%) than Positive Predictive Value,
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 143
Negative Predictive Value of CAN Score (33.3, 82.2%)
respectively.
Table 3. Likelihood ratio of Positive test (LR+) and
Likelihood ratio of Negative test (LR-) of CAN Score
and Ponderal Index for assessment of nutritional
status of newborns N=60
Index Likelihood ratio Likelihood ratio
of Positive test of Negative test
CAN Score 1.80 0.78
Ponderal Index 1.89 0.38
Table 3 revealed that the Likelihood ratio of Positive
test of Ponderal Index was more as compared to CAN
Score indicated the better ability of the Ponderal Index
to rule in malnourishment among newborns whereas
Likelihood ratio of Negative test of Ponderal Index was
less as compared to CAN Score which indicated the
better ability to rule the incorrect malnourished
newborns.
Table 4. Chi square Value showing association between nutritional status assessed by Ponderal Index with
gestational age of newborns in terms of New Ballard Score. N=60
New Ballard Score Gestational age(wks) Ponderal Index χχ
χχ
χ2
<2.2 (29) f (%) ≤≤
≤≤
≤2.2(31) f (%)
31-34 37(n=21) 15 71 06 29
35 38(n=13) 07 53 06 47 12.9*
36-39 39(n=16) 02 13 14 87
≥40 40(n=10) 05 50 05 50
χ2*(3) =7.81, *significant (p≤0.05)
The data presented in Table 4 revealed that
computed chi square value between the nutritional
status of newborns assessed by Ponderal Index (12.9*)
with gestational age of newborns was found to be
statistically significant at 0.05 level of significance.
DISCUSSION
Analysis of the study in terms of frequency and
distribution indicated that WHO categorized 78.4%
newborns as AGA and 21.6% newborns as SGA. These
findings were consistent with the findings of
Soundarya.M1313 Mahalingam Soundarya et al.
Comparative Assessment of Fetal Malnutrition by
Anthropometry and CAN Score. Iran J Pediatr.Mar
2012; 21 ( 1): 70-76 in which weight for gestational age
categorized 77% newborns as AGA and 23% newborns
as SGA and Waghmare.P14 which classified 23%
newborns as SGA.CAN Score identified 25% newborns
as malnourished which were consistent with the
findings of Sankhyan.N i.e (26.97%) and Soundarya.M
(23%).Ponderal Index classified 48.4% newborns as
malnourished. This findings were not concordance
with the findings of Soundarya.M (26%) and Sanjay
Mehta (75%).15Ponderal Index categorized more
newborns 48.4% as malnourished in relation to CAN
Score (23%) and WHO Intrauterine growth curves
(21.6%) which was a golden standard in this study.
These findings were partially consistent with the
findings of Mehta.S14 in which Ponderal Index
categorized majority of newborns (75%) as
malnourished as CAN Score (40%) and Intrauterine
growth curves (70%).CAN Score classified 38%
newborns as SGA and 21.3% AGA as malnourished.
These findings were not consistent with the findings
of Sankhyan.N (78.5% in AGA and 79.1% in SGA) 16.
CAN Sore identified 21.3% newborns AGA as
malnourished and 62% SGA as well nourished. These
findings were also not consistent with the findings of
Sankhyan. N (malnourished AGA-4%, well nourished
SGA-42.9%) 15.
Table 5: Distribution of Malnutrition by CAN Score in relation to Intrauterine Growth Curves
Malnutrition in relation Herbaksh Waghmare Kushwahaet.al Deodharet.al Edwardet.al Mehtaet.al Metcoff et.al Raoet.al
to AGA / SGA (2012) (2011) (2004) (1999) (1999) (1998) (1994) (1998)
FM (Fetal Malnutrition)in SGA 38.3% 84.8% 79.10% 84.2% 90% 76.7% 54% 50.3%
FM in (AGA + LGA) 21.3% 22.7% 21% 15.9% 35% 27.8% 55% 9.4%
The above table mentioned that 38.3% SGA and 21.3
%AGA were categorized malnourished by CAN Score.
The findings pertaining to malnutrition in AGA by
CAN Score was consistent with the findings of
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144 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Waghmare Preeti, KP Kushwaha whereas malnutrition
in SGA assessed by CAN Score showed different
pattern of malnutrition from the findings of other
authors. i.e Rao, Metcoff, Mehta, Edward, Deodhar,
Kushwaha, Waghmare.
The above table also showed the lower malnutrition
rate in the present study. It may be in relation to small
sample size (60). An important feature of this study
was to use clinical methods to assess the malnutrition
and this can provide assessment of nutritional status
of newborns.17 Ponderal Index showed the Negative
predictive value of 90.3% which was concordance with
the findings of Soundarya.M (88.7%)12.The Sensitivity
and Negative predictive value of Ponderal Index
(76.9%,90.3%) was higher than CAN Score
(38.4%,82.2%).These findings were consistent with the
findings of Soundarya.M in which Ponderal Index had
higher sensitivity and specificity (65.2%, 98.7%) than
CAN Score (50%, 73.7%).
CONCLUSION
CAN Score classified more newborns as well
nourished as compared to Ponderal Index whereas
Ponderal Index categorized more newborns as
malnourished as compared to CAN Score .The
Likelihood ratio of Positive test of Ponderal Index was
more as compared to CAN Score indicated the better
ability of the Ponderal Index to rule in malnourishment
among newborns whereas Likelihood ratio of Negative
test of Ponderal Index was less as compared to CAN
Score which indicated the better ability to rule the
incorrect malnourished cases. Thus it can be inferred
that Ponderal Index is better than CAN Score to screen
the malnourishment among newborns at birth. The
nutritional status of newborns assessed by WHO
Intrauterine growth curves and CAN Score was
independent of gestational age of newborns whereas
the Ponderal Index was dependent on gestational age
of newborns.
ACKNOWLEDGEMENT
I would like to thank almighty for his presence
experienced during the study. I am greatful to research
committee for their constructive criticism and guidance
towards successful completion of my study. I am
obliged to entire experts for valuable suggestion
towards validity in tool.
Conflict of Interest: There is no conflict of interest
Funding Source: Self financed
REFERENCES
1. WHO. Malnutrition-The Global Picture. World
Health Organization.. Available from http://
www.who.int/home-page/.
2. UNICEF REPORT Available fromhttp://
www.childinfo.org/low_birthweight _status
_trends.html
3. Ashok K Deorari, Ramesh Agarwal , Vinod K
Paul. Management of infants with intra-uterine
growth restriction.AIIMS NICU Protocol
4. Mehta S, Tandon A, Dua T, Kumari S, Singh SK.
Clinical assessment of nutritional status at birth.
Indian Pediatr 1998; 35: 423-428.
5. Boxwell Glenys. Neonatal Intensive Care
Nursing. Available from- http://books.google.
co.in/ books? id=qs FmJev0zak C&sitesec=
reviews
6. Agal p*, Kamath n. Utility of clinical assessment
of nutritional status score (can score) in detecting
fetal malnutrition. Available from http://
www.commedtvm.org/ natconpapers /natcon
_paper_41.html
7. Cloherty , Eichenwald,Stark.Manual of neonatal
care.Google online books.2008;6th edn:114
117.Availablefromhttp:// books.google.co.in/
books?id=5nMu71qnrq AC&pg= PA115&lpg=
PA115&dq =lubchenco+intrauterine +growth+
curves +in+in+manual +of+neonatal+ care
&source =bl &ots=MDRPT teffO&sig=3g Q5O
DRVvVLlXan UVNqAQXPKd0 &hl= en&sa=
X&ei=F_OKT5a MAsbsrAe74 KHK Cw&ved=
0CB8Q6AEw AA#v= onepage &q&f= false
8. Dure Samin Akram, Fehmina Arif. Ponderal
Index of Low Birth Weight Babies - a Hospital
Based Study. 1993;341:938-41.
9. Kushwaha KP, Singh YD, Bhatia VM, Gupta
Yogita Clinical Assessment of Nutritional Status
(Cans) In Term New Borns And Its Relation To
Outcome In Neonatal Period. Journal of
neonatology.2004 Mar;18(1):55-59
10. Adebami et al.Prevalence and problems of fetal
malnutrition in terms at South Western Nigeria.
West African journal of medicine 2007;26(4):
278-282.
11. Preeti Waghmare, D N Balpande, Bhavana B
Lakhkar.Assessment of fetal malnutrition by
CAN Score
12. Available from-https://www.macr. org.my/
ennr/pdf%5CIntrauterine%20 Growth% 20
Chart.pdf
13. MahalingamSoundarya et al. Comparative
Assessment of Fetal Malnutrition by
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 145
Anthropometry and CAN Score. Iran J
Pediatr.Mar 2012; 21 ( 1): 70-76
14. Preeti Waghmare, D N Balpande, Bhavana B
Lakhkar.Assessment of fetal malnutrition by
CANScore Available fromhttp://
www.pediatriconcall. com
15. Mehta S, Tandon A, Dua T, Kumari S, Singh SK.
Clinical assessment of nutritional status at birth.
Indian Pediatr 1998; 35: 423-428.
16. Naveen Sankhyan. Detection of Fetal
Malnutrition Using “CAN Scor≥.Indian Journal
of paediatrics.2008Nov;203-206.
17. Kushwaha KP, Singh YD, Bhatia VM, Gupta
Yogita Clinical Assessment of Nutritional Status
(Cans) In Term New Borns And Its Relation To
Outcome In Neonatal Period. Journal of
neonatology.2004 Mar;18(1):55-59
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146 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
Birth asphyxia is responsible for 20% of neonatal
deaths. Among 26 million infants born in India per
annum, 4 to 6% fail to take spontaneous breathing at
birth and suffer from asphyxia. Timely and appropriate
management and asphyxiated baby’s can save them
and provide a better quality of life amongst survivors
without any neurological sequelae1.
Randomized Control Trial to Evaluate the effectiveness of
Helping Babies Breathe Programme on Knowledge and
Skills Regarding Neonatal Resuscitation among Auxiliary
Nurse Midwives Students
Jagadeesh G Hubballi1, Sumitra L A2, Sudha A Raddi3
1Lecturer, 2Professor, HOD of Child Health Nursing, 3Principal, K.L.E University's Institute of Nursing Sciences,
Belgaum, Karnataka
ABSTRACT
Helping Babies Breathe is a simple, evidence-based training for birth attendants that delivers the
skills needed to help. Helping Babies Breathe coordinates with the Neonatal Resuscitation Program,
which includes techniques of advanced care. Effective resuscitation of the newborn requires adequate
training and preparation of staff involved in the care of women in labour. Hence the present study
intends to evaluate the effectiveness of helping Babies Breathe Programme on knowledge and skills
regarding neonatal resuscitation among Auxiliary Nurse Midwives students.
The objectives of the study were to assess the knowledge and skills regarding neonatal resuscitation
among experimental and control group of Auxiliary Nurse Midwives students, to evaluate the
effectiveness of Helping Babies Breathe Programme on neonatal resuscitation among experimental
group of Auxiliary Nurse Midwives students and to compare the knowledge and skills regarding
neonatal resuscitation among experimental and control group of Auxiliary Nurse Midwives students.
The study was conducted using randomized control trail research design by lottery method. The
study was confined to 60 ANM students who were studying in KLEU's institute of nursing sciences
and Bharatesh college ANM training center Belgaum. Randomized sampling technique was used for
sample selection. An experimental study was conducted using randomized control trail research
design. Data collection was done through structured knowledge questionnaire. Pre test was taken
for the both control and experimental group. Then Helping Babies Breathe programme (neonatal
resuscitation) was given to experimental group with the help of demonstration on mannequin. After
7 days post test was taken from both experimental and control group.
Data obtained were tabulated and analyzed in terms of objectives of the study using descriptive and
inferential statistics. Findings revealed that gain in knowledge and skills of subjects under experimental
group were higher than the control group.
Keywords: Auxiliary Nurse Midwives, Neonatal Resuscitation, Helping Babies Breathe programme,
Knowledge, Skill
DOI Number: 10.5958/j.0974-9357.5.2.054
The World Health Organization (WHO)estimates
that globally, between four and nine million newborns
suffer birth asphyxia each year. Of those, an estimated
1.2 million die and almost the same number develop
severe consequences. The WHO also estimates that
globally, 29% of neonatal deaths are caused by birth
asphyxia2. Thus, birth asphyxia or perinatal asphyxia
is a huge global problem with fresh stillbirth, neonatal
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 147
death and long-term neurodevelopment problems as
its main serious outcomes3. Neonatal mortality rate
(NMR) in India is 30/1,000, while it is, 8/1,000 in Sri
Lanka and, 10/1,000 in China.Community education
should be a focus of the National Rural Health Mission
(NRHM) and Integrated Management of Neonatal and
Childhood Illness (IMNCI) program being
implemented in Karnataka4.
The added capacity of the new Accredited Social
Health Activists (ASHAs) could enable more women
to be reached. With careful tailoring of behavior change
messages to the local context, government outreach
workers can become effective brokers of positive
change and significant improvements in home
newborn care and neonatal mortality are possible.
American academy of pediatrics (AAP) is working to
increase the number of birth workers around the world
who are trained to assist babies in that golden minute
through the Helping Babies Breathe curriculum.
Helping Babies Breathe has a system-based focus
designed to change clinical practice across systems of
care5.
The objective of Helping Babies Breathe is to train
birth attendants in developing countries in the essential
skills of newborn resuscitation, with the goal of having
at least one person who is skilled in neonatal
resuscitation at the birth of every baby and focuses on
practices that protect healthy babies and assist babies
who do not breath on their own. Cleanliness, drying,
and warmth are essential for all babies.A major cause
of neonatal mortality is seen in developing nations
where there is lack of resources and health workers6;
hence the present study intends to assess the
knowledge and skills of Auxiliary Nurse Midwives
students regarding Helping Babies Breathe
Programme on neonatal resuscitation that provides
care in community sectors. Adequate knowledge and
skills regarding neonatal resuscitation make the
Auxiliary Nurse Midwives students to become
confident and competent in their ability to manage
Birth asphyxia7.
OBJECTIVES
1. To assess the knowledge and skills regarding
neonatal resuscitation among experimental and
control group of Auxiliary Nurse Midwives
students.
2. To evaluate the effectiveness of Helping Babies
Breathe Programme on neonatal resuscitation
among experimental group of Auxiliary Nurse
Midwives students.
3. To compare the knowledge and skills regarding
neonatal resuscitation among experimental and
control group of Auxiliary Nurse Midwives
students.
MATERIAL AND METHOD
The research approach adopted is quantitative.
Research design used is experimental (randomized
control group) design8. The Stufflebeams CIPP
(context, input, process, and product) evaluation
model [1983] was used as a conceptual framework for
this study9.
The study was confined to 60 ANM students who
were studying in KLEU’s institute of nursing sciences
and Bharatesh college ANM training center
Belgaum.The study was conducted using randomized
control trail research design by lottery method.They
were divided into two groups. Experimental group:
30 ANM students. Control group: 30 ANM students...
Table1
Group Randomization Pre treatment assessment Intervention Post treatment
ER O
1XO
2
CR O
1-O
2
Table 1 reveals that Randomized sampling
technique (lottery method) was used for sample
selection. An experimental study was conducted using
randomized control trail research design.
The independent variable was Helping Babies
Breathe Programme on neonatal resuscitation.The
dependent variable was knowledge and skills of
Auxiliary Nurse Midwives students regarding HBB
(neonatal resuscitation) programmed8.
After extensive review of literature structured
knowledge questionnaire to assess the knowledge
regarding Helping Babies Breathe on neonatal
resuscitation and Objective Structured Practical
Evaluation (OSPE) to identify the skills regarding
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148 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Helping Babies Breathe on neonatal resuscitation. The
tool was given for validity to experts of pediatric
nursing and neonatologists. As per their guidance
amendments were made. The lesson plan was
prepared for giving teaching to ANM students
regarding neonatal resuscitation.
The tool consisted of following 3 sections
Section I: Socio demographic data consists of items
seeking information regarding age, gender, marital
status and exposure of child health programmes
Section II: This section was contains structured
knowledge questionnaire on the knowledge of
neonatal resuscitation. To elicit the knowledge 16
Multiple Choice questions were framed. The
maximum score for knowledge was 16.
Knowledge score of HBB (neonatal resuscitation) is
graded as follows
• Poor: 0-5
• Average: 6-11
• Good: 12-16
Section III: This section was contains the
observational checklist is to assess the skill score
regarding neonatal resuscitation. The observational
checklist was used to observe the skill of neonatal
resuscitation performed by ANM students who were
included during the study. The maximum score for
skill was 47.
Skill score of neonatal resuscitation is graded as
follows
• Adequate : 36 to 47
• Moderate : 12 to 35
• Inadequate : 0 to 11
The hypotheses formulated for the study were
H1: The mean post test knowledge scores of the
experimental group compared to control group will
be higher than the mean pre test knowledge scores.
H2: The mean post test skill scores of the
experimental group compared to control group will
be higher than the mean pre test skill scores.
The collected data was tabulated and analyzed
according to the objectives of the study using
descriptive and inferential statistics.
RESULTS
Major findings of the study
Finding related to demographic variables
In the present study it was found out that, majority
of Auxiliary Nurse Midwives students 43(71.66 %)
were in the age group of 17-20, 47(78.66%) Auxiliary
Nurse Midwives students are unmarried, 55(91.66%)
Auxiliary Nurse Midwives students are not attended
Child health programmes like workshops/seminars.
Findings related to the effectiveness of HBB (neonatal resuscitation) programme
Table 2. Comparison of pre test and post test percentage of knowledge score between the experimental and control
group n=60
Group Pre test percentage Post test percentage Percentage of
of knowledge of knowledge gain knowledge
Experimental group 49.58% 68.95% 19.37%
Control group 48.75% 50.41% 1.66%
Table 2 reveals that in the experimental group, the
pre test Auxiliary Nurse Midwives students scored in
only 49.58% of knowledge score after implementation
of HBB regarding Neonatal Resuscitation (Bag and
Mask technique) programme they scored 68.95%. The
difference is 19.37%.
Table 3. Comparison of pre test and post test percentage of skill score between the experimental and control group. n=60
Group Pre test Post test Percentage of
percentage of skill percentage of skill gain skill
Experimental group 11.91% 81.34% 69.43%
Control group 12.12% 12.76% 0.64%
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Table 3 reveals that in the experimental group, the
pre demo of Auxiliary Nurse Midwives students
scored in only 11.91% of skill score after
implementation of HBB regarding Neonatal
Resuscitation (Bag and Mask technique) programme
they scored 81.34%. The difference is 69.43%.
In control group they scored 12.12% in pre demo
and 12.76% in post demo. The difference between pre
and post demo is only 0.64%.
This indicates that experimental group gained the
skills of HBB regarding Neonatal Resuscitation (Bag
and Mask technique) programme.
Evaluate the effectiveness of helping babies breathe
programme regarding neonatal resuscitation (bag
and mask technique) among ANM students in terms
of gain in knowledge scores and skill scores.
Table 4. Standard error of difference (SEd), paired‘t’ values of knowledge scores among experimental and control
group on Neonatal Resuscitation procedure. n=60
Knowledge Paired t value
Pre test Post test Mean Standard Calculated Table value
difference Error difference value at 29 degree of
(d) (SEd) freedom
Mean SD Mean SD
Experimental group 7.93 1.96 11.03 1.83 3.10 0.530 t=5.8453* P=0.0001 t=2.045
Control group 7.80 2.14 8.07 2.10 0.27 0.185 t=1.4392P=0.1608 t=2.045
*(P<0.05)
Table 4 reveals that calculated paired t value of
experimental group (t= 5.8453) is greater than
tabulated value (t=2.045). This indicates that gain in
knowledge score is statistically significant at P<0.05
levels. Therefore, HBB programme regarding neonatal
resuscitation improved the knowledge of Auxiliary
Nurse Midwives students. The calculated paired t
value was t=5.8453. P=0.0001
Whereas in control group the calculated paired t
value (t=1.4392) is lesser than tabulated value (t=2.045).
There is no significance difference in knowledge scores
of control group. The calculated paired t value was
t=1.4392, P=0.1608.
Table 5. Standard error of difference (SEd), paired‘t’ values of skill scores among experimental and control group
on Neonatal Resuscitation procedure. n=60
Skills Paired t value
Pre demo Post demo Mean Standard Calculated Table value
difference Error difference value at 29 degree of
(d) (SEd) freedom
Mean SD Mean SD
Experimental group 5.60 1.89 38.23 2.60 32.63 0.637 t=51.2335*P=0.0001 t=2.045
Control group 5.70 1.88 6.00 1.74 0.30 0.445 t=0.6741P=0.5056 t=2.045
*(P<0.05)
Table 5 reveals that calculated paired t value of
experimental group (t=51.2335) is greater than
tabulated value (t=2.045). This indicates that gain in
skill score is statistically significant at P<0.05 levels.
Therefore, HBB programme regarding neonatal
resuscitation improved the skills of Auxiliary Nurse
Midwives students. The calculated paired t value was
t=51.2335, P=0.0001
Whereas in control group the calculated paired t
value (t=0.6741) is lesser than tabulated value (t=2.045).
There is no significance difference in skill scores of
control group. The calculated paired t value was
t=0.6741, P=0.5056.
Compare the outcome of Experimental and Control
group in terms of gain in knowledge and skill.
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Table 6. Mean difference, standard error of difference (SEd), unpaired‘t’ values of post test knowledge scores
among experimental and control group on Neonatal Resuscitation procedure. n=60
Knowledge Experimental group Control group Unpaired t value
Pre test Post test Mean Standard Calculated Table value
difference Error difference value at 58 degree of
(d) (SEd) freedom
Mean SD Mean SD
11.03 1.83 8.07 2.10 2.97 0.508 t=5.8358*P=0.0001 t=1.6715
*(P<0.05)
Table 6 reveals that calculated unpaired t value of
Post test knowledge scores between experimental and
control group (t= 5.8358) is greater than tabulated value
(t=1.6715). Hence H1 is accepted. This indicates that
gain in knowledge score is statistically significant at
P<0.05 levels. Therefore, HBB programme regarding
neonatal resuscitation improved the knowledge of
experimental group. The calculated unpaired t value
was t=5.8358, P=0.0001
Table 7. Mean difference, standard error of difference (SEd), unpaired‘t’ values of post demo skill scores among
experimental and control group on Neonatal Resuscitation procedure. n=60
Skill Group Unpaired t value
Experimental Control group Mean Standard Calculated Table value
group Post demo difference Error difference value at 58 degree of
Post test (d) (SEd) freedom
Mean SD Mean SD
Station i 9.17 1.05 3.07 0.78 t=25.4366*P=0.0001 t=1.6715
Station ii 9.27 0.69 2.47 1.22 t=35.2303*P=0.0001 t=1.6715
Station iii 19.80 1.90 0.27 0.69 t=53.8403*P=0.0001 t=1.6715
Total 38.23 2.60 6.00 1.79 32.23 0.571 t=56.4795*P=0.0001 t=1.6715
*(P<0.05)
Table 7 reveals that calculated unpaired t value of
Post test skill scores between experimental and control
group (t= 56.4795) is greater than tabulated value
(t=1.6715). Hence H2 is accepted. This indicates that
gain in skill score is statistically significant at P<0.05
levels. Therefore, HBB programme regarding neonatal
resuscitation improved the skill of experimental group.
The calculated unpaired t value was t=56.4795,
P=0.0001
DISCUSSION
There was significant increase in post-test
knowledge and post demo skill scores in experimental
group whereas in control group there was no
significance gain in post test knowledge and post demo
skill scores. The findings revealed that there was
significant increase in post test knowledge scores and
post demo skill scores of experimental subjects exposed
to Helping Babies Breathe (neonatal resuscitation)
programme compared to control group. The finding
were supported with the study done by ( Newton
Opiyo1*, Fred Were2, Fridah Govedi3, etal; Kenya51
Medical Research, Nairobi, Kenya), conducted a
randomized, controlled trial. Trained providers
demonstrated a higher proportion of adequate initial
resuscitation steps compared to the control group
(trained 66% vs control 27%; p<0.001). In addition,
there was a statistically significant reduction in the
frequency of inappropriate and potentially harmful
practices per resuscitation in the trained group.
Conclusions/Significance; Implementation of a simple,
one day newborn resuscitation training can be
followed immediately by significant improvement in
health workers’ practices. However, evidence of the
effects on long term performance or clinical outcomes
can only be established by larger cluster randomized
trials10.
CONCLUSION
The findings of the study showed that Helping
Babies Breathe programme is effective to improve the
knowledge and skill regarding neonatal resuscitation
among experimental group of ANM students. Findings
revealed that Helping Babies Breathe programme was
effective to improve knowledge and skill of subjects
under study. There was no gain in knowledge and skill
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 151
regarding neonatal resuscitation among control group
of ANM students.
RECOMMENDATIONS
1. A Similar study can be replicated with a large
sample in order to generalize the data.
2. Comparative studies can be conducted in different
settings.
3. A Similar study can be conducted with different
teaching strategies.
4. A study may be conducted on problems
encountered by nurses in relation to newborn
resuscitation (Bag and Mask technique).
5. A study can be conducted to find out the
knowledge, skills and attitude of staff nurses
regarding neonatal resuscitation (Bag and Mask
technique) in labour room.
ACKNOWLEDGEMENT
We express our thanks to participants and the
authorities who provided permission to conduct the
study
Conflict of Interest
A major cause of neonatal mortality is seen in
developing nations where there is lack of resources
and health workers; hence the present study intends
to assess the knowledge and skills of Auxiliary Nurse
Midwives students regarding Helping Babies Breathe
Programme on neonatal resuscitation that provides
care in community sectors. Adequate knowledge and
skills regarding neonatal resuscitation make the
Auxiliary Nurse Midwives students to become
confident and competent in their ability to manage
Birth asphyxia.
Source of Funding
Self funding
Ethical Clearance
Ethical clearance taken from Ethical Clearance
Committee. Secretary Ethical Clearance Committee-
Prof. Milka Madhale. Vice Principal KLEU’S Institute
of Nursing Sciences, Belgaum. Chairman Ethical
Clearance Committee- Prof. Sudha A Raddi. Principal
KLEU’S Institute of Nursing Sciences, Belgaum.
REFERENCE
1. Drissen EM, Hollinzer R: Cardiopulmonary
resuscitation guidelines for CPR and emergency
cardiac care. Journal of NNT. Aug:2007 vol:3;p55
2. WHO collaborating centers for training and
research in newborn care department of
pediatrics: All Institute of Medical Sciences. New
Delhi: available from: http://
www.newbornwhoccorg/images/header2.gif
3. Helping Babies Breath [internet]. 2010
Updated2010. Available from: http://one.org/
blog/2011/04/20/helping- babies- breathe-can -
save-a-million-lives-each-year
4. Helping Babies Breath [internet]. 2010
Updated2010. Available from :http://
www.helpingbabies.org/about.html
5. Wiswell TE. Neonatal resuscitation respiratory
care; March2 003 vol:48, p.288.
6. Pileggi Castro Souza C. Neonatal
Care.2005.Available from: http://clinical
trail.gov/ct2/show/nct000136708
7. Lin IJ,Chi CS; The preliminary results of training
courses of pediatric advance life support: Acta
pediatrics. Taiwan 1999:40(1);4
8. Polit DF, Beck CT. Nursing Research: Principles
and Methods.7th ed. Philadelphia: Lippincott
Williams and Wilkins; 2004. 46- 48
9. The Stufflebeam (1983) CIPP evaluation model
available from: http://www.cglrc.cgiar.org/
icraf/toolkit/The_CIPP_evaluation_model.htm
10. Newton Opiyo1*, Fred Were2, Fridah
Govedi3, etal;Kenya Medical Research, Nairobi,
Kenya, available from: http://
www.medicaljournal-ias.org/Belgelerim/Belge/
04
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152 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
Ageing is a natural process. In words of Seneca;
“Old age is an incurable disease”, but recently they
commented it as “we do not heal old age but protect
it; promote it; extend it”. People can be considered old
because of some changes in their activities or social
roles. There is often a general physical deterioration,
and people become less active.1 Depression is a
common problem in older adults .The symptoms of
depression affect every aspect of life, including energy,
appetite, sleeps, and interest in work, hobbies, and
relationships. Depression not only makes one feel
sick—with aches, pains, and fatigue—it actually makes
physical health worse. Depression also gets in the way
of memory and concentration2. Laughter is a strong
A Study to assess the effectiveness of Laughter Therapy
on Depression among Elderly People in Selected Old Age
Homes at Mangalor
Jaya Rani George1, Vineetha Jacob2
1M.Sc Nursing IInd Year, 2Assistant Professor, Department of Mental Health Nursing, Yenepoya Nursing College,
Deralakatte, Mangalore
ABSTRACT
Many older adults find themselves more alone than ever before as longstanding friends and relatives
die and family and friends relocate to different geographical areas. If entry into residential care is
necessary, older adults become more isolated. The most common emotional disorder in the elderly
population is depression. A study to assess the effectiveness of laughter therapy on depression among
elderly people in selected old age homes at Mangalore.The main objective of the study to determine
the effectiveness of laughter therapy among experimental group. The conceptual framework adopted
for the study was based on the framework of Roy's adaptation model. The study design was two
group pre-test post- test design. The population of the study was elderly people at selected old age
homes at Mangalore.Purposive sampling technique was used for selecting the study subjects. The
sample comprised of 60 samples above the age of 60 years .The tool used for the study were
demographic proforma and modified Geriatric Depression Scale. The study result showed that the
mean post-test depression scores (11.97) was apparently lower than the mean pre-test depression
score (16.97). The pre-test depression score rocked to 43.3% for the moderate level of depression
while the post-test depression score reached an all-time high of 63.3% for the mild level of depression.
There was a significant difference between pre-test depression score and the post-test depression
scores (t= 37.696, p < 0.05).The pre-test depression score was independent of all the demographic
variables such as age, gender, religion, marital status, years of stay in old age home, any illness. The
findings of the study shows that the intervention programme was effective in reducing the depression
among elderly people.
Keywords: Effectiveness, Elderly, Depression, Laughter Therapy
DOI Number: 10.5958/j.0974-9357.5.2.054
and powerful force that has the most positive effects
on the body. Laughter helps to get rid from stress,
depression, anxiety, pain , and conflict3.
MATERIAL AND METHOD
The study design was two group pre-test post- test
design. The population of the study was elderly people
at selected old age homes at Mangalore. Purposive
sampling technique was used for selecting the study
subjects. The sample comprised of 60 samples above
the age of 60 years .The tool used for the study were
demographic proforma and modified Geriatric
Depression Scale The data collection was between 19th
November and 8th December 2012. After a brief self
introduction, the investigator explained the purpose
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 153
of the study and obtained informed consent from the
subjects. Firstly, the investigator assessed the
depression level of the subjects in both experimental
group and control group through Geriatric Depression
scale. After completing it, the investigator
administered laughter therapy for patients in
experimental group for 10 days .Duration of the session
was half an hour. Post test depression level was
assessed on the eleventh and sixteenth day. And same
procedure was followed for control group without
administering laughter therapy .Control group was
sent to watering of plants in the morning to avoid
ethical issues. Repeated measure ANOVA and
independent ‘t’ test will be used to determine the
difference between the score of pre – test and post –
test of experimental and control group.
FINDINGS
Table 1: Mean, standard deviation, df and ‘F’ value of pre-test and post-test depression scores in the experimental
group N=30
Test Mean score Standard deviation F value df
Pre-test 16.17 3.63 724.039* (2,27)
Post-test 1 11.97 3.55
Post-test 2 13.90 3.52
The mean depression score of sample were 16.17±3.63 during pre-test; 11.97±3.55 for the post-test 1; 13.90±3.52
for the post-test 2. The one-way repeated-measures ANOVA shows that these depression scores were significantly
different, F(2, 27)= 724.039, p<.001.
Table 2 : Comparison of mean, standard deviation, mean difference and ‘t’ value of post-test depression scores in
experimental and control group N=60
Test Group Mean Standard Mean ‘t’ value
score deviation difference
Post-test 1 Experimental group 11.97 3.55 5.13 5.869*
Control group 17.1 3.22
Post-test 2 Experimental group 13.9 3.52 5.53 6.848*
Control group 19.43 2.68
T58=1.671, p<0.05 *significant
Data in Table 2 shows that the mean post-test 1
depression scores of experimental group (11.97±3.55)
was lower than mean depression score of control group
(17.1±3.22) and the mean post-test 2 depression scores
of experimental group (13.9±3.52) was lower than
mean depression score of control group (19.43±2.68).
The calculated ‘t’ values (t=5.869 and t=6.848) was
greater than the table value (t58=1.671) at 0.05 level of
significance in both post-tests.
Association of depression level and demographic
variables
The pre test depression score is independent of
selected demographic variables that is, age (x2 =
1.285,table value = 5.991) , religion ( x2= .2, table value
3.841) , marital status (x2 = 3.74, table value = 7.815) ,
years of stay in old age home (x2= .584, table value
=7.815) ,any illness (x2 = 1.6 , table value 3.841) . There
was no significant association between pre-test
depression score and selected demographic variables
like age, religion, marital status, years of stay in old
age home, any other illness, practicing any relaxation
technique.
CONCLUSION
The present study highlighted the effectiveness of
laughter therapy on depression as a non-
pharmacological and cost effective intervention for
elderly people. A better understanding of health issues
associated with the depression among elderly people
has constituted a challenge for clinician and
researchers. So there is a great lot scope for exploring
this area. Research should be conducted to identify the
scope of laughter therapy to alleviate depression
among elderly.
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154 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
ACKNOWLEDGEMENTS
I acknowledge my love and gratitude to all those
loving hearts who helped me throughout my
endeavour. With sincere gratitude and humility I
acknowledge the Almighty God for his abundant
grace, love, compassion and immense showers of
blessings on me which gave me strength, courage to
overcome all the difficulties during the study process.
His unseen presence helped me to complete this study
successfully.
Conflict of Interest: Nil
Source of Funding: Nil
Ethical clearance
Ethical Clearance Obtained
REFERENCES
1. Neeraja KP. Textbook of growth and development
for nursing students.Vol. 1. New Delhi: Jaypee
Publicatios; 2006.
2. Townsend MC. Psychiatric mental health
nursing. 5th ed. New Delhi: Jaypee Brothers
Medical Publishers Private Limited; 2011. p. 483-
503.
3. Wendy L. Use of complementary and alternative
medical interventions for the management of
procedure –related depression, anxiety, and
distress in old age. Journal of Advanced Nursing
2010 Nov;25:566-79.
4. Melinda S. Laughter therapy is the best medicine.
[cited 2011 Oct 12]: 16(4):252. Available from:
URL:http://www.helpguide.org/life/homor-
laughter-health.html
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 155
INTRODUCTION
The environmental pollution affects the health of
more than 100 million people across the world. Our
Knowledge and Practice of Housewives on Domestic
Plastic Waste Management
Jince V John1, Sarita T Fernandes2, Sujith Kuriakose3
12nd Year M.Sc Nursing Student, 2Associate Professor & HOD , 3Lecturer, Community Health Department, Nitte
Usha Institute of Nursing Sciences, Nitte University, Mangalore
ABSTRACT
Background: The environmental pollution affects the health of more than 100 million people across
the world. The plastic litter situation in India is a more serious threat to future generations than the
menace is posed by nuclear weapons. As waste management should start right at home, the researcher
strongly believe that housewives have to be empowered with knowledge first.
Objective: The aim of this study is to assess the knowledge and practice of housewives regarding
domestic plastic waste management and preparation of an information booklet based on the findings
of the study.
Methods: A descriptive survey approach was used for this study. The study was carried out in 300
housewives from selected areas of Mangalore. Sample was selected by cluster random sampling
technique. Structured knowledge questionnaire and practice checklists were used for the data
collection. The data was analyzed using descriptive and inferential statistics.
Result: Analysis of the data revealed that among housewives, 77.4 % (233) had average knowledge,
22.3% (67) had poor knowledge and none of them had good knowledge regarding domestic plastic
waste management and 75.1 % (225) had average practice, 24.9% (75) had poor practice and none of
them had good practice regarding domestic plastic waste management. The study shows a positive
correlation between knowledge and practice of housewives on management of domestic plastic waste
(r=0.071).The more the housewives are empowered with knowledge on management of domestic
plastic waste, its disposal becomes more easy and effective. The analysis shows that age, type of
family, education and source of information has a significant association between knowledge of
housewives on management of domestic plastic waste.
Conclusion: The findings of this study indicated the need for educating the housewives about domestic
plastic waste management. They must be motivated for household management of plastic waste.
Keywords: Knowledge; Practice; Housewives; Domestic Plastic Waste Management
DOI Number: 10.5958/j.0974-9357.5.2.054
Corresponding author:
Jince V John
2nd year M.Sc Nursing Student
Nitte Usha Institute of Nursing Sciences,
Paneer,Mangalore
Email : jincevjohn@hotmail.com
Mobile : 08904135202
planet is becoming increasingly contaminated by
plastic pollution.4 The plastic litter situation in India
is a more serious threat to future generations than the
menace is posed by nuclear weapons. Unless and until
we think about a total ban on plastic bags or put in
place a system for manufacturers mandating them to
collect back all plastic bags, the next generation will
be threatened with something more serious than the
atom bomb.1Several countries have already banned
their use and more will doubtless follow, with the
nation overindulging in using 11.6 billion plastic bags
every year.6,7
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156 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
India will emerge as the third biggest consumer of
plastics in the world by 2012 year end, according to
studies by the Plastic Development Council under the
department of Chemicals and Petrochemicals8. India’s
plastics consumption is one of the highest in the world9.
Plastic bags are difficult and costly to recycle and most
end up on landfill sites where they take around 300
years to photo degrade. They break down into tiny
toxic particles that contaminate the soil and waterways
and enter the food chain when animals accidentally
ingest them.3.Central and State Government of India
are concerned about the drastic situations due to plastic
wastes.10-12
The domestic waste generated by households
comprises mainly of organic, plastic and paper waste
and small quantities of other waste.14 Recent studies
also shows the importance of domestic plastic waste
management.19-26 As waste management should start
right at home, the researcher strongly believe that
housewives have to be empowered with knowledge
first.
MATERIAL AND METHOD
Objectives of the Study
1. To assess the knowledge and practice of
housewives on domestic plastic waste
management.
2. To assess the correlation between knowledge and
practice of housewives on management of plastic
waste.
3. To find out the association between the knowledge
of housewives on management of plastic waste
with selected demographic variables.
4. To develop an information booklet for housewives
regarding domestic plastic waste management.
Hypothesis
H1: There will be a significant co relation between
housewives knowledge and practice on domestic
plastic waste management.
H2: There will be a significant association between
housewives knowledge and practice with
demographic variables.
Research Methodology
Research Approach: In this study, it gives the
overall plan for carrying out a quantitative survey to
collect the data from the sample population by using
a structured knowledge questionnaire and practice
checklist and prepare an information booklet on the
basis of their knowledge.
Research Design: A descriptive survey design was
selected in this study. The design is used to examine
the level of knowledge and practice of housewives
regarding domestic plastic waste management.
Setting of the Study: The study was conducted in
selected community areas under Natekal PHC.
Population: In this study population consists of all
housewives from selected community areas of
Mangalore.
Sample: The sample for the study comprised of 300
housewives from the population.
Sampling techniques: For the present study cluster
random sampling technique was used to select the
housewives and the samples. In this study, the
researcher assumes that there is one housewife in each
family. The Natekal PHC is divided into three sub-
centers (clusters) such as Belma, Konaje and
Manjanadi. From each cluster the researcher collected
samples through randomization procedure.
Data Collection Instruments
Following instruments were developed by the
researcher for the present study.
Tool 1: Demographic Performa.
Tool 2: Structured Knowledge Questionnaire.
Tool 3: Practice Checklist.
ANALYSIS
The data was analyzed in terms of objectives of the
study using both descriptive and inferential statistics.
• The results of the study are grouped under the
following headings
Section 1: Description of Sample According To
Demographic Characteristics
The demographic characteristics of the sample are
presented in the following table.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 157
Table 1: Distribution of housewives according to the
demographic characteristics n=300
Sl.No. Sample charecteristics Frequency Percentage
1. Age
1. <25 0 0.00
2. 25-35 112 37.3
3. 36-45 105 35.0
4. 46-55 52 17.3
5. 56-65 30 10.0
6. >65 1 00.3
2. Religion
1. Hindhu 76 25.3
2. Muslim 219 73.0
3. Christian 5 1.7
3. Type of Family
1. Nuclear Family 213 71.0
2. Joint Family 73 24.3
3. Extended Family 1 0.3
4. Single Parent Family 13 4.4
4 Educational Status
No Formal Education 71 23.7
Primary 143 47.7
Secondary 62 20.7
PUC 13 4.3
Diploma 6 2.0
Graduate or above 5 1.6
Professional education 0 0.0
5. Source of information
Newspaper/magazine 30 10.0
Radio/Television 49 16.3
Informal Conversations 167 55.7
No Information 54 18.0
The above table depicts the following findings
Age
Distribution of housewives according to the age
shows that highest percentage 37.3 %of them were in
the age group of 25 to 35 years, 35% in the age group
of 36 to 45yrs, 17.3 % were in the age group of 46 to 55
yrs, 10 % in age group between 56 to 65 yrs and 0.3 %
were in the age group of above 65 yrs.
Religion
Distribution of subjects according to the religion
showed that among housewives majority 219(73%)
were Muslims, 76(25.3%) were Hindus and 5(1.7%)
were Christians.
Type of Family
Distribution of subjects according to the type of
family showed that among housewives highest
percentage 213 (71%) belonged to nuclear family,
73(24.3%) belonged to joint family, 13(4.4%) belonged
to single parent family and 1(0.3%) belonged to
extended family.
Educational Qualification
Distribution of subjects according to the
educational qualification showed that among
housewives majority 143(47.7%) were having primary
education, 71(23.3%) were having no formal education,
62(20.7%) were having secondary education, 13(4.3%)
were having PUC education, 6(2%) were having
diploma education, 5(1.6%) were having degree or
above education and none were having professional
education.
Source of Information about Domestic plastic waste
management
Distribution of housewives according to the source
of information about the domestic plastic waste
management reveals that most of them 55.7% of them
have got information through informal conversations,
16.3% from radio/television, 10% from newspaper/
magazine, and 18% of them does not have any source
of information about the domestic plastic waste
management.
Section: 2 Assessment of Knowledge of
Housewives Regarding Domestic Plastic waste
Management
Fig. 1. Bar diagram representing the knowledge score of
housewives regarding domestic plastic waste management.
Section: 3 Assessment of Practice of Housewives on
Domestic Plastic waste Management
Fig. 2. Bar diagram representing the practice score of housewives
on domestic plastic waste management.
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158 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Section: 4 Assessment of the correlation between
knowledge and practice of housewives on
management of plastic waste
Table 2: Correlation between knowledge and practice
of housewives on management of plastic waste
Pearson d.f ‘p’ value
Correlation
1 Knowledge and Practice +0.071 300 0.0001
Karl Pearson’s ‘p’ value is 0.0001 which is less than
0.05,So there is a relation between knowledge and
practice. Karl Pearson’s Correlation-coefficient value
ranges between ‘-1’ and ‘+1’. The table value ranges
between 0 to +1, so there is a positive correlation. Table
shows a positive correlation (+0.071) with knowledge
and practice of housewives on management of
domestic plastic waste.
Section 5: Association between the knowledge of
housewives on management of domestic plastic waste
with selected demographic variables.
To find the association between knowledge score
and demographic variables, chi-square (Fishers exact
test) value was computed. The significance level
selected for testing the hypothesis was 0.05.
Table 3: Association between the knowledge of housewives on management of domestic plastic waste with
selected demographic variables
Variables Knowledge Fishers Level of
rating exact test significance
Poor(0-3) Average(4-7) Good(8-10)
1. Age
<25 0 0 0
25-35 27 85 0 0.047
36-45 21 84 0 0.297 (p< 0.05,S)
46-55 9 43 0 S
56-65 9 21 0
>65 1 0 0
2. Religion
Hindhu 19 57 0 0.103
Muslim 47 172 0 0.128 p>0.05
Christian 1 4 0 NS
3. Type Of Family
Nuclear Family 51 162 0 0.017
Joint Family 15 58 0 1.648 p<0.05
Extented Family 0 1 0 S
Single Parent Family 1 12 0
4. Education
No Formal Education 13 58 0
Primary 27 116 0 0.004
Secondary 20 42 0 2.21 (P<.05,S)
PUC 4 9 0
Diploma 1 5 0
Graduate or Above 2 3 0
5. Source of Information
News paper/Magazine
Radio/Television 2 28 0
Informal Conversations 5 44 0 11.334 0.0001
No Information 7 160 0 (p<0.05,S)
53 1 0
S=Significant, NS=Not Significant,
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 159
The above table depicts that since Fisher’s exact
test value for age (F=0.047,p<0.05) , type of family
(F=1.648), education (F=2.210) and source of
information(F=11.334) are greater than p value(p
<0.05), the research hypothesis is accepted, that is there
is significant association between knowledge of
housewives regarding domestic plastic waste
management and the above mentioned demographic
variables.
The above table (5) depicts that since Fisher’s exact
test value of the demographic variable , religion
(0.1083), is less than p value ( p > .05), the research
hypotheses is rejected. That is there is no significant
association between knowledge of housewives
regarding domestic plastic waste management and
religion.
DISCUSSION
Pollution is the interference of contaminants into
an environment that causes instability, disorder, harm
or discomfort to the ecosystem i.e. physical systems
or living organisms. Pollution is a growing painful
crisis.. We must be wise in managing our resources,
and take positive action towards preventing any forms
of pollution to the environment. Make the world a
better place to live34. The findings of the study have
been discussed under various sections with reference
to the objectives and hypothesis
Section 1: Description of sample characteristics
The present study showed that with regards to age
majority 112(37.3%) of housewives belonged to the age
group of 25-35 yrs.The present study is supported by
a study conducted on household waste management
where the majority of the respondents (38%) were in
the age group from 26 to 35 years12. The present study
showed that with regards to the type of family majority
213 (71.0 %) housewives from nuclear family.
The present study showed that with regards to
educational qualification majority 143(47.7%) of
housewives were having primary education. The
present study findings were consistent with a study
conduct on household waste management which
shows that 51.8% finished their primary education12.
The present study showed that with regards to source
of information on domestic plastic waste 167(55.7%)
of housewives were from informal conversations.
Section 2: Knowledge of housewives regarding
domestic plastic waste management.
The result of this study revealed that 77.4%
housewives had average knowledge and 22.3%
housewives had poor knowledge and none of them
had good knowledge regarding domestic plastic waste
management. In contrast, a study conducted in
Myanmar migrants regarding household waste
management shows that level of knowledge towards
household waste management were half of the
respondents (49.8%) had high knowledge, 36% had
moderate knowledge and only little percentage (14.2)
had low knowledge.12
Section 3: Practice of domestic plastic waste
management among housewives
On analyzing the practice of domestic plastic waste
management among housewives, the present study
showed that 24.9% of housewives are on poor practices
on domestic plastic waste management, 75.1 % of
housewives are on average domestic plastic waste
management and none of them had good practice’ s
of domestic plastic waste management. The present
study was supported by the study conducted on
Manmar migrants on household waste management.
The study shows that 16.5% have good practice, 51.2%
have moderate practice and 32.2 5 have poor practice.
The results were very compactable.12
CONCLUSION
Thin plastic carry bag has become an intrinsic part
of our lives and the urban landscapes. It is one of the
most ignored environmental and health problems.
Almost everyone including chemists, grocers,
vegetable/fruit vendors, restaurants, fast food centers
and super markets, put everything we buy in plastic
carry bags, as they find it cheaper, easier and cleaner
to get them20
Being non-biodegradable, they choke the earth for
hundreds of years, making the soil unfertile, apart from
polluting ground water through leaching of toxic
substances. In the light of environmental and health
risks, the cost factors and other problems involved in
the management of domestic plastic waste, it is
desirable to reduce the quantum of waste generated,
by minimizing the use of plastic carry bags and by
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160 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
reusing them in our daily lives. This can be achieved
by increasing the thickness of carry bags, so as to make
them expensive and to discourage their liberal
dispensation, use and disposal. As waste management
should start right at home, the researcher strongly
believe that housewives have to be empowered with
knowledge first.
ACKNOWLEDGEMENTS
The authors acknowledge the experts for their
contribution for tool development and the participants
for their co-operation.
Conflict of Interest : None
Ethical Clearance : Obtained from Ethical Committee
of Nitte University,Mangalore held on 16 th February
2012.
Source of Funding : None
REFERRENCES
1. Robert H.; Shaw, David G.; Ignell, Steven E.
“Quantitative distribution and characteristics of
neustonic plastic in the North Pacific Ocean. Final
Report to US Department of Commerce, National
Marine Fisheries Service, Auke Bay Laboratory.
Auke Bay, AK” (PDF). pp. 247–266. http://
swfsc.noaa.gov/publications/TM/SWFSC/
NOAA-TM-NMFS-SWFSC-154_P247.PDF
2. Environment & Pollution; Introduction.[Internet]
agritech.tnau.ac.in/environment/envi_
pollution_ introduction.htm
3. Plastic Bags to be banned in Abu Dhabi.UAE
Interact. 2009 Jun 11. [Internet],Available from
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4. China Watch: Plastic Bag Ban Trumps Market
and Consumer Efforts. World watch. 2010 Nov
30. [Internet], Available from http://
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5. Plastic development council to create awareness
on use and disposal of plastics. 2006
April.[Internet]Available from http://
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6. Plastic Bag Pollution.[Internet], http://
www.gits4u.com/envo/envo5.htm
7. Parivesh . Central Pollution Control Board. Plastic
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144.pdf
8. Environmental Pollution in India.[Internet] http:/
/www.gits4u.com/envo/envo5.htm
9. Waste Management. [Internet].
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WasteManagement.pdf.
10. Ban on Plastic Carry Bags in Dk. Times of India,
2012 September 1
11. Cutting plastic waste.Editorial,The Hindhu.
February 27, 2011 http://www.thehindu.com/
opinion/editorial/article1495532.ece
12. Ye Hein Naing.Factors influencing the practice
of household waste management among
Myanmar migrants in Muang district,Ranong
province, Thailand. [Thesis]. Chulalongkorn
University;2009.
13. Geraldine Daniëlle de Wet. Recycling soft plastic
household waste into aesthetic products[Thesis].
Magister technologiae: textile design
andtechnology. South Africa; Tshwane university
of technology;2006.
14. Sinha.A.H,Ijaz Hossain etal.Composition of
plastic waste and market assessment of the plastic
recycling sector in Dhaka city.waste Concern
Consultants;2006
15. Maja.R,Mladen.S,Ana.P.Plastic in the household
waste.[Thesis]Mechanical Engineering and Naval
Architecture;Croatia;University of Zagreb;2011
16. Shan-Shan Chung, ,Carlos W. H. Waste
Management in Guangdong Cities: The Waste
Management Literacy and Waste Reduction,
September 2004, Volume 33, Issue 5, pp 692-711.
17. Siddique R, Khatib J, Kaur I. Use of recycled
plastic in concrete: a review. Waste Manag.
2008;28(10):1835-52. Epub 2007 Nov 5. http/
www.nibi.nlm.nih.gov/pubmed/ 17981022
18. Shuokr Qarani Aziz, Hamidi Abdul Aziz,
Mohammed Jk Bashir, Mohd Suffian Yusoff.
Appraisal of domestic solid waste generation,
components, and the feasibility of recycling in
Erbil, Iraq. 2011 Aug;29(8):880-7. Epub 2011 Jan
17 21242179.
19. Burnley SJ. A review of municipal solid waste
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2007;27(10):1274-85. Epub 2006 Oct http/
www.nibi.nlm.nih.gov/pubmed/17011771.
20. Foo Tuan Seik . Recycling of domestic waste:
Early experiences in Singapore.Habitat
International . Volume 21, Issue 3, September
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http://dx.doi.org/10.1016/S0197-3975(97)
00060-X.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 161
INTRODUCTION
God has a supreme power of taking care of all the
needs of the baby in the womb. The baby is
comfortably nested in a flexed posture with hands in
the midline close to his mouth. Despite several
attempts, scientists have failed to fabricate an incubator
with all the qualities and characteristics of the womb.1
The growth of the immature cerebellum is
particularly rapid during late gestation. However this
accelerated growth seems to be impeded by premature
birth and associated injury. The long term neuro-
developmental disabilities seen in survivors of
premature birth and associated injury may be
attributable in part to impaired cerebellar
development.2
Effectiveness of SIM Versus PIM on Neonatal
Developmental Supportive Care in Terms of Knowledge
among Nursing Students
Kuldeep Kaur1, Jyoti Sarin2, Gurneet Kaur3
1Assistant Professor, 2Principal, 3Assistant Professor, M. M. College of Nursing, Mullana Ambala, Haryana
ABSTRACT
Developmental care is a broad category of Interventions designed to minimize the stress of the
newborns. Current study aimed to assess and compare the knowledge of nursing students regarding
Neonatal Developmental Supportive Care before and after the administration of SIM and PIM and
to determine the acceptability of SIM and PIM on Neonatal Developmental Supportive Care among
nursing students. An experimental approach was used with pretest-posttest comparison group design
on a sample of 60 B.Sc. Nursing IVth Year students i.e. 30 in SIM group and 30 in PIM group from
M.M. College of Nursing, Mullana, Ambala, selected by Simple Random and Total Enumeration
sampling technique respectively. The data was collected using Structured Knowledge Questionnaire
and Structured Opinionnaire. In SIM group, the mean post-test knowledge score (36 ± 3.39) were
significantly higher than the mean pre-test knowledge score (18.67 ± 3.81). In PIM group, the mean
post-test knowledge score (43.63 ± 2.79) was higher than the mean pre-test knowledge score (19.27 ±
3.89). The mean post-test knowledge score (43.63 ± 2.79) and the mean acceptability score (27.07±2.08)
of PIM group was higher than the mean post-test knowledge score (36 ± 3.39) and the mean
acceptability score (24.87±1.66) of SIM group. Therefore both, SIM & PIM were effective methods for
enhancing the knowledge of nursing students regarding Neonatal Developmental Supportive Care
& PIM was more effective and highly acceptable method in terms of its approval and usefulness than
SIM.
Keywords: Neonatal Developmental Supportive Care, Effectiveness, Knowledge, Acceptability, Nursing
Students, Self Instructional Module, Programme Instructional Module
DOI Number: 10.5958/j.0974-9357.5.2.054
Developmental care introduced in the mid 1980’s
provides a strategy to address the environmental
concerns. Different strategies have been used to modify
the extra-uterine environment to decrease a variety of
stresses including noise and light reduction, minimal
handling and the provision of longer rest periods.3
Developmental care is a broad category of
Interventions designed to minimize the stress of the
NICU environment.4
The principles of DSC include individualized infant
care with initiation of cluster care for nursing activities,
family-centered care, minimal and appropriate
handling and touching of the preterm infant,
developmentally supportive positioning (DSP), non-
nutritive sucking, and manipulation of the external
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162 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
environment to reduce negative stimuli (noise and
light reduction) and increase positive smell stimuli.
These Interventions lead to stress reduction and an
increase in rest periods, and are therefore beneficial to
the preterm infant.5
Effectiveness of self-directing learning modules has
been tested for providing continuing nursing
education among nurse educators. Effectiveness and
acceptance of the learning modules was enhanced by
educational strategies and revealed that self-
instructional module was effective in self directed
learning.6
Nurses enter the profession relatively earlier than
other professions. Soon after the final year of education
in Basic B.Sc Nursing, the graduates have many lives
placed into their hands including the little ones
newborns. Hence it is essential that the graduating
nurses acquire adequate knowledge on developmental
supportive care in order to avoid mishandling of
newborns especially in critical conditions. Investigator
felt need to enhance the knowledge of nursing students
regarding the Neonatal Developmental supportive
care as Developmental supportive care concept is not
explicitly mentioned in the B.Sc Nursing Curriculum.
As there are reviews related to these two methods
of teaching strategies but no study has been done to
compare these self directed learning strategies and
about their acceptability .Therefore the investigator felt
the need to compare the effectiveness of Self
Instructional Module versus Programme Instructional
Module on Neonatal Developmental supportive care
among nursing students and this further emphasis the
need of the study.
OBJECTIVES
1. To assess and compare the knowledge of nursing
students regarding Neonatal Developmental
Supportive Care before and after the
administration of SIM and PIM.
2. To determine the acceptability of SIM and PIM on
Neonatal Developmental Supportive Care among
nursing students.
MATERIALS AND METHOD
The research approach adopted for the study was
Experimental with pretest-posttest comparison group
research design. The conceptual framework adopted
for the study was based on Ludwig Von Bertalanffy
General System Model in 1968.
The present study was carried out on nursing
students of M. M. College of Nursing, Mullana,
Ambala, Haryana to assess their knowledge and
acceptability on Neonatal Developmental Supportive
Care. 60 B.Sc. nursing IVth year students were taken
and 30 nursing students were selected by total
enumeration sampling technique and 30 students were
selected by simple random (lottery method) sampling
technique.
The tools developed and used for data collection
were Structured Knowledge Questionnaire and
Structured Opinionnaire. Structured Knowledge
Questionnaire was comprised of two sections: Section
I: It comprised of items seeking information pertaining
to characteristics of nursing students such as student’s
age, gender, religion, type of family, family income per
month, place of residence, parental education and
parental occupation. Section II: It comprised of 50
objectives type items like multiple choice (21), true or
false (21) and match the following (8). These
knowledge items are covering the following areas:
• Concept about Neonatal Developmental
Supportive Care
• Identification of signs of healthy and alert baby
• Identification of signs of stress and stability in
neonates during Neonatal Developmental
Supportive Care
• Interventional strategies for promoting Neonatal
Developmental Supportive Care
The maximum possible score on the Structured
Knowledge Questionnaire was 50 (reliability was
found to be 0.79 by KR20). Structured Opinionnaire
comprised of 10 statements. A three point rating scale
was developed by the investigator to determine the
acceptability of SIM and PIM by nursing students. Each
respondent was required to give his/her opinion for
each of the statement. The respondents were instructed
to indicate their extent of agreement to items in the
tool by responding to one of the three categories: “Fully
met”, “mostly met” and “Met to some extent”. The
content validation of all these tools was established
by getting the valuable opinions from the experts. SIM
and PIM were prepared for the development of
knowledge of nursing students on Neonatal
Developmental Supportive Care. It was prepared
based on the review of research and non-research
literature. Criteria rating scale was formulated for
validating the content of the SIM and PIM. Content of
both the modules were same in terms of language,
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 163
description and pictorial illustrations.SIM and PIM
was submitted to the same nine experts for validation.
Suggestions given by experts were duly made and final
draft was prepared.
The data obtained were analysed using both
descriptive and inferential statistics.
RESULTS
• B.Sc. nursing IVth year students in SIM and PIM
group were similar in their characteristics and the
groups were homogenous as calculated chi square
is less than the tabulated value at 0.05 level of
significance.
Table 1: Range, Mean, Median and Standard deviation of Pre-test and Post-test Knowledge Score of Nursing
Students in SIM and PIM group N-60
Group Knowledge score
Range Mean Median S.D
SIM(n=30)Pre-testPost-test 13-28 18.67 17.5 3.81
28-42 36 36 3.39
PIM(n=30)Pre-testPost-test 12-26 19.27 20 3.89
39-50 43.63 43.5 2.79
Maximum Possible Score: 50
• Table:1 reveals that The range of post-test
knowledge score 28-42 was higher than the mean pre-
test range of knowledge score i.e. 13-28 and mean post
test knowledge score (36 ± 3.39) was higher than the
pre-test knowledge score (18.67 ± 3.81) in SIM group.
The median of post-test knowledge score (36) was
higher than the median of pre-test knowledge score
(17.5) in SIM group.
• The range of post-test knowledge score (39-50) was
higher than the mean pre-test range (12-26) of
knowledge score and mean post test knowledge
score (43.63 ± 2.79) was higher than the pre-test
knowledge score (19.27 ± 3.89) in PIM group. The
median of post-test knowledge score (43.5) was
higher than the median of pre-test knowledge
score (20) in PIM group.
Table 3: Mean, Mean Difference, Standard Deviation Difference and Standard Error of Mean Difference and ‘t’ of
Pre-test and Post-test Knowledge Score of Nursing Students in SIM and PIM group N=60
Group Knowledge score
Mean MDSDDS.EM.D ‘t’
SIM(n=30)Pre-testPost-test 18.67 17.33 0.42 0.93 16.86*
36.00
PIM(n=30)Pre-testPost-test 19.27 24.36 1.1 0.87 27.91*
43.63
t (29)=2.05, (*)Significant ( pd” 0.05)
Table 3 shows that the mean post-test knowledge
score of SIM (36) of nursing students was higher than
the mean pre-test knowledge score (18.67) with a mean
difference of 17.33. The computed “t” value of 16.86was
found to be statistically significant at 0.05 level which
shows that the difference between the mean pre-test
and post-test knowledge score of Nursing students was
a true difference and not by chance. Hence, null
hypothesis (H01) was rejected and research hypothesis
(H1) was accepted.
The data also show that the mean post-test
knowledge score of PIM (43.63) of nursing students
was higher than the mean pre-test knowledge score
(19.27) with a mean difference of 24.36. The computed
“t” of 27.91was found to be statistically significant at
0.05 level which shows that the difference between the
mean pre-test and post-test knowledge score of
Nursing students was a true difference and not by
chance. Hence, null hypothesis (H02) was rejected and
research hypothesis (H2) was accepted.
Thus both SIM and PIM were effective methods of
enhancing the knowledge of the nursing students on
Neonatal Developmental Supportive Care.
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Table 4: Mean, Mean difference, Standard Deviation Difference and Standard error of Mean Difference and ‘t’ of
the Pre-test and Post-test Knowledge Score of Nursing Students in SIM and PIM group N=60
Group Knowledge score
Mean MD SDD S.EM.D ‘t’
Pre-testSIM(n=30)PIM(n=30) 18.67 0.6 0.08 0.99 0.60NS
19.27
Post-test SIM(n=30)PIM(n=30) 36.00 7.63 0.6 0.8 9.5*
43.63
t (58)=2.00; (*)Significant( pd” 0.05); (NS) Not Significant (p>0.05)
Table 4: shows that the mean pre-test knowledge
score (19.27) of nursing students who were exposed
to PIM was higher than the mean pre-test knowledge
score (18.67) of nursing students who were exposed
to SIM with a mean difference 0.6, which was found
to be statistically not significant with calculated ‘t’
(0.60) for df 58 at 0.05 level of significance. This shows
that the obtained mean difference was not a true
difference but by chance. This shows that the Nursing
students in SIM and PIM group did not differ initially
in terms of their knowledge score.
The findings also reveal that the mean post-test
knowledge score (43.63) of nursing students who were
exposed to PIM was higher than the mean post-test
knowledge score (36) of nursing students who were
exposed to SIM with a mean difference 7.63, which
was found to be statistically significant with‘t’ of 9.5
for df 58 this shows that the obtained mean difference
was true difference and not by chance.
Hence, null hypothesis (H03) was rejected and
research hypothesis (H3) was accepted, indicating that
the PIM on Neonatal Developmental Supportive Care
was significantly more effective method of enhancing
the knowledge of the nursing students as compared
to SIM on Neonatal Developmental Supportive Care
at 0.05 level of significance.
Table 5: Area Wise Mean, Mean Difference, Standard Deviation Difference and Standard Error of Mean Difference
and ‘t’ of Post-test Knowledge Score of Nursing Students in SIM and PIM group N=60
Knowledge Areas Mean MD SDD SEMD ‘t’
Post-test Post-test
SIM (n=30) PIM(n=30)
1. Concept about Neonatal 5.87 7.07 1.2 0.31 0.34 3.48*
Developmental Supportive Care
2. Identification of signs of 6.37 7.87 1.5 0.45 0.32 4.66*
healthy and alert neonate
3. Identification of signs of stress 7.5 8.5 1.0 0.31 0.34 2.90*
and stability in neonates during
Neonatal Developmental
Supportive Care
4. Interventional strategies 16.27 20.23 3.96 0.94 0.52 7.50*
for promoting Neonatal
Developmental Supportive Care
t (58)=2.00; (*)Significant ( pd” 0.05)
Table 5: shows that the area wise mean post-test
knowledge score of nursing students in PIM group was
higher in all areas as compared to the area wise mean
post-test knowledge score of nursing students in SIM
group. Findings further reveal that the computed ‘t’
in each area i.e. “Concept about neonatal
Developmental Supportive Care” (3.48),
“Identification of signs of healthy and alert
neonate”(4.66), “Identification of signs of stress and
stability in neonates during Neonatal Developmental
Supportive Care”(2.90) and “Interventional strategies
for promoting Neonatal Developmental Supportive
Care” (7.50) were found to be statistically significant
at 0.05 level which showed that the mean post-test
knowledge score of nursing students in SIM and PIM
group were truly different and not by chance. Thus, it
can be concluded that the PIM was more effective in
enhancing the knowledge of nursing students
regarding Neonatal Developmental Supportive Care
in all the areas as compared to SIM.
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Table 6: Mean, Mean difference, Standard Deviation Difference and Standard error of Mean Difference and ‘t’ of
Acceptability Score of Nursing Students in SIM and PIM group N=60
Group Acceptability score
Mean MDSDDS.EM.D ‘t’
SIM(n=30)PIM(n=30) 24.8727.07 2.2 0.42 0.48 4.58*
t (58) =2.00; (*)Significant ( pd” 0.05)
Table 6: shows that the mean acceptability score
(27.07) of nursing students who were exposed to PIM
was higher than the mean acceptability score (24.87)
of nursing students who were exposed to SIM with a
mean difference of 2.2, which was found to be
statistically significant as evident with ‘t’ of 4.58 for df
58. This shows that the obtained mean difference was
true difference and not by chance.
Hence, null hypothesis (H04) was rejected and
research hypothesis (H4) was accepted. This shows that
the PIM on Neonatal Developmental Supportive Care
was significantly more acceptable method by nursing
students as compared to SIM on Neonatal
Developmental Supportive Care at 0.05 level of
significance.
DISCUSSION
The purpose of the study was to assess and
compare the effectiveness of SIM Versus PIM on
Neonatal Developmental Supportive Care in terms of
knowledge among nursing students.
The present study findings indicated that mean post
test knowledge score was significantly higher than the
mean pre-test knowledge score in SIM group, so there
was an adequate enhancement of knowledge among
nursing students by SIM on Neonatal Developmental
Supportive Care. The findings of VermaP(2003)7 ;
Swank C., et. al (2000)8 revealed that SIM is an effective
method for enhancing the knowledge of nursing
students.
The findings indicated that the mean post-test
knowledge score was significantly higher than the
mean pre-test knowledge score in PIM group. So there
was an adequate enhancement of knowledge among
nursing students by the PIM on Neonatal
Developmental Supportive Care. The findings of
Mamudu J.A. et. al.(2009) , N. Izzet Kurbanoglu. et al.
(2006), revealed that PIM is an effective method for
enhancing the knowledge of nursing students.
The findings also indicated that the mean post-test
knowledge score of PIM group was significantly
higher than the mean post-test knowledge score of SIM
group. Thus PIM was more significant method of
enhancing knowledge of nursing students as
compared to SIM.
ACKNOWLEDGEMENT
At very outset, I would like to thank almighty for
his presence. My sincere thanks goes to all participants
of my study. lastly and most importantly I am grateful
to everybody who was important to successful
realization of thesis.
Ethical Consideration: Ethical approval to conduct the
study was obtained from Institutional Ethical
Committee of M.M University, Mullana, Ambala,
Haryana. Written informed consent was obtained from
the study subjects regarding their willingness to
participate in the research project.
Conflict of Interest: There is no conflict of interest.
Funding Source: self financed.
REFERNCES
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2. Soul J S. Late gestation cerebellar growth is rapid
and impeded by premature birth. Pediatrics. 2005
March; 115(3): 688-95.
3. Marlow. Textbook of Paediatric Nursing.6thedi.
New delhi.2004:15-20,25-35.
4. Singh M. Care of the newborn. 6thedi. New Delhi.
Sagar Publications.2004: 12-19.
5. Prendergast CC. et. al. Barriers to provision of
developmental care in the neonatal intensive care
unit: neonatal nursing perceptions. Journal of
Perinatology. 2007 Feb; 24(2): 71-77.
6. Sparling Leslie. Enhancing the Learning in Self-
Directed Learning Modules. Journal for Nurses
in Staff Development – JNSD. July/August 2001;
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7. Swank C., et., al., Effectiveness of a genetics self-
instructional module for nurses involved in egg
donor screening. The American Journal of
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Maternal/Child Nursing. May/June 2000; 35(3):
132-137.
8. Mamudu J.A.et. al. Relative effects of
programmed instruction and demonstration
methods on students’ academic performance in
science. College Student Journal. June 2009. See
all results for this publicationBrowse back issues
of this publication by date
9. N. Izzet Kurbanoglu. et al. Programmed
instruction revisited: a study on teaching
stereochemistry. Journal of Chemistry Education
Research and Practice.2006;7 (1): 13-21.
10. Verma, P. Impact of self instructional module for
the nurses on nursing management of the patients
having chest tube drainage. Nursing Journal of
India. Feb 2003; 25(2): 15-25.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 167
INTRODUCTION
Effective teaching is one of the challenges that nurse
educators encounter. The challenge in nursing
education lies in the production of nursing workforce
1 which requires nurturing the nursing students with
the necessary skills and knowledge to facilitate their
development into qualified nurses. This challenge has
placed the role of the nurse educators in the central
position of nursing education.2
BACKGROUND
The shortage of nursing faculties and the workload
that nurse educators stressed of have formed an
obstacle to achieve effective teaching and learning.3
Therefore, the trend in nursing education has moved
towards innovation in which nurse educators are
encouraged to adapt some incremental change in
teaching styles and move from didactic traditional
teaching towards students-centre learning approach.4
Impact of Students-Teacher Relationship on Student's
Learning: A Review of Literature
Yusra Sulaiman Al Nasseri1, Lakshmi Renganathan1, Fadhila Al Nasseri2, Ahmed Al Balushi3
1Assistant Tutors, Oman Nursing Institute, Muscat, Oman, 3Staff Nurse, Ministry of Health, Oman, 4Senior Staff
Nurse Al Buraimi Hospital, Oman
ABSTRACT
Introduction: The teacher student relationship is very important for a good learning environment.
There should be an excellent relationship between a student and teacher in order to facilitate the
learning and gain positive attitude. This relationship between teacher and student has vast influence
on the learning process of the students.
Method: The literature review was conducted using multimodal search of different databases such
as CINAHL, Pub Med, Medline, Psych Info, and Hands on searching.
Results: Although there is still limited empirical research about student teacher relationship on
learning process, the available studies showed that literature regarding teacher-students' relationship
confirms that, positive teacher-student relationships influence students' learning.
Conclusion: The essence emerged from a connected relationship (caring, support, trust and respect)
which support students self confidence, fosters students' self-trust and increases students motivation
to learn, influencing their professional development towards future career pathway.
Keywords: Caring, Learning process, Respect, Student-Teacher relationship, Support, Trust
DOI Number: 10.5958/j.0974-9357.5.2.054
However, facilitation of learning in nursing education
requires different skills 1 in which nursing educators
must be equipped with necessary characteristics to
ensure that learning will take place.
Adapting different teaching strategies, obtaining
high level of knowledge as well as the years of
experience that teachers have do not necessary result
in quality teaching and learning.5 In a study, an author6
has suggested that teacher’s attributes and positive
relationship with the students can be a powerful
motivator for students learning.
Therefore, since the process of discovering new,
innovative pathways to facilitate leaning in nursing
education is still continuous, 3 this paper aims to find
an innovative way through exploring the literature of
whether the relationship that connects nurse educators
and the nursing students in nursing education has an
impact on students learning.
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MATERIALS AND METHODS
Data Sources and Search Strategy
The literature was obtained by searching different
databases which include CINAHL, Pub Med, Medline,
Psych Info, and Hands on searching. In view of the
apparent paucity of literature on teacher-students
relationship, the review period covers the period from
1997 to 2008.
Inclusion criteria
• The articles related to nursing education all over
the world
• Research based articles
Exclusion criteria
• All educational articles rather than nursing
• All articles published before 1997
• Literature review based articles
Summary of the evidences
There are multitudes of terms offered in the
reviewed articles to describe nurse educator; for
instance, nurse preceptor, mentor, and clinical
instructor. However, there is no single article has
provided a clear definition of these terms. It was
assumed from reading those articles that clinical
instructors and clinical preceptors which were used
mostly by researchers is referred to the nurse educator
who teaches in the clinical area. A nurse educator is
referred to the nurse educator who teaches both theory
and the practice. Therefore, in this paper recognition
will be given to the variety of titles and roles.
Literature review
Regardless of not finding specific literature relating
to student-teacher relationship, information from other
studies used to structure the main body of the review
by analyzing the literature for emerging themes.7 These
themes are:
• Caring
• Support
• Trust and Respect
CARING
Research has shown that, caring relationship is the
valuable factor that influences students learning in the
clinical area.8 This qualitative study aimed to describe
caring student-teacher relationship in nursing
education from the perspective of Jordanian nursing
students. The results revealed that, the students highly
value the caring relationship that clinical instructors
provide as the atmosphere in caring relationship
alleviates students’ anxiety and stress. Also, caring
nurse educators encourages independence which in
turn, builds up students’ confidence and competency
and in turn encourages them to learn. However, the
students who did not experience a caring relationship
with the educators felt as “belittled” which de-
motivated them to learn.9 consequently; this could have
affected the study results.
A similar stance is taken by 10 using trans-cultural,
comparative designs to compare caring relationship
in Jordanian and Australian nursing education. The
results of the study revealed that, caring relationship
encourages the nursing students to learn safely and
without pressure. The Australian students place
greater value on, clinical instructors’ knowledge more
than teacher-student relationship. However, in this
study, the researcher compared between two groups
with different academic years of study and different
size. Also, due to the fact that, the researcher is part of
nursing faculty it is suggested that, Jordanian nursing
students may have provided bias opinion as they were
may be worried about the ramification if they report
negative instances of their encounters. This may be
attributed to cultural differences in beliefs and
practices regarding approaches to teaching and
learning.8
Other authors12 have remarked on caring
relationship by adapting a feminist approach to study
the influence of mentors’ emotional labor on learning
how to care from the perspective of British nursing
students. The results suggests that, caring aspects
assists nursing students to overcome the problems
they may encounter during learning as well as help
them to learn how to care. However, the sample chosen
in this study was opportunistic and purposive.
Although purposive sampling is widely used in
qualitative research, researchers should select the
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 169
relevant sample to ensure data accuracy11 and
representativeness.13 In this study, the researcher was
not clear about the type of sample wanted to include
as opportunistic sample differs from purposive
sample.14 This makes it difficult to judge on the results
and its generalizability as well.
Supporting few study findings, 12 &15 which has
reached to the same results by using a longitudinal
design which aimed to identify the role of supervisors
in integrating theory into practice in clinical area. The
results revealed that, students make sense of caring
aspect in active engagement with mentors where
caring provided to them in a practical way. Similarly
the data were collected from British nursing students
in a study suggests that the data obtained are accurate.
Also, the analyzed information was sent for audit trial
which implies the validity of the results.13
However, a contrasting idea is suggested by an
author 16 as, using a cross sectional design to investigate
how American senior and junior nursing students
learn to care for patients. The results revealed that,
caring aspect was inherent from their parents but was
not influenced by their instructors. However, other
studies17, 18 have indicated that senior student’s
perceptions are different to junior ones. Therefore, it
would be important to consider the senior and junior
responses separately. Moreover, senior and junior
terms were not defined. Generally, the study results
can be considered valid and credible as the scale used
to measure caring efficacy in this study is internally
valid as the results showed.
All the evidences has proven that caring
relationship is required in nursing education as it
fosters students learning, builds up students’ trust,
confidence and competence.8 However, more studies
are required to examine whether caring relationship
fosters caring aspects among senior and junior nursing
students. Also, the research showed that, some
countries value caring relationship differently which
highlights that, cultural variations exist.
SUPPORT
The theme support appeared in most of the reviewed
literature. Supportive relationships help to support
students who are at risk of failing.6 Using a qualitative
design, this study aimed to explore and describe
nursing students’ experiences of connection within the
teacher-students relationship. In this study, Canadian
nursing students elaborated that in a supportive
relationship the chances for learning are maximized.
Supportive teachers do not focus on problems and
deficits in student learning or ignore students’
strengths. They facilitate and help struggling students
to utilize their best talents to succeed. Furthermore this
ensures reliability of the findings of the another study.11
Other authors have remarked that the supportive
relationship provided by nurse educators helps the
students to overcome any stress they may face in a
new clinical environment.19 This quantitative study
aimed to identify the best and worst nurse educator
from students and educators perspective. The study
findings revealed that Australian nursing students’
value moral support more than any other factor as it
makes them feel at ease, encourages them to learn and
seek out learning opportunities.11
Similar comments were suggested 20 by adopting a
mixed method design. The results showed that, one
of the preceptors’ leadership qualities that foster
students’ learning in clinical environment is to be
supportive and responsive to students’ needs.
Interestingly, a similar view was suggested by using
the same design by an author.21 in a study where the
participants were Australian nursing students. The
study concluded that, learning in clinical environment
is influenced by many factors such as students’
satisfaction, nurse-students relationship and clinical
instructors support. Therefore, supportive relationship
is not the only factor that influences student’s
learning.11
The studies 20, 21 could be acknowledged for their
methodology. Using multi-method design not only
provides a complete picture of the study, but also
investigates the concepts with convergent
approaches.22
In conclusion, the literature revealed that
supportive relationship was highly valued by nursing
students. Supportive relationship opens a new future
for failing students where new responsibilities can be
established to support learning. Nurse educators who
provide support to the weak students will not only
help to increase students’ self-motivation, but also will
preserve students’ self dignity, self worth and future
development.6 Although, supportive relationship is
not the only source for student learning, it is still
considered the most important factor that encourages
students to learn.15,19 &20
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170 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Trust and respect
Research has shown that positive teacher–student
relationships build up respect and trust among nursing
students.6 In a qualitative approach study done for
Canadian nursing students’ experiences of connection
within the teacher-students relationship. The study
revealed that when students feel respected by their
teachers, they focus more on learning and the flow of
learning becomes very smooth. The students described
that as ‘feeling at ease’. The researcher has provided
rich quotes and a detailed explanation of the
participants’ experience. This ensures reliability of the
findings.11
Comments from other authors suggest that
respectful teachers consider students’ privacy when
conveying feedback to students.23 This qualitative
study aimed to identify the effective and ineffective
nurse educators from student’s perspective.
A study has shown24 that trust, respect and support
are crucial characteristics of effective mentors which
are required in clinical learning environment. This
qualitative study results revealed that the presence of
trust, respect and support in the clinical environment,
creates an atmosphere where learners are free to ask
questions, disclose their lack of understanding without
fear, clarify any doubts, which in turn, improves
students’ learning.
Although qualitative research is criticized for lack
of scientific rigor, 25 this research used different
measures to establish rigor such as truth-value,
applicability, consistency and conformability 26 which
indicates the accuracy of the obtained data.
Furthermore, two researchers analyzed the data in a
study11 using triangulation for data analysis results in
greater confidence in the obtained findings.
In a study conducted in Thailand by adopting
quantitative design to identify nursing students’
approaches to learning. The study results revealed that
learning approaches are influenced by the positive
environment created by nurse educators when respect
and trust are conveyed.27
Henceforth, the learning is greatly influenced by
an environment where trustful and respectful
relationships create an atmosphere where students feel
at ease, are encouraged to discuss concerns, free to ask
questions, negotiate objectives, become more attentive
and engage in the discussion.28 Also respected students
feel more secure and accepted in the clinical
environment and teachers’ trust of students fosters
students’ self-trust.6 This in turn, builds up students’
confidence, improves their self-esteem and helps them
to grow professionally to reach their potential.29
To conclude the findings, figure 1 outlines a
conceptual framework suggested by the emerging
themes. The framework illustrates that the caring,
support, respect and trust that nurse educators provide
within teacher-students relationships creates an
environment where student nurses become motivated
to learn which enhances their professional
development.
Innovation into practice
This article explores the innovative ideas that may
contribute to enriching nursing students experience
during their education. Therefore, it is envisaged that
by creating a greater self-awareness in the nurse
educators it may impact on their relationships with
the students and offer an experience for the students
to equip them to become skilled and competent nurses.
Exploring the literature has created a new pathway
in nursing education as teacher-student relationship
will not only maximize students learning but also
influence their professional development as learners.
Since innovation is to bring new ideas or make a
change, 30 to ‘create an entire paradigm shift’.
CONCLUSION
The review reveals that positive teacher–student
relationships influence students’ learning. The essence
emerged from a connected relationship (caring,
support, trust and respect) which support students self
confidence, fosters students’ self-trust and increases
students motivation to learn, influencing their
professional development towards future career
pathway. Despite the limitation of some studies, the
literature has offered an insight into the importance of
students-teacher relationship in nursing education.
However, further research should be conducted to
explore the nurse educators’ perspective on teacher-
students relationships and how influential these are
on student academic achievements.
Acknowledgement: None
Ethical Clearance: Not obtained because this is the
Literature Review study
Conflict of Interest: None
Source of Funding: None
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 171
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2. Odetter Gristscti , Brenda Jacona & John Jacono
(2005). The nurse educator’s clinical role. Journal
of Advanced Nursing. 50(1), 84-92.
3. Chan S and Wong F (1999) Development of basic
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4. Lee D (1996) The clinical role of the nurse teacher:
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5. Davis H (2001) The quality and impact of
relationships between elementary school
students and teachers. Contemporary
Educational Psychology 26: 431-453.
6. Gillespie M (2002) Student–teacher connection in
clinical nursing education. Journal of Advanced
Nursing 37(6) 566–576.
7. Cornwell Ros and William.M Daly. (2003).
Nursing roles and levels of Practice: a framework
for differentiating between elementary, spcialists
and advance nursing practice. Journal of Clinical
Nursing. 12(2), 158-167.
8. Lopez V (2003) Clinical teachers as caring
mothers from the perspectives of Jordanian
nursing students. International Journal of
Nursing Studies 40: 51-60.
9. Barnes R, Edmunds L and Ward S (2008) Reality
of undertaking research: the experience of Novice
researchers. British Journal of Nursing 17 (14) 920-
923.
10. Nahas V (2000) A transcultural study of Jordanian
nursing students’ care encounters within the
context of clinical education. International Journal
of Nursing Studies 37: 257-266.
11. Bryman A (2008) Social Research Methods.
Oxford University Press: NewYork.
12. Smith P and Gray B (2001) Reassessing the
concept of emotional labour in student nurse
education: role of link lecturers and mentors in a
time of change. Nurse Education Today 21:
230–237.
13. Crombie I (1996) The Pocket Guide to Critical
Appraisal. BMJ Publishing Group: London.
14. Creswell J (2003) Research Design: Qualitative,
Quantitative and Mixed methods approaches.
Sage publication: London.
15. Spouse J (2001) Bridging theory and practice in
the supervisory relationship: a sociocultural
perspective . Journal of Advanced Nursing 33(4)
512-522
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Health Care. Journal of the American Medical
Association 289 (15) 1969-1975.
17. Kuen M (1997) Perceptions of effective clinical
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18. Guba E and Lincoln Y (1981) Effective evaluation.
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19. Lee W, Cholowski K and Williams A (2002)
Nursing students’ and clinical educators’
perceptions of characteristics of effective clinical
educators in an Australian university school of
nursing. Journal of Advanced Nursing 39(5)
412–420.
20. Zilembo M and Monterosso L (2008) Students’
perception of desirable leadership qualities in
nurse preceptors: A descriptive study.
Contemporary Nurse27(2) 194-206.
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nursing students ’perceptions of their clinical
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Nursing 25(6) 1299–1306.
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Triangulation in qualitative research: evaluation
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INTRODUCTION
Faculty participation on department committees
plays an important role in meeting school of nursing
program goals. Faculty often serves on one or more
committees such as governance, curriculum, outcomes
and evaluation, or research. Each committee functions
to support the mission and vision of the department
or school. This article discusses the efforts of a Faculty
Research and Professional Affairs committee to
facilitate research and scholarship among nursing
faculty in the Jefferson School of Nursing (JSN) and
support the school’s vision and mission.
The Faculty Research and Professional Affairs
committee at the JSN, Thomas Jefferson University in
Philadelphia, PA, USA was developed as part of the
school’s committee structure to address faculty
scholarship and research needs. The Boyer Model of
Scholarship served to guide development of the
committee’s purpose, goals, and activities. The first
principle of the Boyer Model of Scholarship, the
Scholarship of Discovery, concerned with building new
knowledge with original research, served as a
backdrop to identify activities to support faculty
research. According to Boyer(1) discovery is needed to
generate new knowledge for application, teaching and
integration. Boyer’s second principle, the Scholarship
of Integration, was also important in achieving our
goals. Integration is the interpretation of work to bring
new insights to original research(1,2). Integration allows
Lessons from the Field: Using the Work of a Department
Research Committee to Facilitate Nursing Faculty
Research and Scholarship
Lori S Lauver
Associate Professor, Jefferson School of Nursing, Thomas Jefferson University, Philadelphia, PA, 19107, USA
ABSTRACT
The work of faculty on department committees is instrumental in accomplishing the goals of a school
of nursing. Using the Boyer Model of Scholarship as a backdrop, the Faculty Research and Professional
Affairs Committee at Jefferson School of Nursing, Thomas Jefferson University, Philadelphia, PA,
USA, identified three activities, journal clubs, department funding of research, and the sponsorship
of a visiting scholarly annually, to support faculty scholarship. Outcomes of implementing scholarship
activities are discussed.
Keywords: Nursing Faculty Scholarship, Nursing Faculty Research, Boyer Model, Journal Clubs
DOI Number: 10.5958/j.0974-9357.5.2.054
connections to be made across disciplines, and in our
case nursing specialties and organizations, helping to
create larger intellectual patterns for individuals and
the discipline(1,2). This principle was used to guide
decisions about the type of scholarly activity the
committee would champion. A third principle, the
Scholarship of Application, ties theory to practice.
Application is concerned with how new knowledge
can be used or applied beyond the walls in which it is
conceived(1,2). The committee sought to develop
scholarly activities that would encourage application
of findings to practice and teaching, and be useful to
SON partners. Finally, Boyer’s fourth principle, the
Scholarship of Teaching, supports the notion that
‘teaching is not about transferring knowledge but
transforming and extending it’(1 p.24). According to
Boyer(1), ‘good teaching requires faculty to be learners’
(p.4). Thus, the committee selected scholarly activities
to assist faculty in becoming well-read scholars, to
communicate effectively and be intellectually inspired,
thus having the capacity to transform and extend
knowledge into the classroom.
To create a culture of scholarship, the committee
was structured to promote generational equity and
included associate and assistant professors, and
instructors prepared at the master’s degree level.
Senior and junior faculty were viewed as equals;
committee decisions were made by consensus. Active
engagement of all committee members was
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encouraged to prevent isolated decision-making.
Given the detailed planning required for activities,
longevity in committee membership is encouraged
with most members serving a minimum of two years.
One member is elected chairperson at the beginning
of each academic year.
Meetings are held monthly throughout the
academic year; the meeting schedule is set at the end
of the previous academic year. At the beginning of
each academic year, goals are identified and/or
reviewed by committee members then approved by
the Associate Dean. Committee goals are designed to
dovetail with the overall vision, mission, and goals of
the school of nursing. While goals are revised annually
and include collaboration with community partners,
coordination of annual faculty awards and
participation in the accreditation process are additional
responsibilities. However, the committee’s main focus
is in promoting faculty participation in scholarship and
research. Three mechanisms identified to assist this
endeavor are: sponsorship of a visiting scholar, journal
clubs, and department research funding.
Visiting Scholar
The JSN in conjunction with a community
partner co-sponsors a visiting scholar, annually in
October. The scholar’s day budget includes money
for the scholar’s travel expenses, hotel
accommodations, food, and speaker fees or
honorarium, and an honorary luncheon. Money also
is budgeted for printing and mailing save the date
notices; invitations are mailed to SON faculty and co-
sponsors and partners approximately 2-3 weeks in
advance of the event. Invitees are requested to RSVP
at least one week before the event. Co-sponsorship
allows for pooling of resources thus reducing costs for
both agencies.
Identifying a visiting scholar occurs in the previous
academic year. The theme for the scholar’s day event
is most often suggested by the Dean of the School of
Nursing, and in accordance with the JSN and co-
sponsoring organization’s current goals; all JSN faculty
may participate in identifying a scholar speaker. Nurse
researchers having extensive leadership and research
backgrounds with clearly defined, progressive
research are considered. Speaker credentials,
specifically practice, teaching, research, and
scholarship expertise are evaluated by the committee.
After committee members perform a critical review
two or three top candidates are identified after which
a recommendation is made to the Dean of SON. After
the Dean’s approval, the chairperson or a designee
contacts the researcher to discuss availability, speaker
fees, and presentation content.
Journal Club
Originally, journal clubs were valued as means
of keeping abreast with the literature in the practice
setting. Recently, they have been used to promote
evidence based practice, critical appraisal of evidence,
social networking, and continuing education units or
credits(3). A notable pitfall had been low attendance
at these meetings.
Much has been written about the use and
effectiveness of journal clubs to promote scholarly
inquiry in academic medicine. A systematic review of
the literature by Deenadaylan, Grimmer-Somers, Prior,
and Kumar(4) provides insight into both the
effectiveness of and characteristics of successful journal
clubs. Likewise, Kleinpell(5) described key strategies
including the use of journal clubs to encourage nurse
participation in research. In the US, West Virginia
University School of Nursing in West Virginia, outlined
a format and guidelines for faculty journal club
presentations(5). Using this evidence, the faculty
research and professional affairs committee created a
faculty journal club. Because having a consistent
leader has been identified as important to the success
of journal clubs(3), one committee member was
designated to lead this scholarly activity.
As a committee, the first steps in the process were
to determine the frequency of which the journal club
would occur and then identify the day and time of
week most convenient for faculty participation.
Faculty teaching and clinical schedules were evaluated,
and the day of week selected based on the largest
number of faculty potentially available to attend.
Noting time as a precious commodity, the nature of
teaching schedules and availability of faculty, the
committee determined journal clubs would be held
on the same day each month, and at the same time
(during the lunch break) whereby faculty could eat
lunch while attending the meeting. Because journal
club was a new endeavor, during the first year of its
existence, members of the committee served as the
presenters; topics were identified each month,
advertised via posted flyers and e-mail notices.
Recruiting presenters was initially challenging but by
networking with faculty more became interested in
serving in a presenter role. Over time, the practice of
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 175
identifying presenters has changed so that
identification occurs at the end of the academic year
and the list of presenters and topics is finalized and
publicized at the beginning of the next academic year.
This new practice is extremely useful in that it allows
the presenter adequate time for presentation
development and for those interested in a particular
journal club topic the ability to plan attendance well
in advance.
In order to increase the number of presenting
faculty, the SON general faculty meeting recently was
used as a recruitment tool whereby the chair of the
committee discussed the purpose of the journal club,
approval processes, and presentation requirements. In
addition, committee members solicited individual
faculty members requesting they either present a
scholarly article of interest retrieved from the literature
or present their own publications or research. What
was most useful in recruiting presenters was
committee members’ knowledge of faculty interests
and current scholarly work. As the committee’s efforts
to promote scholarship evolved, those individuals
securing a department seed money grant to pursue
research became the next generation of presenters for
the monthly journal clubs. Individuals receiving
department funding present either an article from the
literature used in the evidentiary review of a proposal
or their own research.
A final step to promote faculty attendance at journal
club presentations was the inclusion of continuing
education credit (CEU). Journal clubs are one hour in
length and equivalent to one CEU. Working with an
affiliated clinical agency’s nursing education
department, and an approved provider of continuing
education, the committee was able to apply for and
obtain CEUs from a continuing education approving
body, the American Nurses Credentialing Center
(ANCC)(6). To receive CEU approval, application forms
for both the sponsoring agency and speaker/presenter
are completed and submitted to the ANCC. One
member of the faculty and professional affairs
committee works closely with the CE sponsoring
agency to ensure accurate and timely submission of
forms.
Seed Money
The introduction of the seed money grant has
proved to be an important mechanism in encouraging
faculty research. The Dean of the SON sponsors
research by including seed money as a line item in the
SON budget. The amount available for research varies
from year-to-year. Although the faculty research and
professional affairs committee does not have a role in
the budgeting process, it makes recommendations for
the amount of money to be awarded to faculty
applicants.
When charged with facilitating faculty research
funding, the committee began developing a clear
process for applying for a SON grant. A Powerpoint®
presentation was developed and a member of the
committee or a faculty member with a history of
successful application scheduled a presentation for
faculty. Slides were subsequently posted on the
committee’s website for future reference. The
presentation included the purpose of the seed money,
proposal requirements, timeline for proposal
submission, IRB, and dissemination requirements.
Proposal requirements are shown in Table 1. Initially,
the seed money process presentation was carried out
at the end of the fall semester and those interested
encouraged to submit a proposal within a few weeks
of beginning the spring semester. However, faculty
required more time to prepare a complete research
proposal and the presentation was changed to the
annual fall faculty meeting occurring at the beginning
of the academic year.
Evaluation and scoring of research proposals is
carried out by each committee member. Scores for each
criteria range between one and five, with a total score
calculated for all criteria ranging from six to 30. Table
2 shows evaluation and scoring criteria. Proposals are
discussed and scores are reported at a routinely
scheduled committee meeting, after which scores are
totaled for each criterion then averaged. All scores,
committee comments, and recommendations for
funding are made to the Dean of the School of Nursing.
Recommendations may be to fund the research or fund
pending clarification or revision. On occasion, a
recommendation not to fund the research but resubmit
the proposal in the next seed money proposal cycle
may be made. However, the final decision for funding
and the dollar amount rests with the Dean.
DISCUSSION
Effectiveness and success of the committee can be
measured in terms of goals met. Over time, the
number of seed money applications has grown from
two to seven per academic year. It is anticipated many
more research proposals will be submitted for potential
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176 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
funding as faculty have more leeway to develop a
proposal and or consult with committee members on
proposal development prior to submission deadlines.
Journal club presentations by faculty have remained
relatively stable since inception, with one faculty
member presenting monthly throughout the academic
year. However, since one of the requirements of
research funding is dissemination of findings,
recruiting presenters is easier. Moreover, developing
relationships with community partners has led to an
interest in hospital nurses attending faculty led journal
clubs and staff nurses presenting scholarly articles at
a hospital based journal club.
Annual sponsorship of a visiting scholar will
continue. While requiring much planning by the
committee, the benefits and rewards in supporting this
type of activity are many. One such reward is
formation of positive relationships between SON
faculty and community partners thereby extending
scholarship beyond the walls of academia.
CONCLUSIONS
The methods we identified and implemented to
encourage scholarship worked well to stimulate our
faculty’s participation in research. The use of one or
all of these mechanisms may be useful in stimulating
scholarship and research in other academic nursing
organizations. Added incentives such as tying these
activities to faculty evaluations and promotion
requirements may also be of value.
Table 1: Research Proposal Checklist
1. Evidence of completed IRB and
HIPPA training
2. Title
3. Author
4. Date of submission
5. Narrative
A. Objective/aim
B. Human Subjects protection via
IRB rules
C. Significance
D. Activity implementation
E. Timeline for completion
F. Methodology, design, sample,
data collection, analysis
G. Future research potential
H. Budget
I. Bibliography
6. Reporting
A written summation of utilization and outcomes at the
conclusion of the research.
Table 2. Seed Money Research Proposal Evaluation Rubric
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 177
Table 2. Seed Money Research Proposal Evaluation Rubric (Contd.)
ACKNOWLEDGEMENTS
The author wishes to acknowledge the service of
the members of the Faculty Research and Professional
Affairs Committee
Conflicts of Interest: None
Source of Funding: None
Ethics: Report does not involve human subjects and
does not require Thomas Jefferson University IRB
approval
_____Recommend ______ Recommend with revisions ____ Do not Recommend Comments: Total Score:____________
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178 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
REFERENCES
1. Boyer EI. Scholarship Reconsidered. Princeton:
The Carnegie Foundation for the Advancement
of Teaching, 1990.
2. Beattie D. Expanding the View of Scholarship:
Introduction. Academic Medicine, 2000; 75(9):
871-876.
3. Swift G. How to make journal clubs interesting.
Psychiatric Treatment, 2004; 10: 67-72.
4. Deenadayalan, Y., Grimmer-Somers, K., Prior, M.,
& Kumar, S. (2008). How to run an effective
journal club: A systematic review. Journal of
Evaluation in Clinical Practice, 14(5), 898-911.
5. WVU. West Virginia University School of
Nursing. Academic Faculty Practice - Journal
Club. [online] Available from: http://
nursing.hsc.wvu.edu/FacultyPractice/Journal-
Club [Accessed 13th September 2013].
6. ANCC. American Nurses Credentialing Center.
FAQ Contact Hours (CNE Credit). [online]
Available from: http://
www.nursecredentialing.org/Functional
Category/FAQs/AccreditationFAQs/Accred
ContactHoursFAQ [Accessed 13th September
2013].
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 179
INTRODUCTION
Worms are parasitic, soft bodied organisms that can
infest human and animals. Parasitic worms fall into
several different classes and includes flukes, hook
worms, round worms, tapeworms, whipworms, and
pinworms1. The parasitic infestations are acquired by
ingestion, inhalation or penetration of the skin by the
infective forms. Worm infestation remains one of the
main problems of child development2. The
roundworm that causes ascariasis enters the body in
unwashed or contaminated raw food3.
Awareness of Mothers of Under Five Year Children
Regarding Round Worm Infestation, its Prevention and
Management: A Descriptive Analysis
Mamatha G1, Munirathnamma K2
1Assistant Professor, Dept. of Medical Surgical Nursing, 2Assistant Professor, Dept. of OBG Nursing, JSS College of
Nursing, Mysore
ABSTRACT
Background: Ascarisis is common during pre-school period from 1-5 years of age when the child
begins to lay a more independent life. In India, intestinal parasites are the priority health problem
because of unhealthy practice, poor awareness, misbelieve, illiteracy of parents and poverty. Mothers
should essentially have the knowledge of early identification and prevention of worm infestation in
under five children. So that serious complications associated with intestinal helminthes such as protein
energy malnutrition, iron deficiency anemia, and Vitamin A deficiency can be prevented
Materials and Method: The descriptive survey approach was adopted. The population consisted of
mothers of under five children in Mysore. Purposive sampling was used to obtain the sample of 100
mothers in selected urban area of Mysore. A two-part questionnaire was used to collect the data. The
first part comprised information about mother's age, level of education, occupation, food habits,
previous exposure to mass media and health education. The second part contained 30 items about
prevention and management of worm infestation
Results: Majority (51%) of mothers belongs to 18 to 25 years of age and majority (45%) of them
studied up to high school and majority (93%) were homemakers and their (51%) family income of
Rs5000/-, 69% were belongs to mixed dietary habit and majority 93% and 79% had no previous
exposure to health education and mass media respectively.
Conclusion: Child care is mostly the responsibility of mothers. The study is undertaken to assess the
levels of mothers' knowledge regarding prevention and management of round worm infestation in
under five children and to determine whether there is any association between their level of knowledge
with age, level of education, occupation, and previous exposure to education information.
Keywords: Mothers' Knowledge, Round Worm Infestation, Under Five Children
DOI Number: 10.5958/j.0974-9357.5.2.054
The World Health organization estimates that
infection with round worm, hookworm, whip worm
associated morbidity affects approximately 250
million, 46 million and 151 million people respectively.
About half of the population in south India, and 50%
of school children in tribal areas of central India are
affected with ascaris lumbricoides, trichuris trituria
and hook worm. Almost half of the pre-school children
in India have a high prevalence of intestinal geo-
helminthus4.
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180 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Young children have a high infection rate and suffer
with a heavy worm burden of A. lumbricoides, Trichuris
trichiura and/or schistosomes. These parasitic infections
manifest themselves as reduced growth rates through
impaired nutrient utilization. Consequently the
children are not able to achieve their full potential in
physical performance and education. 4
It is great health hazard in developing countries In
India, more than 200 million children are infected with
roundworm, hookworm and whip worm; 60-80% of
population of West Bengal, Andhra Pradesh, Uttar
Pradesh, and Orissa is infected with worms. In low
and middle income countries about 1.2 billion people
are infected with roundworm and more than 700
million are infected with hookworm or whipworm5.
The incidence of intestinal helminthes in urban
children was 56.8%. While in rural, it was 79.2%.
Ascaris lumbricoid was the single pre dominant
species in both rural and urban population6.
Parasitosis is a major health problem in developing
countries. This is a major problem in places where safe
water supply and other sanitary facilities are lacking.
Population with low education and income families
are more prone to get this problem, because they do
not know about the disease, there transmission
methods and ways of prevention7.
The complications associated with intestinal
helminthes are impairment of nutritional status such
as protein energy malnutrition, iron deficiency anemia,
and Vitamin A deficiency. Although malnutrition is
now recognized as having many causes closely related
to socio economic factors, available evidence indicates
that several of intestinal helminthiases contribute to
the generation and persistence of malnutrition in
developing countries. Lower standard of personal
hygiene, indiscriminate defection and disposal of
excreta, low literacy, especially of mothers, lack of food
hygiene, improper storage of potable water coupled
with lower socioeconomic status have contributed
towards high rate of intestinal parasites8.
A study was conducted to gather the information
needed to design an integrated control program for
intestinal helminthes. Mothers were questioned about
their knowledge and perception of intestinal
helminthes, their hygienic habits and health-seeking
behavior. Almost all the respondents considered
worms harmful and were aware of the need for
treatment. More than adequate knowledge was present
on ways to prevent infection; good hygienic practices
were associated with a low prevalence of infection in
the household9.
From the above statistics and research studies it is
clear that there is a need to motivate and improve the
knowledge and practice of mothers of under five
children in communities on the prevention of worm
infestation and research studies also highlights the
importance of gathering information on mothers’
perceptions and behavior in the design and
implementation of a community-based intestinal
helminthes control program. Hence the investigators
were motivated to conduct the study.
OBJECTIVES OF THE STUDY
1. To determine the levels of knowledge of mothers
of under five children regarding round worm
infestation as measured by a structured knowledge
questionnaire.
2. To find the association between the levels of
knowledge of mothers of under five children
regarding round worm infestation and with their
selected personal variables
Hypothesis
H1 : There will be significant association between
the levels of knowledge of mothers of under five
children with their selected personal variables.
Findings
Part I: Sample characteristics
Table 1: Frequency and percentage distribution of
mothers of under five children according to their
selected personal characteristics N=100
Sl. Sample Frequency Percentage
No Characteristics (f) (%)
1 Age (years)
a. 18-25 51 51%
b. 26-30 35 35%
c. 31-35 6 6%
d. Above 35 8 8%
2 Educational Qualification
a. Illiterate 7 7%
b. Primary education 28 28%
c. High School 45 45%
d. PUC & Above 20 20%
3 Occupation
Home makers 93 93%
Coolie 1 1%
Others 6 6%
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 181
Table 1: Frequency and percentage distribution of
mothers of under five children according to their
selected personal characteristics N=100
Sl. Sample Frequency Percentage
No Characteristics (f) (%)
4 Income
a. < Rs 2000 36 39%
b. Rs 2001 – Rs 5000 51 51%
c. > Rs 5000 10 10%
5 Food Habits
a. Vegetarian 31 31%
b. Non-vegetarian 0 0%
c. Mixed 69% 69%
6 Previous Exposure to health education
a. Yes 7 7%
b. No 93 93%
7 Previous exposure to Mass media
a. Yes 21 21%
b. No 79 79%
The data presented in table 1 shows that Majority
(51%) of mothers belongs to 18 to 25 years of age and
majority (45%) of them studied up to high school and
majority (93%) were home makers and their (51%)
family income of Rs5000/-, 69% were belongs to mixed
dietary habit and majority 93% and 79% had no
previous exposure to health education and mass media
respectively.
PART II: Description of knowledge score of mothers
of under five children regarding prevention and
management of round worm infestation.
Table 2: Mean, median, standard deviation and range
of knowledge score of mothers of under five children
regarding prevention and management of round worm
infestation. N=100
Variable Mean Median SD Range
mothers of children 14.77 15 ±4.34 7-28
between 1- 5years
The data presented in table 2 shows that mean
knowledge score of mothers is 14.77 with SD ±4.34 and
median was 15.
Table 3: Frequency and percentage distribution of
mothers of under five children regarding prevention
and management of round worm infestation according
to their levels of knowledge. N=100
Level of Knowledge Frequency Percentage
Good 43 43%
Average 27 27%
Poor 30 30%
It is evident from the table 3 that majority (43%)
had good knowledge regarding prevention and
management of round worm infestation.
PART III
Table 4: Association between the levels of knowledge of mothers of under five children regarding prevention and
management of round worm infestation with their personal variable. N=100
Personal variables Levels of knowledge
Average Poor Chi square Level of
& Good value significance
Age (yrs)
a. 18-35 46 46 *2 NS
b. Above 35 6 2
Educational status
a. Educated 50 43 1.75 NS
b. Uneducated 2 5
Occupation
a. House makers 49 44 0.39 NS
b. Others 3 4
Family Income (Rs)
a. <5000 44 46 3.62 NS
b. > 5000 8 2
Food habit
a. Vegetarian 17 14
b. Mixed diet 3 34 0.13 NS
Yates correction p>0.05 t (59) =3.84
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182 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
It is evident from the Table 5 that there is no
significant association between levels of knowledge
of mothers of under five children regarding prevention
and management of round worm infestation with their
personal variable.
CONCLUSION
Awareness of worm infestation among the general
public is an integral part of prevention-oriented
approach. In view of high incidence of intestinal
parasitosis in the pediatric age group and the
complications due to these, steps need to be taken for
their prevention and prompt treatment, especially in
developing countries where malnutrition is co-
existent. Therefore gathering information on mothers’
perceptions and behavior related to child care helps
in the design and implementation of a community-
based control programs.
ACKNOWLDGEMENT
We express our thanks to mothers who participated
in the study and the authorities who provided
permission to conduct the study.
Conflict of Interest
The mother’s knowledge about child care
influences the nature and quality of care that is given
to the child.
The study revealed that, even majority of mothers
had good knowledge, more than fifty percentage
mothers had average and poor knowledge, signifies
the importance of involvement of health care personnel
and institutions in health care education.
Ethical Clearance: Ethical clearance was obtained from
the ethical committee of the college.
Funding Sources: Not obtained any funds from any
sources.
REFERENCES
1. Beers MH, Berkow R, The Merck manual of
diagnosis and therapy. NJ: Merck Research
laboratories; 2002.
2. Park K. Textbook of preventive and social
medicine. 18th ed. Jabalpur: Banarasidas Bhanot;
2005.
3. http://www.therealessentials.com/
parasites.html
4. Awasthi S, Verma T, Kotecha PV, Venkatesh V,
Joshi V, Roy S Indian Journal of Medical
Sciences.2008 Dec; 62(12): 484-491
5. Wong DL, Hockenberry MJ. Wong’s nursing of
infants and children. 7th ed. St. Louis: Mosby;
2003.
6. Dr.Ousepparampil J. Research in Ayurveda.
Health action, June 2004; (17):7.
7. www.who.int/water_sanitation_health/
takingcharge.html
8. Stephenson LS, Latham MC, Ohesen EA. Global
malnutrition parasitology; 2000
9. Curtale F, Pezzetti P, Sharbini AL, al-Maadat H,
Ingrosso P, Sad YS, Babille M. Knowledge,
perceptions and behaviour of mothers toward
intestinal helminthes in Upper Egypt:
implications for control. Health Policy Plan 1998
Dec; 13(4):423-32.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 183
INTRODUCTION
Job Satisfaction is one of the most widely explored
subjects in the area of Organizational Behavior and
Human Resource Management. Satisfied employees
are more productive and committed to their jobs,
whereas dissatisfied ones experience absenteeism,
grievances and turnover.1 There are five job
dimensions that represent the most important
characteristics of a job about which people have
affective responses. These are: The work itself, Pay,
Promotion opportunities, Supervision and
Coworkers.2
A Comparative Study on Level of Job Satisfaction among
Nurses in Government and Private Hospitals of Andhra
Pradesh, India
Gupta M K1, Reddy S1, Prabha C2, Chandna M3
1Assistant Professor, Institute of Health Management Research, Bangalore, 2Research Scholar, Institute of Medical
Sciences, Banaras Hindu University, Varanasi, 3Apotex, Bangalore
ABSTRACT
Objective: To find out and compare the level of job satisfaction among nurses in government and
private hospitals.
Method: A cross sectional design was adopted for this study in which 15 variables were chosen to
assess the level of job satisfaction using a five point Likert scale. Two hundred nurses (100 from
government hospitals & 100 from private hospitals) of Andhra Pradesh were interviewed using a
non probability sampling technique.
Results: Government nursing employees were more satisfied with their profession as well as salary
structure. Migration to gulf countries in future was disagreed by the nursing personals. This
disagreement was significantly (p <0.05) more strong among government nursing employees.
Conclusion: The level of job satisfaction is found to be more in case of government nurses as compared
to the private nurses.
Keywords: Job Satisfaction, Nurses, Hospital, Turnover
DOI Number: 10.5958/j.0974-9357.5.2.054
Corresponding author:
Manoj Kumar Gupta
Assistant Professor & Dean Research Coordinator
Institute of Health Management Research, Site No. 319,
Thimma Reddy Layout, Huli Mangla Village,
Electronic City, Phase I, Near Shikari Palaya, Bangalore
Phone: 9482301473
Email: drmkgbhu@gmail.com
Job satisfaction is an essential element for the
maintenance of the workforce numbers of any
organization. Unsatisfied workers report a higher
intent to leave which leads to high turnover rates and
have detrimental effect on the individual, like burnout
(a syndrome where the worker experiences emotional
exhaustion, depersonalization, and a reduced sense of
personal accomplishment).3, 4 Turnover provides the
organization with new ideas and is a normal process.
However, it does not need to be unnecessary and
excessive.5
The growth of managed care has had major
financial implications for health care delivery. One of
the major implications is the quality of care which is
directly affected by the quality of work life of patient
care personnel (nurses) and the level of satisfaction
they see in their jobs. Nurses play an important role in
maintaining the quality and cost of healthcare
industry.6 Healthcare organizations require a stable,
highly trained and fully committed nursing staff to
provide effective levels of patient care. Nurse’s job
satisfaction and organizational working environment
are found to influence hospital reputation and is
37. Manoj Kumar Gupta--183--188.pmd 1/6/2014, 9:30 AM183
184 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
positively linked to patients’ satisfaction and to quality
of care.7 Yet a growing shortage of qualified nurses
has led to a steady increase in the turnover rate among
nurses.8 Many hospitals are facing this significant
problem of nursing turnover which is a major issue
impacting the performance and profitability of
healthcare organizations.9 So it is necessary that their
needs have to be taken care and a congenial
atmosphere is created for them to work with utmost
job satisfaction and content, the result of which would
be a high quality nursing care.10
With this background this study has been planned
with the following objective.
OBJECTIVE
To find out and compare the level of job satisfaction
among nurses in government and private hospitals.
METHOD
Period of study: This study was conducted for a
period of 2 months. Initial 2 weeks were utilized for
extensive literature search and designing and
finalization of interview schedule. Next one month was
utilized for data collection, data entry and quality
check. Data analysis and write up were done in last
two weeks.
Study design: A cross sectional study design was
adopted for this study.
Sampling methodology: A hypothesis had been
formulated to check the difference in level of job
satisfaction and attitude of nursing employees for their
job in private and government hospitals. It is an
analytical type of research where data has been
collected from nursing staff of 2 government & 2
private hospitals of Andhra Pradesh, with the help of
a reliable and validated questionnaire. A sample of 200
Nurses (100 from government hospitals & 100 from
private hospitals) has been drawn using a non
probability convenience sampling technique. A sample
size of 200 was targeted due to limited resources, such
as limited amount of time, and budget constraints.
Fifteen variables were included to assess the
attitude and level of satisfaction towards their job. A
five point Likert type scale has been used in the
questionnaire to measure Job Satisfaction of nurses,
where the scale rates 5 for strongly agree (SA), 4 for
agree (A), 3 for neither agree nor disagree (NAD), 2
for disagree (D) and 1 for strongly disagree (SD).
Analysis of data
Data thus generated was analyzed using Microsoft
excel 2007 and SPSS v.16 software. Since the data is
primarily categorical in nature (5-point Likert scale),
nonparametric (Mann-Whitney U) test are adopted to
test the hypotheses.
RESULTS
Table 1: Descriptive statistics for the variables used in the study
S. No. Factors Median Mode Range IQR
G* P* G* P* G* P* G* P*
1. Profession is satisfactory 5 5 5 5 1 1 0 0.75
2. Salary is satisfactory for the kind of work 4 3 4 3 3 4 1 1.75
3. Leave permission/granting procedures are satisfactory 4 3 4 3 3 4 0 1
4. Getting satisfactory benefits (accommodation, 4 3 4 3 3 4 0 1
food, and incentives)
5. Hospital have satisfactory personal welfare and 4 3 4 3 3 4 0 1
grievance resolution activities
6. Feel proud to work in this hospital 4 4 4 4 2 3 1 0
7. There is Job security 5 3 5 3 1 3 0 0.75
8. Time bound promotion is job motivator 5 4 5 4 1 4 0 1
9. Rotational shifts disturb personal life 4 4 4 4 3 3 1 1
10. Free to discuss any problem with the management 4 4 4 4 4 3 1 0
11. Supervisors and colleagues are supportive 4 4 4 4 3 3 0 0
12. There is more clerical work to do than the regular work 3.5 3 4 4 4 4 2 2
13. High starting salary is the sure fire way to improve 4 4 4 4 2 2 1 1
employee retention
14. Various in training sessions are beneficial 4 4 5 4 3 3 1.75 1.75
15. Interested in going to gulf countries 2 3 2 3 3 4 1 1.75
G*- Government Hospitals, P*- Private Hospitals, IQR- Inter Quartile Range
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 185
Table 1 show the descriptive statistics in terms of
median, mode, range and Inter Quartile Range of score
of the variables which were assessed in the study both
in Government as well as Private Hospitals.
Table 2: Level of job satisfaction among nursing employees.
S. No. Factors Mean Mann- P
Score Whitney U value
Govt. Private
Hospitals Hospitals
1. Profession is satisfactory 4.82 4.75 4650 0.229
2. Salary is satisfactory for the kind of work 3.68 3.35 4170 0.034
3. Leave permission/granting procedures are satisfactory 3.89 3.43 3320 <0.01
4. Getting satisfactory benefits (accommodation, food, and incentives) 3.91 3.28 2781 <0.01
5. Hospital have satisfactory personal welfare and 3.9 3.48 3876 0.004
grievance resolution activities are
6. Supervisors and colleagues are supportive 3.98 3.93 4829.5 0.634
7. Feel proud to work in this hospital 4.25 3.92 3725 <0.01
Table 2 shows that the nursing employees who were
working in government hospitals were found strongly
satisfied towards profession compared to employees
who were working in private hospitals, but this
relation was not statistically significant. In comparison
to private hospitals, nursing employees who were
working in government hospitals were significantly
(p <0.05) more satisfied with the salary which they
were getting for the kind of work, the leave
permission/granting procedures of the hospitals, with
the benefits viz. accommodation, food, and incentives
which they were getting and with the personal welfare
and grievance resolution activities of the hospital.
Supervisors and colleagues were felt supportive both
by government as well as private hospital nursing staff.
Government nursing employees had significantly (p
<0.05) more proud to work in the hospital as compared
to private hospital employees.
Table 3: Attitude of nursing employees for their job.
S. No. Factors Mean Mann- P
Score Whitney U value
Govt. Private
Hospitals Hospitals
1. There is Job security 4.84 3.15 450.0 <0.01
2. Time bound promotion is motivator 4.94 3.58 880.0 <0.01
3. Rotational shifts disturb personal life 3.44 3.68 4356 0.095
4. Free to discuss any problem with the management 3.62 3.9 4435 0.111
5. There is more clerical work to do than the regular work 3.14 3.08 4870 0.736
6. High starting salary is the sure fire way to improve employee retention 3.68 4.22 4888 0.751
7. Various in training sessions are beneficial 3.98 3.9 4775 0.560
8. Interested in going to gulf countries 2.45 2.98 3380 <0.01
Table 3 shows attitude of nursing employees for
their job. Sense of job security was significantly (p
<0.05) more among government nursing employees
and their consideration for time bound promotion as
a strong motivator for job was significantly (p <0.05)
strong as compared to private hospital employees.
Migration to gulf countries in future was disagreed
by the nursing personals. This disagreements was
significantly (p <0.05) more strong among government
nursing employees. Although compared to
government hospitals, private hospital nursing staffs
were freer to discuss any problem with the
management, yet they perceived more disturbance of
personal life due to frequent rotating shifts in hospitals.
Majority of private as well as government hospital
nursing employees had shown neutral response for
the load of more clerical work to do than the regular
work. High starting salary was considered as the sure
fire way to improve employee retention by all nursing
staff irrespective of government or private setup.
Government nursing staffs had comparatively strong
belief in getting benefits through various training
sessions conducted in hospital as compared to private
hospitals nursing employees.
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DISCUSSION
In the present study it was found that variety of
factors acts as the job motivational and de-motivational
factors for nursing employees. Those factors affect their
dedication regarding professional behaviour and can
turn them to find out some alternate ways of job
satisfaction. Study conducted by Chen Ai-Hong
(2012)11 reveals that, overall, nurses were relatively
more satisfied in terms of supervision, the nature of
the work, and communication, but were less satisfied
with operating conditions among the 9 facets of the
Job Satisfaction Survey scale considered within the
profession.
In previous studies12-15 nurses identified
tremendous workloads as the leading cause of
dissatisfaction with their job, followed by poor staff
cohesiveness, poor staffing, and poor working
relationships with administrators.
In this study Government nursing employees were
more satisfied with their profession, salary structure,
leave granting procedure of the hospital, benefits
which hospital administration has provided to them,
personal welfare and grievance resolution activities of
the hospital, supportive nature of supervisors and co-
workers and so they were feeling proud to work in
the hospital and showing less interest in migrating to
gulf countries as compared to private hospital nursing
employees. Beside that they have better feeling of job
security, consider time bound promotion as job
motivator and have feeling that various in training
sessions are beneficial. These findings are in
accordance with the findings of Patil SB (2011)16, who
found that nurses of Government hospitals are more
satisfied with their salary benefits, the chance of
promotion, training and continue education than the
nurses of private hospitals. He also indicateed that the
working conditions should be improved in private as
well as government hospitals. Park .M, Jones B. C
(2010)17 in their study stated the importance of
orientation programs among nursing employees and
suggested that the orientation programs were
successful in improving their confidence in caring for
patient and in enhancing their competencies such as
knowledge and critical-thinking skills in the clinical
environment. By doing so, these programs encourage
new graduates to stay in the organization.
Nursing employees in private hospitals have
feeling that starting salary should be high to improve
employee retention. They were feeling disturbance in
personal life due to rotational shifts in the hospital.
Although they were freer to discuss any problem with
the management and they have less clerical work to
do, yet they were showing more interest in going to
gulf countries as compared to government hospital
employees. Sharma SK et al. (2009)18 compared attrition
rate among public and private hospitals and found that
the attrition rate was higher in private hospitals as
compared to government hospitals and also found that
possible causes for nurses to leave the hospital are
lucrative job opportunities ,high salaries ,better quality
of life and also recognition of their profession.
According to Laschinger et al. (1997)19 access to more
and better information for nurses can be obtained
through formal and informal communication channels
among nurses and the management team.
Communication mechanism available in the
government hospitals are poor than those in private
hospitals.16
CONCLUSION
There are many factors that contribute to
satisfaction as well as dissatisfaction in the work place.
According to the study conducted nurses from both
the sectors seemed to be quite satisfied from their jobs.
However the level of satisfaction is found to be more
in case of government nurses as compared to the
private nurses but at the same time there are certain
factors on which private nurses are more satisfied. This
type of research could help hospitals to understand
the close connection between nurse’s job satisfaction
and quality of patient care, which in turn improve
health care system in the society. Thus in order to
increase the level of job satisfaction among nurses
hospital management should provide rationalize
compensation and promotion policy, establish
grievance redressal forums and must provide more
and more professional growth opportunities.
LIMITATIONS OF THE STUDY
1. The study was restricted to the nurses working in
Andhra Pradesh only. These views may not be
attributed to the nurses of the whole country
because of economic, social and cultural
differences in the attitude and preferences.
2. Due to constraints of resources, the study is limited
to small sample size i.e. only 200 nurses.
3. The data was obtained through questionnaire (5-
point Likert scale) which has its own limitations.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 187
ACKNOWLEDGEMENT
This work would not have been possible without
the support of Dr Dhirendra Kumar (Director IHMR-
Bangalore).
Conflict of Interest: None
Source of Funding: Self funded
Ethical Clearance: The study does not have any
intervention so ethical clearance is not necessary.
However, at the outset the hospital Medical
Superintendents (MS) were contacted and explained
about the purpose of the study.
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INTRODUCTION
Many of today’s nursing students are tech savvy
yet easily bored. They have grown up with computers,
cell phones, twitter and Facebook. This technology has
created a fast-paced, changing learning environment.
Helping students stay focused and actively involved
in their education can be a challenge. This article
describes our integration of a modified flipping/
reverse instructional approach with a generic
baccalaureate program student body aged 18-30 years
of age.
Nursing is an applied profession requiring learners
to comprehend, analyze and apply content in varying
patient situations2. Students typically have on-campus
lectures and practice labs (often involving high fidelity
simulators) as well as actual clinical experiences with
patients. It is virtually impossible to expose students
to every possible patient situation. Some patient
experiences are not safe for students because of acuity
and others are rarely found in hospitals. Yet new
graduate nurses are expected to respond accurately
and effectively upon hire to the patient care
environment.
Engaging Millennial Nursing Students To Bring Theory
Into Practice
Margarett S Alexandre
Assistant Professor, York College, CUNY, Nursing Program, 94-20 Guy R Brewer Boulevard, Jamaica, NY 11451
CUNY Graduate Center, 365 Fifth Avenue, New York, New York 10016
ABSTRACT
Reverse instruction/flipping, is an innovative method of teaching that promotes an atmosphere of
active learning. Originally this technique was used in secondary education to teach science and math1.
This method of teaching keeps students on track and engaged in learning. This article describes a
pilot- modified flipping/ reverse instructional approach with generic baccalaureate program students,
between the 18-30 years of age. Reversing/flipping the typical classroom students, to keep students
engaged required them to read, watch videos and podcasts at home. Class time was used for tackling
difficult problems, working in groups, analyzing, applying, researching, and collaborating. The results
revealed students were satisfied with the reverse instruction/flipped approach. They were able to
share their lecture content with each other in an active learning environment.
Keywords: Student Engagement, Teaching Modality, Innovations In Education, Nursing Education
DOI Number: 10.5958/j.0974-9357.5.2.054
Reversed /flipped classroom
Flipping involves reversing traditional lectures
with homework assignments and having students’
complete assigned reading, for lecture content prior
to class1. In this approach, students can watch and
listen to your lectures via Camtassia or podcast at home
before the class. Students access this content at a time
and place that is most convenient for them. This allows
the very limited class-time be used for tackling difficult
problems, working in groups, analyzing, applying,
researching, collaborating, and creating.
But most importantly class time is used for faculty
to be more engaged with the students. Reversing the
typical classroom order involves preparing for class
with technological support and being actively involved
in one’s own learning. It requires students to read,
watch videos and podcasts, access online lectures
which the professor has posted, prior to class time.
Therefore, class time is used to bring theory to practice.
The Educase Center for Applied Research3, reports that
students much prefer blended learning environments
combining technology and traditional face-to-face
educational strategies.
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One reported benefit 2 of flipping is that the
theoretical/lecture-based component becomes more
easily accessed and controlled by the learner. Students
come to class ready to discuss challenging content and
expand their understanding in advanced activities. For
example, students typically use phones and I-pods
during these activities; to quickly access information-
definitions, lab values, videos of online procedures.
These technological supports are great assets,
especially for some of the visual learners. Students can
also review content that is difficult to understand; or
that need further reinforcement; as well as those that
are of particular interest the learners.
The reverse/flipped learning approach allowed us
to create classrooms focused on actual patient
experiences, and yet ensure that the content delivery
is preserved. The students have greater autonomy and
are more vested in their learning, by taking an active
role. They can listen multiple times to the content at
home, while jogging, driving and come to the
classroom better prepared. Both the Carnegie report:
“Educating Nurses: A Call for Radical
Transformation”2 and the Institute of Medicine report,
“The Future of Nursing: Leading Change Advancing
Health”4, stress the need for re-evaluating current
nursing education to ensure that future nurses are
prepared to manage the rapidly changing healthcare
environment. Rather than overloading students with
all the facts related to new technology, medications,
treatments; educators should also focus on helping
them critically analyze information and apply what
has been learned in a variety of clinical scenarios. New
graduate nurses need to be able to communicate with
other health team members in a concise, succinct
manner; recognize how and where to access needed
information; and make sound clinical judgments.
Utilizing the reversed/flipped classroom gives the
students an arena to start making those key clinical
judgments.
Literature review
Most of the literature related to flipping is focused
on its use with elementary and high school students
and much is anecdotal. Specific comments include:
students displayed a more comprehensive
understanding of course content; and increased
student- teacher connectedness derived from the use
of class time to complete assignments, homework, and
group activities during class time. Faculty who have
used flipping were interviewed and their evaluation
of its effectiveness was very positive 5. Many faculty
members noted that outsiders may view their classes
as chaotic and unfocused; there is however
demonstrable learning and greatly increased
interactions: both student-to-student and faculty-
student. Suggestions to manage these issues include
the use of clickers, short quizzes and other strategies
to evaluate students’ comprehension of the pre-class
assigned readings and podcasts at the start of the
flipped session5.
Another benefit of flipping is that it allows for
immediate recognition of students’ difficulties and
instructor feedback in the classroom before
examinations and also relays that the recent move to a
focus on education outcomes has sparked interest in
using flipping; and economic pressures make more
productive use of classrooms an imperative 6.
Another suggestion is for faculty to review student
postings on discussion boards and blogs so that the
flipped session can target challenges and difficult
content. Creating a cloud-based interactive system-
allows faculty to create in-depth questions for use in a
flipped session. The system analyzes the student
responses, via their phones and other handheld
devices. The intent is then that faculty can develop
appropriate assessment tools. An additional benefit of
this system is that faculty can access other teachers’
questions since it is cloud-based 3,5.
Students who are absent from a class session can
use these podcasts, pre-class discussion blogs and
postings, and other learning activities. This reduces
the burden on faculty to re-teach content1. Additionally
these materials can be used by students to prepare for
exams and review prior to starting more advanced
classes.
Another author notes that the flipped class can
promote a learner’s ability to adapt to changing
problem situations 7. This is really important since it is
impossible to provide every possible situation,
especially in nursing. Faculty who are considering the
use of flipping should be cognizant that much of the
reports in the literature are anecdotal. Thus, when
planning to use this concept begin with a small
percentage of class time initially. It should not take over
the entire semester 8.
METHOD
Impact on the nursing students
Our experience at CUNY York College occurred as
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a result of the recent super storm Sandy. The campus
was closed initially because of a lack of power and
transportation; this shut down continued because the
school sheltered more than 800 persons displaced by
the storm. Some nursing faculty chose to contact
students via Blackboard and provided videos,
readings, and pre-class activities so the students would
arrive at the next class prepared.
Blackboard, a course content program used in many
schools, has a downloadable app so users can access
content through cell phones and tablets. Because it
remains available, students can also re-access before
exams; as a review for future lectures; as often as they
wish. Technology is readily available for faculty to
create podcasts of lectures for students. The lecture
becomes homework in preparation for the real work
of applying the content in a variety of situations, such
as role play, development of concept maps or group
discussion. Class time can use case studies,
simulations, 3D scenarios; group work and other
strategies to help students think through, reflect,
collaborate, debate, and create solutions.
Reversed/flipping and millennial students
Nursing traditionally uses case studies; often
assigned as homework. Some students excel at solving
these scenarios, while others have more difficulty.
Using a flipped class model, faculty can guide students
through the process and ensure that all are involved
in decision-making and focus on priority setting.
Students also become more actively engaged and
responsible for their own learning. Philosophically,
students come to class to share the knowledge rather
than find answers.
The so- called millennial populations have grown
up with constant access to technology and use it daily
to socialize, study, research, and practice. These
individuals were born from the middle 1980s to today.
They are adept with the use of technology; do not fear
its use; and feel free to “fail forward.” 9
The Pew Research Center 10 reports that these
individuals spend ten hours or more online daily and
view the world as interconnected. They are further
described as very confident of their own capabilities
and adaptable. Their technology use is both social and
educational. We view this to be a strength that can be
exploited in promoting collaborative, interactive
learning. Recognizing that our generic student body
was very involved with social media and technology
we chose to incorporate this in our educational
approaches.
Sample/Setting
A cohort of generic baccalaureate program student
body aged 18-30 years of age, in their third year of the
nursing program. Medical/surgical lecture course time
was used for the pilot during the spring semester.
Procedure
We looked at the course syllabus and created
videos, uploaded YouTube videos, and quizzes to
supplement the assigned readings. The students were
divided into four small groups and were tasked to
analyze problems. One example topic was of
preoperative education for a patient undergoing a
permanent pacemaker insertion. Pre-class readings,
videos, quizzes, were expected to be completed.
Various tools, such as, short quizzes, clickers, case
studies and development of caremaps; were used to
evaluate the pre-class assignments.
Completions of assignments prior to class were
tracked for all students. Class time was spent for
clarification, question and answer. Each group was
assigned a patient; for whom a profile had to be created
and presented to the other groups. This proved to be
an example of learning in context, at the same time
providing the opportunity for them to develop critical
thinking/ reasoning process. Prior to exams, the
students came with questions for additional
clarification. These questions were often combined into
an electronic game that they would use their phones
to log in to answer.
DATA COLLECTION
Students were required to complete all the pre-class
exercises, quizzes and assignments were compared
with post-class performances of all the students. The
students’ evaluation of the weekly course contents
were also collected for satisfaction/dissatisfaction and
suggestions.
DATA ANALYSIS
Students were required to complete all the course
assignments as part of the course requirement. Course
exam scores were also analyzed, throughout the
semester. Students were given the opportunity to
evaluate each of the assignments presented. While this
approach was new to the students, initially some of
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them were not very willing participants. They
verbalized that they did not like it at first, but as time
went by they did verbalize that it was helpful,
especially in the clinical area. Utilizing the reversed/
flipped approach helped them to think critically. Some
of the students, verbalized feeling more confident
when taking exams and in the clinical area.
Nursing Implications
When the reverse instruction class concept was
used with a group of younger generic students, it
proved to be extremely beneficial. The students
initially resisted their need to be better prepared for
class but soon became engaged with the use of
technology and each other in collaborative activities.
They participated more in class discussions. Many of
the theoretical concepts in the text came to life in their
discussions, and presentations. Even the initially quiet
students became engaged in the discussion groups and
classroom presentations. This was the first time that
the reversed/flipped approach was used in our
nursing program. While the traditional classroom is
still in place in some of our courses, it is important to
introduce the students to a variety of learning
modalities that can help them succeed in the program
and the profession.
RESULTS
Our results were very positive: students reported
that they were very satisfied with the reverse
instruction/flipped class; they were able to share some
of their experiences from their various work
backgrounds in the discussions. But more importantly,
we had one hundred percent pass rate in the course.
All the students evaluated the course as a positive
experience in their learning.
Another result we found in an increase in dialogue
among students and faculty. Students become engaged
in the classroom activities especially if they are in small,
interactive groups that are tasked with analyzing and
solving problems. Table 1 offers suggestions for
implementation.
CONCLUSION
Should reverse instruction replace typical nursing
education classes? No, but it can be a valuable strategy
especially with today’s tech-savvy nursing students.
Our next steps will be to use this technique with our
older, more traditional RN completion nursing
students. We plan to survey these students as well as
compare course grades and clinical evaluations with
a fuller interjection of this technique in our curricula.
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Table 1: Suggestions for implementation (Contd.)
Table 1: Suggestions for implementation
Conflict of Interest Statement: Margarett S. Alexandre
has no conflict of interest to disclose and have received
no financial support.
I am submitting the article to the International
Journal of Nursing Education and have not submitted
to any other journal. Margarett S. Alexandre.
Acknowledgement: None
Source of Funding: There was no funding used for
this project.
Ethical Clearance: I do not have an actual or potential
conflict of interest relative to this article. This article is
original and has not been submitted elsewhere for
publication. We Do Not have a financial interest/
affiliation with one or more organization that could
be perceived as a real or potential conflict of interest
or ethical conflict relative to this article.
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INTRODUCTION
Schizophrenia impairs self awareness for many
individuals so that they do not realize they are ill and
in need of treatment. Schizophrenia affects about 7 per
thousand of the adult population, mostly in the age
group 15 – 35 yrs 8. Though the incidence is low (3 -
10000), the prevalence is high due to chronicity. Though
its common the disorder has been diagnosed in
children as well, approximately 75%of persons
diagnosed as having schizophrenia develop their
clinical symptoms between the age of 16 and 25 yrs.
schizophrenia usually appears earlier in men , in their
late teens or early twenties, than in women, who are
generally affected in their twenties or early thirties1
Effective intervention strategies are available and
the cost of treatment of a person suffering from chronic
schizophrenia is about 500 per month; the quaint
essential principle being “earlier the initiation of
treatment, better the efficacy the earlier the treatment
is initiated, effectiveness will be more. However,
majority of the persons with chronic schizophrenia do
Effectiveness of Occupational Therapy on Symptoms of
Schizophrenia
Minnu Prasad1, Nalini M2
1Msc Nursing 2nd year, 2Associate Professor and HOD of Psychiatric Nursing, Nitte Usha Institute of Nursing
Sciences, Nitte University, Mangalore, India
ABSTRACT
Schizophrenia is a group of psychotic disorders that interfere with thinking and mental or emotional
responsiveness that last longer than 6months. It affects about 24 million persons worldwide. Due to
this, a study was undertaken in selected hospitals of Mangalore with an objective to assess the
effectiveness of occupational therapy on symptoms of schizophrenia. Using purposive sampling
technique 30 subjects were undertaken for the study. Scale for assessment of negative symptoms
(SANS) was used to assess the symptoms of schizophrenia in schizophrenic clients. Statistical analysis
revealed that more than half of subjects (53.4%) were within the age group of 21-40years.Both males
and females constitute 5o%. About 46.6% of the subjects were married and with lower socio economic
status.43.4% were Hindus.36,8% of the subjects completed primary school education. About 40% of
the subjects resides in urban area. Majority of the subjects 60% were diagnosed with paranoid
schizophrenia. Nearly half of the subjects 63.3% were not on regular medication. Highest percentage
of subjects 70%were hospitalized before. Finding reveals that occupational therapy was not effective
for negative symptoms of schizophrenia. The calculated t valve (0.942) was lower than the table
value (2.05) at 0.05 level of significance
Keywords: Occupational Therapy, Symptoms of Schizophrenia, Schizophrenic Clients, Effectiveness
DOI Number: 10.5958/j.0974-9357.5.2.054
not receive treatment, which contributes to the
chronicity of the disease2
There are different methods to treat schizophrenia,
such as drug therapy, psychotherapy. A variant method
derived from the research is known as occupational
therapy. This treatment focuses on helping patients in
achieving independence in all areas of their lives. The
concept of this method involves proper guidance and
support to patients in doing certain activities that allow
them to learn new skills. This also focuses on assisting
patients in practicing positive ways to focus on their
self-improvement.it provides a creative outlet to
patients in opening the doors to some greater
recoveries, self improvements, and increased
confidence1.
The occupational therapy helps the patients to
work through all the steps by taking the time and
concentration on learning new skills. This process can
enable them to practice new skills, for instance,
frustration tolerance and gaining self-confidence while
participating in leisure activities. Of important to let
39. Minnu Prasad--195--200.pmd 1/6/2014, 9:31 AM195
the patients feel better about themselves and their
abilities through this therapy. The program makes the
patients feel productive and take pride in their efforts2.
A program in occupational therapy
promotes positive attitude and belief in self; it
establishes awareness for sufferers that they can handle
and resolve problems by adapting a step by step
procedure; and it also brings help to the loved ones of
patients2.
At present, a number of methods are
in use there are different methods used by experts to
apply occupational therapy on schizophrenic patients.
It usually involves valuable pursuits wherein they can
develop new skills while establishing other positive
attributes that would help them in coping with their
mental condition. All activities involved in the
program are designed to help patients in maintaining
an active mind and restoring normal functioning. By
participating in these activities, patients can nurture
their minds in a positive and enriching way2
Although schizophrenia is a treatable disorder
more than 50% of persons with schizophrenia do not
receive the appropriate care due them. Recent statistics
indicate that about 90% of the population with
schizophrenia resides in developing countries.
Therefore Care for such individuals can be provided
at the community level, with active family and
community involvement
METHODOLOGY
A Pre experimental research approach was used
for this study. The main goal of the study was to assess
the effectiveness of occupational therapy (embroidery
in which running method) on symptoms of
schizophrenia in schizophrenic clients. The population
for the study female and male patients with negative
symptoms of schizophrenia who are admitted in
psychiatry ward in selected hospitals in Mangalore.
Purposive sampling method was used to collect 30
samples, and convenient sampling for selecting the
hospitals. The researcher developed -demographic
proforma for collecting information from subjects, and
symptoms of schizophrenia was assessed using –
SANS. Demographic proforma has 11 items and SANS
has 5 items and each had a score 0, 1,2,3,4,5,the score
were interpreted as o-not at all. 1-questionable
decrease, 2- mild, 3- moderate,4- marked, 5- severe.
The tool was developed by Nancy C Andersen. Using
intra class correlations coefficients reliabilities ranged
from 0.83 to 0.92 ,Internal consistency for the total
scores was .90 for the SANS. The samples for
interventional group were selected based on the
inclusion criteria and assessed the symptoms of
schizophrenia in those subjects then Occupational
therapy (embroidery in which running method) is
given to schizophrenic clients for 12 hours weekly for
30 days. Symptoms were assessed after occupational
therapy using SANS .Finally data was analysed using
frequency percentage, paired t test, and fishers exact
test.
FINDINGS
1 . Majority of subjects 53.4% were within the age
group of 21-40yrs Both males and females
constitute to 50%. about 46.6% of the subjects were
married and with lower socio economic
status.43.4% were Hindus.36,8% of the subjects
completed primary school education. About 40%
of the subjects resides in urban area. Majority of
the subjects 60% were diagnosed with paranoid
schizophrenia. Nearly half of the subjects 63.3%
were not on regular medication. Highest
percentage of subjects 70%were hospitalized
before.
Table 1: Distribution of Sample n= 30
Demographic Variables Frequency Percentage
Age
Less than 20 years 0 0
21-40 years 15 53.4
41-60 years 14 46.6
More than 61 0 0
Gender
Male 15 50
female 15 50
Marital Status
Married 14 46.6
Unmarried 4 13.4
Widow/widower 3 10
Separated 5 16.6
Divorce 4 13.4
Religion
Hindu 13 43.4
Christian 9 26.6
Muslim 8 30
Others - -
Socio Economic Status
Lower class 14 46.7
Middle class 10 33.3
Upper class 6 20
39. Minnu Prasad--195--200.pmd 1/6/2014, 9:31 AM196
Table 1: Distribution of Sample n= 30 (Contd.)
Demographic Variables Frequency Percentage
Education
Illiterate 0 0
Primary school 11 36.8
High school 9 30
Puc/diploma 5 16.6
Pg/graduate 5 16.6
Residence
Urban 12 40
Rural 8 26.7
Semi urban 10 33.3
Type of Schizophrenia
Paranoid 18 60
Residual 0 0
Hebephrenic 0 0
Undifferentiated 5 16.7
Catatonic 0 0
Schizo affective 7 23.3
Disorganized 0 0
Duration
Acute 4 13.3
Chronic 22 73.4
Semi acute 4 13.3
On Regular Medication
Yes 11 36.7
No 19 63.3
Previous Hospitalization
yes 21 70
no 9 30
2. 100% of subjects have no unchanging facial
expression, Paucity of expressive gestures
Affective non responsivity, Lack of vocal
inflections, Inappropriate affect, Global rating of
affective flattening, Blocking Increased latency of
response Global rating of alogia, Physical anergia,
Global rating of apathy, Global rating of attention,
global rating of asociality.
Majority of subjects 73.3% have no decreased
spontaneous movements, 6.7% have mild, moderate,
severe symptoms, 3.3% have marked symptoms.
Majority of 63.3% have no poor eye contact 13.3%
have severe symptoms.
53.3% of subjects have no poverty of speech, 16.7%
have mild symptoms, 13.3% have severe symptoms,
3.3% have marked symptoms rest have6.7% have
moderate and questionable decrease in symptoms.
In poverty of content of speech, majority of subjects
have 73.3% no symptoms, 16.7% have moderate
symptoms, 6.7% have severe symptoms, 3.3% have
mild symptoms.
50% are not maintaining grooming and hygiene ,
16.7% have mild, 13.3% have questionable decrease,
6.7% have moderate, marked, severe symptoms.
Majority of subjects reveals that 63.3% have no
impersistence at work or school, 13.3% have moderate
symptoms, 10% have marked symptoms, 6.7% have
severe symptoms, 3.3% have mild and questionable
decrease symptoms.
70% have no recreational interests and activities,
13.3% have mild ,6.7% have severe.
Highest percentage of subjects 96.7% have no
sexual interests and activities, 3.3% have marked
symptoms.
96.7% have no Ability to feel intimacy and
closeness, 3.3% have mild symptoms.
70% have not maintaining relationship with friends
and peers 3.3% have severe symptoms, rest 6.7% have
mild moderate, marked symptoms
In social inattentiveness 10% have mild social
inattentiveness and 6.7% have moderate social
inattentiveness. Highest percentage of the subjects
83.3% have no social inattentiveness.
53.3%have no inattentiveness during MSE 16.7%
have severe inattentiveness during MSE, 10% have
questionable decrease and rest 6.7% have mild
moderate, marked inattentiveness during MSE.
3. Effectiveness of occupational therapy on
symptoms of schizophrenia was analyzed by
“paired t test . The results revealed that the mean
post test score of the subjects by rating
scale(11.133) were significantly higher than pre
test score( 10.90) of the subjects. The calculated t
valve (0.942) was lower than the table value (2.05)
at 0.05 level of significance. The result showed in
this study was that occupational therapy was not
effective for negative symptoms of schizophrenia..
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198 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Tab 2: Paired‘T’ test value between the Pre test and Post test scores of the Subjects by sans to assess the
occupational therapy and symptoms of schizophrenia n=30
Mean sd t value df P value
Pre test 10.90 4.543 0.942 29 0.354
Pos test 11.133 4.240
t29=2.05 p<0.05 level
4. The effectiveness of occupational therapy in
affective flattening/ blunting showed that the
mean post test score of affective flattening/
blunting by SANS scale (2.23), were significantly
higher than the pre test score (2.0) of the subjects.
The calculated t value (1.56) was lower than the
table value (2.05) at 0.05 level of significance. The
results showed that occupational therapy was
found to be not effective in negative symptoms of
schizophrenia( affective flattening/ blunting)
Effectiveness of occupational therapy in alogia
showed that the mean post test score of alogia by SANS
scale (1.06), were significantly higher than the pre test
score (1.0) of the subjects. The calculated ‘t’ value (0.34)
was lower than the table value (2.05) at 0.05 level of
significance. The results showed that occupational
therapy was found to be not effective in negative
symptoms of schizophrenia(alogia)
Effectiveness of occupational therapy in apathy
showed that the mean post test score of apathy by
SANS scale (1.36), were significantly higher than the
pre test score (1.26) of the subjects. The calculated ‘t’
value (0.57) was lower than the table value (2.05) at
0.05 level of significance. The results showed that
occupational therapy was found to be not effective in
negative symptoms of schizophrenia(apathy)
Effectiveness of occupational therapy in asociality
showed that the mean post test score of asociality by
SANS scale (1.88), were significantly higher than the
pre test score (1.66) of the subjects. The calculated ‘t’
value (1.75) was lower than the table value (2.05) at
0.05 level of significance. The results showed that
occupational therapy was found to be not effective in
negative symptoms of schizophrenia(asociality)
Effectiveness of occupational therapy in attention
showed that the mean post test score of attention by
SANS scale (1.933), were significantly higher than the
pre test score (1.866) of the subjects. The calculated’ t
value (0.284) was lower than the table value (2.05) at
0.05 level of significance. The results showed that
occupational therapy was found to be not effective in
negative symptoms of schizophrenia (attention).
Tab 3: Item Wise Paired’t’ Test Value Between the Pre Test and Post Test Score of the Subjects by Sans to Assess
Occupational Therapy and Symptoms of Schizophrenia
Sl.No Items Pre Test Post Test T Value Df P Value
Mean Sd Mean Sd
1Affective Flattening Blunting 2.0 1.74 2.23 1.43 1.56 29 0.129P>0.05NS
2Alogia 1.0 0.74 1.06 1.25 0.348 29 0.73P>0.05NS
3Avolition- Apathy 1.26 0.739 1.366 1.21 0.571 29 0.573P>0.05NS
4Anhedonia-asociality 1.66 1.72 1.9 1.88 1.75 29 0.09P>0.05NS
5Attention 1.866 1.925 1.9333 .827 0.284 29 0.778p>0.05NS
5. Association of symptoms of schizophrenia
(attention) with demographic variables is assessed
using fishers exact test . The result revealed that
there was no significant association between the
symptoms of schizophrenia(attention) and age,
gender, socio economic status, education, religion,
type of schizophrenia, duration of illness, previous
hospitalization and previous medication of
subjects at 0.05 level of significance.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 199
Table 4: Association between the Attention and Selected Demographic Variables
Areas Mild Moderate Severe LOS
Age
21-40 7 6 4 P>o.o5 0.207 NS
41-60 8 2 3
Gender
Male 10 5 2 P>0.05 0.385, NS
Female 5 3 5
Socio economic status
Lowerclass 9 7 1 P>0.05 0.06 NS
Middle class 3 1 4
Higher class 3 0 2
Education
Primary school 7 5 1 P>0.05 O.359 NS
High school 2 0 2
Puc/diploma 4 1 3
Pg/graguate 1 2 2
Marrital status
Married 9 4 4 P>0.05 0.526 NS
Unmarried 1 1 1
Widow/widower 0 1 1
Separated 4 0 1
Divorsed 1 2 0
Residence
Urban 7 3 3 P>0.05 O.243 NS
Rural 4 4 0
Semi urban 4 1 4
Type of schizophrenia
Paranoid 9 6 5 P>0.05 0.645 NS
Undifferenciated 3 0 1
Schizo affective 3 2 1
Duration of illness
Acute 5 0 2 P>0.05 0.65 NS
Chronic 9 7 5
Semi acute 1 1 0
Previous medication
Yes 8 2 2 P>0.05 0.772 NS
No 7 6 5
Previous hospitalization
Yes 9 7 6 P<0.05 0.168 NS
No 6 1 1
NS- not significant
DISCUSSION
Section I: Description of sample characteristics
• The demographic characteristics of the study
indicate that 53.4 %( 15) of the subjects were in the
age group of 21 – 40 years and 46.6 %( 14) in 41 –
60 years.
The above study was supported by a study
conducted in Israel by Noomi Katz and Navah Keren
has showed that most subjects were under the age
range of 20-383
Both male and female subjects constitute the same
percentage for the present study i.e. 50%.
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200 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
The above study was supported by a study
conducted on the age and gender effects on negative
symptoms of schizophrenia among two various age
groups revealed that gender was not significant for
any outcome measure. 4
Section2: Effectiveness of occupational therapy on
symptoms of schizophrenia
Mean pre test balance scores in the experimental
group were10.9, whereas after intervention the post
test means scores is increased to11.133, which showed
no significant improvement in the symptoms after
intervention. t calculated value (0.942) is lesser than t
table value (2.05) at 0.05 level of significance. Hence, it
was concluded that occupational therapy is not an
effective strategy for symptoms of schizophrenia
Extensive review of literature was carried out to
find the effectiveness of occupational therapy on
symptoms of schizophrenia. . But no supportive
studies were found.
Section 3: Association between attention and selected
variables.
The calculated value for age (1.19), gender(1.112),
socio economic status(0.7), education(0.12),
residence(0.224), type of schizophrenia(0.89), duration
of illness(0.679), previous hospitalization(1.77) and
previous medication (0.65)of subjects is less than table
value (2.05 )at 0.05 level of significance. Hence there is
no association between attention and age. Gender,
socio economic status, education, residence, type of
schizophrenia, duration of illness, previous
hospitalization and previous medication.
Extensive review of literature was carried out to
find association between attention and demographic
variables. But no supportive studies were found.
CONCLUSION
Schizophrenia affects about 24 million persons
worldwide. It is a treatable disorder, with treatment
being more effective in the initial stages of the disease
course. However, more than 50% of persons with
schizophrenia do not receive the appropriate care due
them. Recent statistics indicate that about 90% of the
population with schizophrenia resides in developing
countries. Therefore Care for such individuals can be
provided at the community level, with active family
and community involvement 2
ACKNOWLEDGEMENTS:
Heartfelt thanks to all those who supported in any
respect during the completion of the study
Conflict of Interest: None
Source of Funding: None
Ethical Clearance: Obtained from Ethical Committee
of Nitte University, Mangalore held on 16 th February
2012.
REFERENCE
1. Schiziphrenia(internet):http://www.who.int/
mentalhealth/management/schizophrenia/en
2. Importance of occupational therapy in
schizophrenia (internet) http://www.ncbi.
nim.nib.gov/pmc/articles/pmc1140960/
3. Katz Noomi, Keren Navah. On effectiveness of
occupational goal intervention in schizophrenic
clients, (internet) http://jot.aotapress. net/
content/ 65/3/287 .abstract
4. Liberman, R.P, Wallace C.J, occupational therapy
for persons with persistent schizophrenia.
American Journal of Psychiatry, 155(8), p. 1097-
1091
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 201
INTRODUCTION
Children are the future of the nation. If the children
are healthy, the nation is bound to be strong. In the
light of these observations, it was felt that the health
education to school children is important.1
A Comparative Study to assess the Effectiveness of Video
Recorded Instruction and Pamphlet Regarding
Prevention of Swine FLU among High School Children, in
Selected Schools of Belgaum City
Moreshwar S A1, YumnamM2, Shivaswamy M S3
1Asso professor, HOD of Community Health Nursing, KLEU's Institute of Nursing Sciences, Belgaum, 2Lecturer,
RIMS College Of Nursing, Imphal, 3Professor, Department of Community Medicine, JNMC, KLE University,
Belgaum
ABSTRACT
"A comparative study to assess the effectiveness of video recorded instruction and pamphlet regarding
prevention of swine flu among High school children, in selected schools of Belgaum city."
The school children are at risk of getting infection, because of their closeness in the group at the same
time. The school environment offers a great opportunity to educate school children, since school
children are available at a large group at given particular time and place. Looking at the gravity of
the situation created by H1N1 and the pace at which it is spreading in a country there is an urgent
need to improve people's understanding about H1N1 flu by developing effective, interesting and
easily accessible educational material regarding cause, spread and prevention of swine flu to ensure
that the spread is arrested. Since the most effective prevention program involves educating the
population at risk, motivating the population to protect themselves and changing individual's
behavior. The objectives of the study were to assess the knowledge of school children on cause,
spread and prevention of Swine flu; to evaluate the effectiveness of video recorded instruction and
pamphlet on cause, spread and prevention of swine flu, to compare the results of video recoded
instruction and pamphlet. The study was conducted using one group pretestposttest design. The
study was conducted on a sample of 100 subjects, 50 each for one group, using systematic random
sampling technique. . Data collection was done through structured questionnaire. Data obtained
were tabulated and analyses in terms of objectives of the study using descriptive and inferential
statistics.
The findings of the study revealed that pamphlet administration was effective to enhance the
knowledge of subjects on the cause, spread and prevention of swine flu as compare to video recorded
instruction
Keywords: Video recorded instruction, Pamphlet instruction, School children, Swine flu
DOI Number: 10.5958/j.0974-9357.5.2.054
Health education helps in preparing the younger
generation to adopt measures to remain healthy so as
to help them to make the best use of educational
facilities to utilize in a productive, constructive manner,
to enjoy recreation and to develop concern for others1.
Health education helps the younger generation to
40. Moreshwar--201--205.pmd 1/6/2014, 9:31 AM201
become healthy and useful citizens who will be able
to perform their role effectively for the welfare of
themselves, their families, the community at large and
the country as a promotion of positive health of school
children2.
Educational technologists as well as curriculum
experts have proved that video recorded instruction
has high potential in the teaching and learning
situation for it can multiply and widen the channels
of communication3.
Pamphlet helps to increase interest and help to
gather information in an organized manner. It helps
to attract children.4
Swine influenza was first proposed to be a disease
related to human influenza during the 1918 flu
pandemic, the first identification of an influenza virus
as a cause of disease in pigs occurred about ten year
later in 19305
First case of Swine flu was found in a small town
in Mexico in the spring of 2009. The fact that the rates
of infection and death had held steady throughout the
summer, a time in which cases of the flu usually drop
off is new, however in June 2009 the World Health
organization (WHO) announced that the disease had
reached global pandemic level a distinction that refers
to the spread of the condition, not to its severity6.
The school children are at risk of getting
infection, because of their closeness in the group at
the same time. The school environment offers a great
opportunity to educate school children, since school
children are available as a large group at given
particular time and place7.
METHODOLOGY
This was an evaluative approach which was one
group pre-test post –test design. Study was conducted
in two English medium schools of Belgaum that is
Benson English Medium high School and St. Paul
English Medium High School. Study was conducted
during Jan- Feb 2011. A systematic random sampling
was used. The sample area selection comprised of two
zone that is south zone and north zone school. The
study subjects included 50 each in two groups who
were studying in class VIII and IX. Data from school
children was collected through a structured
questionnaire. Process of data collection were, pre-test
knowledge questionnaire was distributed after this
video recorded instruction was administered in Group
I and after 7 days post test was conducted. Similarly
in Group II pre-test knowledge questionnaire was
distributed followed by pamphlet distribution and
after 7 days post-test was conducted.
The maximum score for knowledge was 40.The
knowledge scores was divided into three categories
viz; good, average and poor according to the mean
and standard deviation.
The reliability of the tool was tested by split half
method by using Karl Pearson’s Co-efficient of
correlation formula. The reliability result is r=0.99.The
collected data was analyzed by using descriptive and
inferential statistics.
OBSERVATION AND RESULTS
In the first group that is video recorded instruction,
pre-test conducted among 50 subjects, 43(86%) had
average knowledge scores, 7(14%) had poor
knowledge scores and none had good knowledge
scores. After 7 days post –test was conducted among
49, 22(42.85%) have average knowledge score,
21(42.85%) have average knowledge score and 6
(12.24%) had poor knowledge score.
In the second group that is pamphlet, pre-test
conducted among 50 subjects,12 (24%) had good
knowledge score, 30(60%) had average knowledge
score and 7 (14%) had poor knowledge score. After 7
days post-test was conducted among 49, 39 (79.59%)
had good knowledge, 7(14.28%) had average, 4(8.16%)
had poor knowledge score.
There was significant increase in post-test
knowledge scores through pamphlet distribution. The
gain in knowledge score was significant at p *=0.0015
(p<0.001) and calculated paired t is 11.66. Findings
revealed that pamphlet distribution was effective to
improve knowledge under study. There was significant
increase in post test scores through video recorded
instruction. The gain in knowledge score was
significant at p*=0.0015 (p<0.001) level and calculated
paired t is 6. Finding revealed that video-recorded
instruction was effective to improve knowledge among
school children.
There was significant increase in the post-test
knowledge score in learning through pamphlet
distribution than video recorded instruction. The gain
in knowledge score was statistically significant as
p*=0.0015 (p<0.001) level and calculated
unpaired‘t’=2.03. Therefore the finding reveal that
40. Moreshwar--201--205.pmd 1/6/2014, 9:31 AM202
pamphlet distribution on cause, spread and prevention
of swine flu was more effective than video-recorded
instruction to improve the knowledge of the subjects,
under study.
Table 1: Mean median, mode, standard deviation and range of knowledge score of subjects on the cause, spread
and prevention of swine flu: n=50
Area of analysis Mean Median Mode SD Range
Pre-test (x) 22.26 22 20.8 3.57 15
Post- test (y) 27.55 29 31.9 6.5 24
Difference(y-x) 5.29 7 11.1 2.93 9
Table 1: Depicts that the mean post- test knowledge score are higher than the mean pre- test knowledge score.
Table II: Distribution of knowledge scores of subjects on the cause, spread and prevention of swine flu through
video recorded instruction n=50
Knowledge score Pre-test Post-test
Frequency % Frequency %
Good >(Mean+1 SD) (30-40) - - 22 44.89
Average(Mean-1SD) to (Mean+1SD) (19to 29) 43 86 21 42.85
Poor < (Mean-1SD) (0 to18) 7 14 6 12.24
TABLE II: Reveals that in pre-test 43(86%) had average knowledge, 7(14%) had poor knowledge and none had good knowledge and in
post-test 22(44.89%) had good knowledge, 21(42.85%) had average knowledge and 6(12.24%) had poor knowledge.
TABLE III: Distribution of knowledge scores of subjects on the cause, spread and prevention of swine flu through
pamphlet distribution n=50
Knowledge score Pre-test Post-test
Frequency % Frequency %
Good >(Mean+1 SD) (30-40) 12 24 39 79.59
Average(Mean-1SD) to (Mean+1SD) (19to 29) 30 60 7 14.28
Poor < (Mean-1SD) (0 to18) 7 14 4 8.16
Table III: Reveals that, in pre-test 30(60%) had average knowledge, 7(14%) had poor knowledge and 12(24%)
had good knowledge and in post-test 39(79.59%) had good knowledge, 7(14.28%) had average knowledge and
4(8.16%) had poor knowledge.
TABLE IV: Mean difference, Standard Error of Difference (SED), hypothesis and paired‘t’ values of knowledge
score on the cause, spread and prevention of swine flu. (n=50)
Mean difference (d) Standard error) Paired’t’ values Hypothesis
Difference(SED)
calculated tabulated
5.24 6.29 06 1.960 Reject Ho
6.53 3.97 11.66 1.960 Reject Ho
Table IV: Reveals that, there was significant increase in post-test knowledge scores through video recorded instruction. The gain in
knowledge score was statistically significant at p*<0.0001 level and calculated paired‘t’ = 6; hence the research hypothesis Ho is rejected.
Findings revealed that video recorded instruction on cause, spread and prevention of swine flu was effective to improve the knowledge
of subjects under study. There was an increase in the post test knowledge scores through pamphlet distribution also.
TABLE V: Mean difference, Standard Error of Difference (SED), hypothesis and unpaired‘t’ values of knowledge
score on the cause, spread and prevention of swine flu. (n=50)
Mean difference (d) Standard error) Paired’t’ values Hypothesis
Difference(SED)
calculated tabulated
2.89 7.10 2.03 1.96 Reject Ho
TABLE V: Reveals that, there was significant increase in the post test knowledge score in learning through pamphlet distribution than
video recorded instruction. The gain in knowledge score was statistically significant as p*=0.0015(p<0.001) level and calculated
unpaired‘t’=2.03. Therefore the finding revealed that the pamphlet distribution on cause, spread and prevention of swine flu was more
effective than video-recorded instruction to improve the knowledge of the subjects under study.
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204 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
DISCUSSION
The present study has been undertaken to assess
the effectiveness of two teaching strategies on cause,
spread and prevention of swine flu in terms of
knowledge among the high school children of class
VIII and IX in Belgaum.
Main findings of the study are discussed under the
following sections
1. The first objective of the study was to assess the
knowledge of school children’s, on cause, spread
and prevention of swine flu:
Section I: Description of Knowledge scores
Section I represents minimum knowledge score in
anatomy and physiology of respiratory tract, whereas
in the post test maximum gain knowledge score was
in the same area the reason could be due to effect of
video recorded instruction.
The results were contradicting with the study done
by Denela Daneila which revealed that, there was a
significant increased knowledge for patients who
viewed the video recorded instruction than those who
were in control group8.
It represents minimum knowledge score in the area
of knowledge regarding cause of swine flu, whereas
in the post test maximum gain in knowledgescore was
in the same area, the reason could be due to much
attention was paid by the subjects through pamphlet.
Section II: Mean, Median, Mode and Standard
deviation and Range of knowledge scores of school
children.
It shows an apparent increase in mean, median,
mode, SD and range of pre-test and post-test score of
50 subjects by using pamphlet regarding cause, spread
and prevention of swine flu.
Section III: Distribution of knowledge scores of
subjects on swine flu
It depicts that in the pre-test none of thesubjects
had good knowledge score while in the post- test there
were 22subjects (49.89%) had good knowledge score.
This could be attributed to the cause that, much in
attention was paid by the subjects through video-
recorded instruction.
The similar finding was shown by the study
conducted By Sadiq Ahmed Shaikh the result revealed
that in the pre-test only 6(20.00%) had good
knowledge, while in the post there was enhancement
of 30 (100%) knowledge score7.
In the pre-test 12(24%) had good knowledge, while
in the post –test there were enhancement of 39 (79.59%)
knowledge scores. This could be attributed to the cause
that much attention was paid by the subjects through
pamphlet distribution.
2. Evaluate the effectiveness of video instruction
and pamphlet on cause, spread and prevention
of swine flu
Results revealed that, there was significant increase
in post-test knowledge scores through video recorded
instruction. The gain in knowledge score was
statistically significant at p*<0.0001 level and
calculated paired‘t’ =6 hence the research Hypothesis
Ho is rejected. Findings revealed that video recorded
instruction on cause spread and prevention of swine
flu was effective to improve the knowledge of subjects
under study. This could be attributed to the cause that
much attention was paid by the subject through
pamphlet distribution as compared to video recorded
instruction.
There was increase in the post test knowledge
scores through pamphlet distribution. The gain in
knowledge score was statistically significant at
p*<0.0001 level and calculated paired ‘t’= 11.66, hence
the research hypothesis Ho is rejected .Findings
revealed that, pamphlet distribution on cause, spread
and prevention of swine flu was effective to improve
the knowledge of the subjects under study. This could
be attributed to the cause that much attention was paid
by the subjects through pamphlet distribution as
compared to video recorded instruction.
3. Comparison the results of video instruction and
pamphlet
Results revealed that, there was statistically
significant increase in post–test knowledge score
through pamphlet distribution than compared to video
recorded instruction.
These findings are supported with the study done
by Kabakian Khasholian T, Campbill OM which
revealed that, women appointment for postpartum
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 205
visits by distributing intervention booklet increased
their knowledge and their use of health service9.
CONCLUSIONS
The findings of the study showed that both the
methods are effective teaching strategies. As a
comparison Pamphlet distribution was more effective
teaching strategy to improve the knowledge of school
children than video recorded instruction.
ACKNOWLEDGEMENT
We express our thanks to participants and the
authorities who provided permission to conduct the
study.
Interest of Conflict
The school children are at risk of getting infection,
because of their closeness in the group at the same time;
hence the present study intendsto assess the
effectiveness of video recorded instruction and
Pamphlet regarding prevention of swine flu among
High school children. Reinforcement of known ideas
and impartation of new ones, allows the learner to
correlate all the areas included in the education
programme. Information regarding cause, spread and
prevention of swine flu through pamphlet distribution
and video instruction will be useful for prevention of
swine flu to the budding students, who in turn will
share this information not only in the school setting,
but also in community at large.
Source of Funding: Self-funding
Ethical Clearance: Ethical clearance was taken from
Chairman of Ethical Clearance Committee- Principal,
Prof. Sudha A Raddi, Vice Principal and Secretary, Prof.
Milka Madhale, KLEU’S Institute of Nursing Sciences,
Belgaum.
REFERNCE
1. Pb. Health government. School health
programmed (online) Nov 2009. Available from
Pb health.gov.in/pdf/school/20 health.
2. Haag Helen Jessie. School Health program,
American publishers, HollyRiehart and Winston
Inc 1968; New York p 210.
3. Videotape- definition of videotaped by free online
dictionary (online) Jun 2009. Available from
www.thefreedictionary.com/videotaped.[cited
on feb 2011]
4. Wikipedia. Pamphlet (online) June 2008.
Available from en.wikipedia.org/wiki/pamphlet
5. Swine influenza- Wikipedia, the free
encyclopaedia (online) may 2009. Available from
en.wikipedia.org/wiki/swine influenza officials.
6. An introduction to Influenza 9H1N1 or “Swine
flu” from the Times Topic page on Swine flu
(online) May 2009. Available from
www.nytimes.com/.../20090501 H1N1
7. Park K, Text book of Prevention and Social
Medicine. 20th ed. Jabalpur Banarsidas Bhanot
publishers,2009,p498-501
8. Denela Daneila .Effectiveness of general health
promotion teaching for patients in the waiting
room, using focused videotaped instruction
(online) Jan 2009. Available from http://
www.ncbi.nlm.nih.gov/pubmed
9. T Khasholian-kabakian, OM Campbell. A simple
way to increase service use triggers of women’s
uptake of postpartum services. (online) Sep 2008.
Available from http://www.ncbi.nlm.nih.gov/
pubmed [cited on feb 2011]
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206 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
Pain is highly subjective experience, and it is one
of the most common reasons for patients to seek
medical help24. Pain has been associated with the
decline in socialization, impaired level of functioning,
sleep disturbance, and depression among patients in
different settings 3, 17, 22, 26. Pain, because of its significant
impact on patients’ wellbeing, is regarded as the fifth
vital sign 24. According to The Joint Commission (TJC)
pain management standards 2001; nurses are required
to screen patients for pain during their initial
assessment and periodically throughout their shift 16.
However, evidence indicates that pain is under-
identified and under-reported by the nursing
personnel 2, 15. Two major reasons for under-reporting
and under-identification are lack of timely assessment
and reassessment of patients’ pain by the nursing staff
5; and lack of nursing personnel’s ability to evaluate
pain in cognitively impaired older adults 13.
Nurses' Compliance at Reporting Patient's Pain: Shift
Handover Observations from a Tertiary Care Hospital in
Karachi, Pakistan
Nazbano Ahmedali1, Fauziya Ali2, Nasreen Sulaiman2, Rozina Roshan3, Zohra S Lassi4
1Instructor, 2Assistant Professor, Aga Khan University, School of Nursing and Midwifery, 3Manager Nursing
Practices, Aga Khan University Hospital, 4Senior Instructor, Research, Division of Women and Child Health, Aga
Khan University
ABSTRACT
Pain is a common and serious problem that affects patients' physical, psychological and social
wellbeing. Evidence suggests that pain is under-identified and under-reported by nursing personnel.
Assessing nurses' compliance at reporting patients' pain at shift handover was the component of the
study aimed at assessing the compliance of nursing shift handover practices. This descriptive cross-
sectional study recruited a total of 43 nurses from a medical and surgical unit of a tertiary care hospital.
Each nurse's shift handover practices were observed and evaluated against the ISBAPARRST tool.
This tool was adapted by incorporating the study setting's shift report policy and tool, and evidence
based literature. The tool's content validity and inter-rater reliability was also verified (K=0.938). A
total of 129 nursing shift handover observations were made, out of which 9.3% of the observations
showed that nurses were compliant at reporting patients' pain; however, 90.7% of the observations
showed nurses' noncompliance. The study findings suggest that report on patient's pain is often
missed at nursing shift handover; and whenever integrated, the pain scale score is never specified.
On the basis of study findings, recommendations are made in relation to nursing administration,
education and research.
Keywords: Pain, Pain Assessment, Pain Report, Nurses Report on Pain, Nursing Shift Handover
DOI Number: 10.5958/j.0974-9357.5.2.054
It is certain that nurses play pivotal role in efficient
pain assessment and management 7 as they spend more
time with the patient than any other healthcare team
members 12. Therefore, it seems reasonable to assume
that bedside nurses can aid continuous assessment and
management of patients’ pain by adding a report on
patients’ pain in shift handovers. Where timely and
effective flow of information between nurses and
doctors has been claimed to contribute to efficient pain
management 21; nurse to nurse communication during
shift handovers has been an area that needs
illumination. Though substantial numbers of studies
have explored pain assessment and management from
different dimensions, there is scarcity of literature that
has assessed the role of shift handover communication
in efficient pain assessment and management. Thus,
assessing nurses’ compliance at reporting patients’
pain at the shift handover was the component of the
study aimed at assessing the compliance of nursing
shift handover practices.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 207
METHOD
This cross-sectional study was conducted at TJC
certified private tertiary care hospital (TCH) in Karachi,
Pakistan. This research was approved by the Ethical
Review committee of the participating institution.
Convenience sampling technique was used to select
one medical and one surgical unit. However, universal
sampling technique was used to enroll nurses and all
the nurses working at selected medical and surgical
unit were included in the study. Each study participant
was informed about the purpose of the study and
voluntary consent was obtained. The demographic
information regarding participants’ age, gender,
highest professional degree, graduating institute, years
of experience, and current position was obtained.
Participants’ confidentiality and anonymity was
maintained throughout the study. In total, 43 nurses
participated in this study and each of them was
observed thrice (once in each nursing shift) while she/
he gave shift handover to the upcoming nurse. Each
nurse’s shift handover communication was observed
for the presence of report on patient’s pain, and to
identify if the report on patient’s pain integrated the
numeric rating scale (NRS) which is currently used in
all the units of the selected TCH. The observations were
guided by the ISBAPARRST tool and the data related
to patient’s pain report was one of the subcomponent
under the “assessment” section. This tool was adapted
by incorporating the TCH’s shift report policy, and tool,
and the available evidence based handover tools1,4, 6,
8,9,10, 18, 25, 28, 30. The study tool’s content validity was
established through expert opinion; this tool was
reviewed by 10 experts that included clinician, clinical
nurses, educators, and nursing administrators. The
Tool underwent a few changes after the experts’
feedback. Tool’s inter-rater reliability was also tested.
The tool has demonstrated good inter-rater reliability
(K=0.938). A total of 129 structured shift handover
observations were made in three nursing shifts
(morning, evening and night); on week days and
weekends (table 1) and all 129 observations were made
by the primary researcher.
Table 1: Shift Handover Observations
Variable n (%)
Nursing Shifts
Morning 42 (32.6)
Evening 48 (37.2)
Night 39 (30.2)
Observation Day
Week Day 90 (69.8)
Weekend 39 (30.2)
RESULTS
Demographic information suggests that the mean
age of the participants was 25.5 years (+3.7). Majority
of them were females, working at the bedside and had
attained diploma in nursing. More than half of the
participants were graduates of a renowned nursing
school associated with the teaching hospital, which
served as the study setting for this study. Majority of
the participants were working in the surgical unit. The
participants’ job experience ranged from minimum of
1 month to maximum of 12.5 years.
The study finding revealed that in 9.3% of the shift
handover observations, nurses were compliant at
reporting patient’s pain. However, 90.7% of the
observed shift handovers suggested that nurses were
non-compliant. Importantly, in all the compliant
observations, nurses did not state patient’s pain rating.
Descriptive analysis of compliant observations in
regard to the nursing shift and report on patients’ pain
suggested that 16.6% of the compliant observations
were taken during the morning shift; while the rest
were from evening and night shift (41.6% each). With
respect to the job experience of nurse and the report
on patients’ pain, findings revealed that nurses who
had less than one year of job experience demonstrated
compliance on the report of patients’ pain less
frequently (16.6%) than those who had more than one
year of job experience (83.3%). In relation to the
specialty and report on patients’ pain, results
highlighted that ¾ (75%) of the compliant observation
were from the surgical unit and 25% were from the
medical unit. Analysis of the findings in relation to
the staff gender and report on patients’ pain indicated
that the compliant observations have equally come
from male and female nurses. Further, result also
explicated that 16.6% of the compliant observations
were contributed by the nurses who completed their
bachelors in nursing while the remaining 83.3% have
been from the nurses who had done diploma in
nursing.
DISCUSSION
It is argued that accurate and comprehensive
nursing shift handover is necessary to enable
upcoming nurse to plan and implement efficient
nursing intervention20. When an off-going nurse
reports patient’s pain at shift handover; this report can
valuably direct an oncoming nurse regarding the
possible plan of care for the patient in the next shift.
However, evidence suggests that shift handovers are
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208 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
given at a very high speed 27, and the verbal handovers
are highly variable in relation to the handover
content29. Nevertheless, at the study setting, pain is
assessed and documented every shift; it is likely that
nurses omit this piece of information during the shift
for it is retrievable from the patient’s bedside file.
Another reason for such a low compliance in reporting
patients’ pain can be attributed to the nurses’ habit of
sharing global assessment during handover. Like this
patient is “Fine” or “Ok” or “Poor” 27. Nonetheless,
the study results highlight the need for improving
nurses’ compliance at reporting patients’ pain at shift
handover.
It is claimed that pain intensity is the most
commonly assessed component of pain 31. And NRS is
one of the most frequently used self-reporting pain
scale that aids pain assessment, guides pain
management 19 and defines level of change in patient’s
pain 11. Therefore, integrating pain scale score in the
pain report helps a nurse to objectify the intensity of
pain and this pertinent information can direct pain
management and reassessment 16. However, current
study results seem to suggest that pain scale score is
usually missed at the time of shift handover.
Conclusion and Recommendations
The current study findings have revealed that
report on patient’s pain is less likely to be shared at
the nursing shift handover. The findings also suggest
that pain scale score is mostly not integrated in the
report on patient’s pain. The nursing education
services can play an influential role in preparing new
joining nurses for conducting a comprehensive nursing
shift handover. Further, hospital administration should
conduct regular in-service sessions for nurses to
educate them about the importance of reporting the
patients’ pain at shift handovers. According to Berry,
& Dahl (2000) nurses especially the ones who are expert
in pain management can be the valuable resource in
the efficient assessment and management of patient’s
pain. Therefore, an initiation of specialized training
program like Pain Resource Nurse (PRN) training
program can be a sustainable step to ensure nurses
take catalyst role in improving the patient’s pain
assessment, reassessment and management
throughout the hospital 14. A part from this, hospital
administration shall regularly audit shift handover
practices to evaluate the nurses’ compliance at
reporting patients’ pain5. Nursing schools should also
teach nursing students regarding the important
elements of nursing shift handover. Moreover, clinical
teachers should provide nursing students ample of
opportunities to practice delivering and receiving shift
handers. This will result in improvement in the nurses’
compliance at reporting patients’ pain. Further
research is needed to identify the factors associated
with the under-reporting of patients’ pain at nursing
shift handover and lack of pain scale score
incorporation in the pain report. Exploring barriers can
suggest the possible strategies to improve the patient’s
pain report and subsequent efficient continuous pain
management.
Limitations
The data collection through structured observations
has only relied on the information that was shared at
the time of shift handover, so it is not known as to
what numbers of patients were actually having pain
and how many patients were reported by nurses at
the time of shift handover. The patients’ file audit could
have helped to get the holistic data; however, the study
findings are consistent with the literature and
highlights that pain is underreported by nurses.
Secondly, these findings are from 129 observations only
nonetheless it has broadened understanding onto the
role of shift handover communication in patients’ pain
assessment and management.
ACKNOWLEDGEMENT
Research team would like to acknowledge the study
setting and participants without whom this study
would have not been possible.
DISCLOSURE
This research did not receive any kind of support.
There is no conflict of interest of the authors attached
with this work.
DECLARATION
It is affirmed that this manuscript has not been
submitted to or published in any other journal.. There
is no conflict of interest of the authors attached with
this work.
Source of Funding: This research did not receive any
kind of financial support.
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Megrill A, Perry A, Rubin O, Ziv A.Improving
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risk.Chest.2008134: 158-162.
7. Berry PH & Dahl JL. The New JCAHO Pain
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8. Caruso EM. The evaluation of nurse-to-nurse
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9. Chaboyer W, McMurray A, Johnson J, Hardy L,
Wallis M, Ying F. Bedside handover quality
improvement strategy to “transform care at the
bedside”. Journal of Nursing Care
Quality.200924(2):136-142.
10. Dufault M, Duquette CE, Ehmann J, Hehl R,
Lavin M, Martin V, Moore MA,
Sargent S, Stout P, Willey C. Translating an
evidence-based protocol for nurse-to-
nurse shift handoffs. Worldviews on Evidence-
Based Nursing.20107(2): 59-75.
11. Farrar JT, Young J P, LaMoreaux L, Werth JL, Poole
RM. Clinical importance of changes in chronic
pain intensity measured on an11-point numerical
pain rating scale. Pain.200194: 149–158.
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LM. The pain resource nurse training program:
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549–556.
13. Ferrell BA, Ferrell BR, Rivera L. Pain in the
cognitively impaired nursing home patients.
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591-598.
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INTRODUCTION
Deep Vein thrombosis is a serious but preventable
cause of morbidity and mortality in the world. Higher
incidence, underestimation of risk, under used
prophylaxis with high fatality has made DVT a
worldwide cause for concern. The immediate need of
the hour is to have standard guidelines for
management of DVT which are practical, acceptable
and implemental in all over institutions. Nurses are
key players in the prevention of deep vein thrombosis
and its complications. They are in the ideal position to
assess patient risk factors early and ask for DVT
prophylaxis. Admission assessments are an opportune
time to evaluate patient’s risk factors such as mobility,
age, previous history of DVT and medical conditions.
Assessment of effectiveness of a Structured Teaching
Programme on Knowledge of Staff Nurses Regarding Risk
Factors and Prevention of Deep Vein Thrombosis in a
Selected Hospital, Ludhiana, Punjab
Nidhi Kumar
Lecturer, Shaheed Kartar Singh Sarabha college of Nursing Sarabha, Ludhiana
ABSTRACT
The National Institute of health (NIH) estimates that deep vein thrombosis (DVT) and pulmonary
embolism (PE) are associated with 300,000 to 600,000 hospitalizations per year, the third leading
cause of death from cardiovascular disease. Because many of the most effective interventions for
preventing deep vein thrombosis are delivered by nurses, nurses can be instrumental in preventing
deep vein thrombosis. Serious health consequences and valuable health care resources can be saved
with nursing interventions aimed at risk assessment and prevention of DVT.In this context, it was
attempted to assess the effectiveness of a structured teaching programme on knowledge of staff
nurses regarding risk factors and prevention of deep vein thrombosis. A quasi experimental approach
with purposive sampling technique was used in the study. A structured knowledge questionnaire
was prepared and was given to 40 staff nurses working in cardiac ICUs and neuro ICUs of a selected
hospital, Ludhiana, Punjab. The findings of the study shows that the difference between pre test
mean knowledge score of control and experimental group was statistically non significant at p< 0.05
level whereas the difference between post test mean knowledge score of both groups was statistically
highly significant at p< 0.001 level. It was thus concluded that the structured teaching programme
was effective in raising the knowledge level of staff nurses regarding risk factors and prevention of
deep vein thrombosis and there was statistically significant effect of age, professional qualification,
total years of experience and type of training institute on knowledge level of staff nurses regarding
risk factors and prevention of deep vein thrombosis.
Keywords: Deep Vein Thrombosis, Risk Factors, Prevention, Knowledge, Structured Teaching Programme,
Effectiveness, Staff nurses
DOI Number: 10.5958/j.0974-9357.5.2.054
Once a patient is considered at risk for developing
DVT, nurses must advocate for timely prevention
mechanisms.
OBJECTIVES
1. To assess the pre test knowledge of staff nurses
regarding risk factors and prevention of deep vein
thrombosis among control and experimental
group.
2. To assess the post test knowledge of staff nurses
regarding risk factors and prevention of deep vein
thrombosis among control and experimental
group.
42. Nidhi Kumar--211--213.pmd 1/6/2014, 9:31 AM211
212 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
3. To compare the pre test and post test knowledge
of staff nurses regarding risk factors and
prevention of deep vein thrombosis among control
and experimental group.
4. To find out the relationship of pre test and post
test knowledge on risk factors and prevention of
deep vein thrombosis among staff nurses in control
and experimental group with selected
demographic variables.
METHODOLOGY
Approach: quasi experimental research approach
Design: Non equivalent pre test- post test research
design
Setting: Selected Hospital, Ludhiana, Punjab
Population: Staff Nurses
Sample Size: 40
Sampling Technique: Purposive Sampling Technique
(Non Random Sampling)
MATERIAL & METHOD
The present study was conducted at Christian
Medical College & Hospital, Ludhiana, Punjab. The
data collection procedure was carried out from Dec
2010 to Jan 2011. The total sample consisted of forty
staff nurses, twenty in control group from Neuro
surgery ICU and Neuro medicine ICU and twenty in
experimental group from Coronary care unit (CCU)
and Cardio thoracic unit (CTU). Pre test of control
group was taken with the help of structured
questionnaire to assess their knowledge regarding risk
factors and prevention of deep vein thrombosis
followed by a post test after seven days. To avoid
contamination pre test and structured teaching to
experimental group was given after post test of control
group. Post test of experimental group was also taken
after seven days.
The demographic variables included in the study
were Age, Professional qualification, Total years of
experience and Type of training institute.
Plan for data analysis
Descriptive statistics: Mean, Mean percentage &
Standard deviation.
Inferential Statistics: Chi square, Paired‘t’ test,
unpaired‘t’ test and ANOVA (F).
Major Findings
• Both in control and experimental group maximum
number of staff nurses belong to age group of 21-
25 years. In control group maximum numbers of
staff nurses were GNM whereas in experimental
group (50%) of the staff nurses were GNM and
(50%) were BSc. In both groups maximum number
of staff nurses were having <2 years of experience
and were trained from CMC.
• Regarding the comparison of pre test and post test
mean knowledge score of staff nurses in control
and experimental group, the pre test and post test
mean knowledge score of control group (22.45,
22.55) was not statistically significant, whereas the
pre test and post test mean knowledge score of
experimental group (23.15, 34.50) was highly
significant at p< 0.001.
Thus it was concluded that structured teaching
program had definite impact to increase the
knowledge level of staff nurses in experimental
group.
• According to percentage distribution, in control
group majority of staff nurses had below average
pretest (75%) and posttest (85%) knowledge score
whereas in experimental group (75%) had below
average pretest knowledge score followed by (20%)
excellent , (75%) good and (5%) average post test
knowledge score.
• According to areas of knowledge, in control group
both pre test and post test mean knowledge score
of staff nurses was lowest in the area of prevention
(42.17%), (41.50%) followed by risk factors
(50.56%), (53.33%) and general information
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 213
(58.33%), (58.89%) respectively.Similarly in
experimental group pre test mean knowledge score
of staff nurses was lowest in area of prevention
(43.83%), followed by risk factors (50.56%) and
general information (60.56%). Whereas the post test
mean knowledge score was highest in the area of
general information (77.22%) followed by
prevention (71.00%) and risk factors (70.56%)
respectively.
• There was statistically significant effect of age,
professional qualification, total years of experience
and type of training institute on knowledge level
of staff nurses regarding risk factors and
prevention of deep vein thrombosis in control and
experimental group.
CONCLUSION
The study concluded that the difference between
pre test mean knowledge score of control and
experimental group was statistically non significant
at p< 0.05 whereas the difference between post test
mean knowledge score of both groups was statistically
highly significant at p< 0.001. It was thus concluded
that structured teaching was effective in raising the
posttest knowledge level of staff nurses in
experimental group.
ACKNOWLEGEMENTS
My heartfelt thanks to all the individuals who had
been a source of inspiration, guidance and support
from the conception of this research to study
completion.
Conflict of Interest: None
Ethical Consideration: An informed verbal consent
was obtained from each study subject. It was ensured
that treatment of patient was not interfered and
confidentiality and anonymity of each subject was
ensured.
Source of Funding: None
REFERENCES
1. Hogston. Nurses perception of impact of
continuing professional education on the quality
of nursing care. Journal of advanced nursing.
1995; 22(3): 586-593.
2. Goldhaber Z Samuel, Fanikos J. Prevention of
deep Vein thrombosis and pulmonary embolism.
Journal of circulation. 2004; 110: 445-447.
3. Piazza Gregory, Goldhaber Z Samuel. Venous
thromboembolism and atherothrombosis: An
integrated approach. Journal of circulation. 2010;
121: 2146-2150.
4. Hyers TM. Venous thromboembolism. American
Journal of critical care medicine. 1999; 1598: 1-14.
5. Stephen M Pastores. Management of venous
thromboembolism in the intensive care unit.
Journal of critical care. 2009; 24: 185-191.
6. Vyas G. Deep vein thrombosis a brief review.
Cardiology Today. 2007; 11:148-153.
7. Bonner Linda. The prevention and treatment of
deep vein thrombosis. Nursing times. 2004; 100:
38.
8. Thieme D, Langer G, Behrens J. Knowledge of
nurses about compression therapy, Survey about
treatment of acute deep venous thrombosis. Pub
med. 2009; 62: 296-301.
9. Gallo Hudak. Critical care nursing. 6th edition. JB
Lippincott Company; 1994.
10. Agarwala Sanjay, Bhagwat Abhijit S, Modhe
Jagdish. Deep vein thrombosis in Indian patients
undergoing major lower limb surgery. Indian
Journal of surgery. 2003; 65: 159-162.
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214 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
Nursing as a profession has evolved in response to
society’s needs for well-prepared, caring practitioners
during clients’ episodes of illness and promote health
among all age groups. Clinical practice, which takes
place in the clinical environment, is a vital component
in the nursing curriculum and has been acknowledged
as central to nursing education1. The clinical
environment encompasses all that surrounds the
student nurse, including the clinical setting, the staff,
the patient, the nurse mentor and the nurse educator2.
The clinical learning environment is an interactive
network of forces within the clinical setting that
influence the students’ clinical learning outcomes3. It
is within this environment that students develop their
attitudes, competence, interpersonal communication
skills, critical thinking and clinical problem-solving
abilities4. Nursing students perceive the practice setting
A Comparative Study To Assess The Perception of
Doctors, Nurses, Faculty of Nursing and Nursing Students
on Ideal Clinical Learning Environment
Preethy J1, Erna J R2, Mariamma V G3
1Assistant Professor, Department of Community Health Nursing, 2Associate Dean and Professor, Department of Child
Health Nursing, 3Associate Professor, Department of Fundamentals of Nursing, MCON, Manipal University, Manipal
ABSTRACT
Objective: The objectives of the study were to describe and compare the perception of doctors, nurses,
faculty of nursing and nursing students on ideal clinical learning environment and to find the
association between the perception scores and selected variables.
Materials and Method: A descriptive comparative survey design was used. Data were collected
from 324 samples (81 doctors, 81 nurses, 81 faculty of nursing and 81 nursing students) in selected
teaching hospitals of Karnataka state by using structured questionnaire.
Result: There was no significant difference between the mean perception scores of doctors, nurses,
faculty of nursing and nursing students on how an ideal clinical learning environment should be.
There was significant association between the total perception scores with teaching experience
(x2=5.294) and educational status (x2=9.430).
Conclusion: Clinical experience for nursing students is a very important aspect of their professional
education. A supportive clinical learning environment is of paramount importance in securing the
required teaching and learning process.
Keywords: Doctors, Nurses, Faculty of Nursing, Nursing Students, Ideal Clinical Learning Environment
DOI Number: 10.5958/j.0974-9357.5.2.054
as the most influential context when it comes to
acquiring nursing skills and knowledge5.
Clinical placement provides the student with
optimal opportunities to observe role models, to
practice by one self and to reflect upon what is seen,
heard, sensed and done6. The learning becomes
integrated into personality to create a holistic way of
seeing and relating. The professional socialization of
nurse learners occurs largely in the practice setting7.
The social climate or learning environment is the
personality of a setting or environment, such as a
family, an office or a class room. Each setting has a
unique personality that gives it unity and coherence.
Environments, like people, also differ in how rigid and
controlling they are. Like some people, some social
environments are friendlier than others. Just as some
people are very task oriented and competitive, some
environments encourage achievement and
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 215
competition. Clinicians and researchers have evidence
to show how social climate affects each person’s
behaviour, feelings, and growth8.
The concept of social climate also emphasizes the
importance of the physical, human, interpersonal and
organizational properties, mutual respect and trust
among teachers and students9. In the process of
teaching and learning, the learning environment has
a dual function. From the teacher’s point of view,
educational environments can be a powerful teaching
instrument at the disposal of the teacher, from the
student’s perspective, educational environments
provide an important vehicle for learning.
The aim of the study is to assess the perception of
doctors, nurses, faculty of nursing and nursing
students on how an ideal clinical learning environment
should be. The findings will help the administrators
to develop effective strategies to improve or modify
the existing clinical learning environment and it will
in turn help to improve the learning outcome of
nursing students.
MATERIALS AND METHOD
A survey approach was adopted with a descriptive
comparative design and was conducted in selected
teaching hospitals of Karnataka state. Tool 1:
Demographic Proforma and Tool 2: Clinical learning
environment inventory were developed by the
researcher and were validated by eleven experts in the
field of nursing and medical education. Pretesting was
done among 20 samples (5 doctors, 5 nurses, 5 faculty
of nursing and 5 nursing students) to determine the
clarity of items. The reliability of the tool 2 was assessed
by cronbach’s alpha by administering the tool to 20
samples and the reliability coefficient obtained for the
tool 2 was 0.93. Pilot study was conducted in a teaching
hospital at Udupi among 40 samples. Main study was
conducted in selected teaching hospitals at Manipal
and Mangalore among 324 samples (81 doctors, 81
nurses, 81 faculty of nursing and 81 nursing students).
The obtained data were analyzed based on the
objectives and the hypothesis by using descriptive and
inferential statistics with the help of SPSS version 16.
RESULTS
Section 1: Description of sample characteristics.
Using demographic proforma, data were collected
about age, gender, religion, marital status, educational
status, designation, teaching experience, clinical
experience, year of study and interest in joining
nursing course.
Table 1: Frequency and percentage distribution of sample characteristics (n=324)
Sample characteristics Doctors Nurses Faculty of Nursing Nursing Students
(n=81) (n=81) (n=81) (n=81)
(f) (%) (f) (%) (f) (%) (f) (%)
Age (in years)
20-29 37 45.7 59 72.8 51 63.0 81 100
30-39 30 37.0 11 13.6 23 28.4 00 00
40-49 10 12.3 08 09.9 07 08.6 00 00
50-59 04 04.9 03 03.7 00 00.0 00 00
Gender
Male 51 63.0 10 12.3 09 11.1 05 06.2
Female 30 37.0 71 87.7 72 88.9 76 93.8
Religion
Christian 13 16.0 29 35.8 46 56.8 54 66.7
Hindu 68 84.0 52 64.2 35 43.2 19 23.5
Muslim 00 00.0 00 00.0 00 00.0 01 01.2
Others 00 00.0 00 00.0 00 00.0 07 08.6
Marital status
Married 54 66.7 29 35.8 40 49.4 00 00
Unmarried 27 33.3 52 64.2 41 50.6 81 100
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216 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Table 1: Frequency and percentage distribution of sample characteristics (n=324) (Contd.)
Sample characteristics Doctors Nurses Faculty of Nursing Nursing Students
(n=81) (n=81) (n=81) (n=81)
(f) (%) (f) (%) (f) (%) (f) (%)
Educational status
Diploma NA NA 57 70.4 00 00.0 NA NA
Graduate 00 00 24 29.6 49 60.5 NA NA
PBBSc NA NA 00 00.0 00 00.0 NA NA
Post graduate 81 100 00 00.0 32 39.5 NA NA
MPhil NA NA NA NA 00 00.0 NA NA
Doctorate NA NA NA NA 00 00.0 NA NA
Designation
Senior Resident 47 58.0 NA NA NA NA NA NA
Assistant Lecturer NA NA NA NA 49 60.5 NA NA
Lecturer NA NA NA NA 22 27.2 NA NA
Assistant professor 17 21.0 NA NA 08 09.9 NA NA
Associate professor 08 09.9 NA NA 02 02.5 NA NA
Professor 09 11.1 NA NA 00 00 NA NA
Staff Nurse NA NA 74 91.4 NA NA NA NA
Ward Incharge NA NA 07 08.6 NA NA NA NA
Teaching experience
Yes 74 91.4 03 03.7 81 100 NA NA
No 07 08.6 78 96.3 00 00 NA NA
Clinical experience
Yes 81 100 81 100 54 66.7 NA NA
No 00 00 00 00 21 33.3 NA NA
Year of study
Third year NA NA NA NA NA NA 40 49.4
Fourth year NA NA NA NA NA NA 41 50.6
Interest in joining nursing course
Own interest NA NA NA NA NA NA 61 75.3
Parents interest NA NA NA NA NA NA 18 22.2
Relatives or friends interest
NA NA NA NA NA NA 02 02.5
Section 2: Description of the perception of doctors,
nurses, faculty of nursing and nursing students on
ideal clinical learning environment.
In order to identify the perception on ideal clinical
learning environment, structured clinical learning
inventory was administered. The maximum score was
350 and minimum score was 70. The scores arbitrarily
categorized as poor (70 – 140), good (141 – 210), very
good (211 – 280) and excellent (281 – 350).
Table 2: Frequency and percentage distribution of the perception score of doctors, nurses, faculty of nursing and
nursing students on ideal clinical learning environment. (n=324)
Perception categories Range of Doctors Nurses Faculty of Nursing Nursing Students Total
score (n=81) (n=81) (n=81) (n=81) (n=324)
(f) (%) (f) (%) (f) (%) (f) (%) (f) (%)
Poor 70 -140 0000000000
Good 141 - 210 0000000000
Very good 211 - 280 17 21 24 29.6 13 16 10 12.3 64 19.8
Excellent 281 - 350 64 79 57 70.4 68 84 71 87.7 260 80.2
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 217
The data presented in table 2 shows that, a total of
17 (21%) doctors, 24 (29.6%) nurses, 13 (16%) faculty
of nursing and 10 (12.3%) nursing students had very
good perception on how an ideal clinical learning
environment should be and 64 (79%) doctors, 57
(70.4%) nurses, 68 (84%) faculty of nursing, and 71
(87.7%) nursing students had excellent perception on
how an ideal clinical learning environment should be.
Table 3: Mean, Median, Standard deviation and IQR perception score of doctors, nurses, faculty of nursing and
nursing students on ideal clinical learning environment (n=324)
Doctors Nurses Faculty of Nursing Nursing Students Total
(n=81) (n=81) (n=81) (n=81) (n=324)
Mean 298.86 298.74 303.77 305.43 301.70
Median 300.00 310.00 306.00 306.00 305.00
Standard deviation 21.35 25.85 19.97 19.17 21.84
IQR (Q1) 281.00 279.00 287.00 288.00 285.00
IQR (Q3) 318.00 312.00 321.00 323.00 319.00
The data presented in table 3 shows that, the total
mean score was 301.70 with standard deviation of
21.84 and the total median score was 305.0 with inter
quartile range of Q 1 (285) and Q3 (319).
Section 3: Comparison of perception of doctors,
nurses, faculty of nursing and nursing students on
ideal clinical learning environment.
As a beginning measure to identify whether to use
parametric or non- parametric test, a normality
assessment was done using Kolmogorov test. As the
distribution followed normality, one way ANOVA was
used to find the significance difference between the
groups.
Table 4: Comparison of perception scores of doctors, nurses, faculty of nursing and nursing students on ideal
clinical learning environment (n=324)
Groups Mean Standard Deviation f Value df p value
Doctors 298.86 21.35 1.998 3, 320 0.114
Nurses 298.74 25.85
Faculty of Nursing 303.77 19.97
Nursing Students 305.43 19.17
The data in table 4 shows that, p value was not
significant. Hence there was no significant mean
difference between the perception scores of doctors,
nurses, faculty of nursing and nursing students on
ideal clinical learning environment. So research
hypothesis was rejected.
Section 4: Association between the perception of
doctors, nurses, faculty of nursing and nursing
students and selected variables.
In order to find association between the perception
scores and selected variables, chi-square was
computed. If the expected cell count is less than 5 in
20% of cells, exact value was taken instead of chi-
square value. The study shows that, significant
association between total perception scores with
educational status (x2=9.430) and teaching experience
(x2=5.294). Excellent perception on ideal clinical
environment was present in majority of the
postgraduates and who had teaching experience more
than six months.
DISCUSSION
The present study found that, a total of 64 (79%)
doctors, 57 (70.4%) nurses, 68 (84%) faculty of nursing
and 71 nursing students (87.7%) had excellent
perception on ideal clinical learning environment. The
above finding is supported by a qualitative study by
Callister on staff nurses perception regarding nursing
programme, in which the need for more importance
for clinical teaching and a positive nurturing learning
environment through close collaboration between
nursing education and service was identified inorder
to improve the outcome of nursing students.
In the present study, there was no significant
difference between the mean perception scores of
doctors, nurses, faculty of nursing and nursing
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218 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
students on ideal clinical learning environment. The
above finding is supported by a study conducted by
Nahas on nursing students perception of effective
clinical teacher, in which there was no significant
difference between the perception of male and female
nursing students. A study conducted by Freeth on
nursing students and tutors perception of clinical
teaching and learning environment also revealed that,
there was no significant difference in the perception
scores between tutors and students. In contrast to the
present study, a comparative study conducted by Chan
on the perception of nurses, tutors and nursing
students existing clinical learning environment
revealed significant difference between the 3 groups.
Acknowledgements: Nil
Conflict of Interest: Nil
Source of Funding: Nil
Ethical Clearance
• Administrative permission was taken from the
principals of Colleges of Nursing in Udupi and
Mangalore district.
• Permission was taken from the administrators of
teaching hospitals in Udupi and Mangalore
district.
• Informed consent was taken from the participants
REFERENCE:
1. Lee D. The clinical role of the nurse teacher: a
review of dispute. Journal of Advanced Nursing.
1996 June; 23:1127–1134.
2. Papp I, Markkanen M, Bonsdorff VM. Clinical
environment as a learning environment: student
nurses’ perceptions concerning clinical learning
experiences. Nurse Education Today. 2003;
23:262–268.
3. Dunn SV, Burnett P. The development of a clinical
learning environment scale. Journal of Advanced
Nursing. 1995; 22:1166–1173.
4. Dunn SV, Hansford B. Undergraduate nursing
students’ perceptions of their clinical learning
environment. Journal of Advanced Nursing.
1997; 25:1299–1306.
5. Chan DSK. Combining qualitative and
quantitative methods in assessing hospital
learning environments. International Journal of
Nursing Studie.2001; 38 (4):447–459.
6. Ekstrand I, Bjorvell H. Nursing students’
experience of care planning activities in clinical
education. Nursing Education Today. 1996;
15:196–203.
7. Lee CH, French P. Ward learning in Hong Kong.
Journal of Advanced Nursing. 1997; 26:455–462.
8. Moos RH. The Social Climate Scales: A User’s
Guide. Consulting Psychologists Press, Palo Alto,
CA. 1987.
9. Knowles M. The Adult Learner: A Neglected
Species, Fourthed. Gulf Publishing Co, Houston.
1990.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 219
INTRODUCTION
The body and the mind have been viewed as
interdependent since ancient times. Any alteration in
the physical health of a person results in lot of
psychological and emotional reactions and
disturbances. Patients who are suffering from terminal
illnesses may be able to cope with the situation but
some are unable and being lost in them and find a way
of communication which is nothing but a cry for help-
suicide2. World Health Organization (WHO) has
ranked depression fourth in a list of the most urgent
health problems worldwide. A host of thoughts and
behaviors are associated with self-destructive acts. The
risk for suicide increases if the patient faces pain in
the face of a progressively debilitating disease3. It is
noteworthy that simply missing dialysis for some
sessions or going on a potassium food binge can
produce death for ESRD patients. The prevalence of
diagnosed depressive syndrome was 58.8% among
patients with a desire to die and 7.7% among patients
Study to assess the Depression and Ideation of Suicide
among Terminally Ill Patients, in Selected Hospitals,
Ludhiana, Punjab
Ramanpreet Kaur
1Lecturer, Shaheed Kartar Singh Sarabha, College of Nursing, Sarabha, Ludhiana, Punjab
ABSTRACT
The whole span of life includes struggles, achievements, successes, and failures, natural and unnatural
distresses. Psychological distress impairs the patient's capacity for pleasure, meaning, and connection;
erodes quality of life which is a major risk factor for suicide and for requests to hasten death. Recent
studies among terminally ill patients found that a desire for hastened death or an interest in assisted
suicide was associated with depression. Depression is often neglected and untreated in the terminally
ill which leads to desire for death1. An exploratory study was conducted on 100 terminally ill patients
diagnosed with end stage renal disease (ESRD) and cancer in selected hospitals of Ludhiana, Punjab.
The result of the study shows that there was a positive correlation between depression and suicide
ideation (r = 0.515, p<0.001). Majority (96%) of patients had depression and (85%) had ideation of
suicide. Significant association of depression was found with age, family income per month, duration
of illness, education level and diagnosis. Significant association of ideation of suicide with variables
was found with gender, and family income per month (p<0.05). The study concluded that the
terminally ill patients had depression and ideation of suicide. Therefore, guidelines were prepared
for them to reduce depression and developing positive attitude towards life.
Keywords: Depression, Ideation Of Suicide And Terminally Ill Patients
DOI Number: 10.5958/j.0974-9357.5.2.054
without such a desire4. The incidence of depression in
dialysis patients ranges from 10% to 66%. Risk factors
identified for completed suicide and suicidal ideation
in cancer patients include mental health, socio-
demographic and illness factors5.
OBJECTIVES
1. To assess the depression among terminally ill
patients.
2. To assess the ideation of suicide among terminally
ill patients.
3. To ascertain the relationship between depression
and ideation of suicide among terminally ill
patients.
4. To find out the relationship of depression and
ideation of suicide with variables like age, gender,
family income per month, duration of terminal
illness, education, diagnosis.
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220 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
METHODOLOGY
Design : Non – experimental with exploratory
approach
Setting : Selected hospitals (CMC & H and
DMC & H), Ludhiana, Punjab
Population : Terminally ill patients (ESRD, Cancer)
Sample size : 100
Sampling : Purposive sampling technique (non
technique random sampling).
MATERIAL AND METHOD
The study was conducted in the selected hospitals
at Ludhiana, Punjab from 6th December 2010 to 10th
January 2011. During this study period the terminally
ill patients admitted in hospital and attending out
patient department were explained regarding the
nature of study and written consent was taken from
them by assuring to maintain their confidentiality.
Structured interview method was used to collect the
data from the samples who gave their consent.
Standardized Beck Depression Inventory II was used
to assess depression and Mini International
Neuropsychiatric Interview for Suicidality to assess
ideation of suicide among terminally ill patients.
Depression was assessed according to the severity of
depression that is minimal, mild, moderate and severe
whereas ideation of suicide was assessed as the risk
category with absent, low, moderate and high risk.
Plan for Data Analysis
Descriptive statistics: Frequency, Percentage, Mean,
and Standard deviation
Inferential statistics: Karl Pearson’s Correlation
Coefficient, z-test, t- test and ANOVA.
FINDINGS
• Majority of terminally ill patients belonged to age
group 51-60 years (34%), Hindu religion (48%) ,
family income per month Rs.15, 001-20,000 (26%),
were males (61%), under matric (33%), married
(76%), diagnosed with cancer (61%) and had
duration of illness less than 1 year (50%).
Table 1: Percentage Distribution of Levels of Depression among Terminally Ill Patients N=100
Levels of Depression Score n %
Minimal 0-13 10 10
Mild Depression 14-19 31 31
Moderate Depression 20-28 34 34
Severe Depression 29-63 25 25
Maximum score= 63
Minimum score = 0
Table 1 depicts that maximum terminally ill patients had moderate level of depression.
Table 2: Percentage Distribution of Risk of Ideation of Suicide among Terminally Ill Patients N=100
Risk of Ideation of Suicide Score n %
Absent 0 10 10
Low 1-5 60 60
Moderate 6-9 20 20
High ≥ 10 10 10
Maximum Score=33
Minimum Score=0
Table 2 depicts that maximum number of terminally ill patients (60%) had low risk of ideation of suicide.
• Depression and ideation of suicide had moderate positive correlation (r = 0.515, p<0.001) i.e. the patients
who has depression have ideation of suicide.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 221
•Statistically significant difference was found in
depression score with variables age, family income
per month, duration of illness, education level and
diagnosis on the other side gender, and family
income per month for ideation of suicide.
CONCLUSION
The study concluded that terminally ill patients
who had depression had ideation of suicide. Therefore,
guidelines were prepared by keeping in mind the
findings of the study to reduce depression and
promoting good health. Nurses working in the areas
dealing with terminally ill patients should understand
the various emotional and psychological problems of
the patients who are suffering from terminal illness,
so that they can prevent the negative thinking which
can lead to depression and ideation of suicide. Health
care professionals can identify more prevalent
symptoms of depression and ideation of suicide at
early stage and differentiate them from the general
course of terminal illness to prevent any negative effect.
ACKNOWLEDGEMENT
I express my deep sense of gratitude and heartfelt
thanks to all my seniors, classmates, participants and
all those who helped me to complete my project.
Conflict of Interest: None
Source of Support: Didn’t get any financial support
from any body. It was an individual project during post
graduate period and got guidance from my supervisor.
Ethical Clearance: Written permission was taken from
MS and ethical committee of both the hospitals before
collecting the data. Written consent was taken from
the participants.
REFERENCES
1. Srivastava AS, Kumar R. Suicidal Ideation and
Attempts in Patients with Major Depression.
Indian Journal of Psychiatry. 2005; 47: 225-28.
2. Cohen Lewis M, Steven K Dobscha, Kevin C
Hails, Penelope S Pekow, Harvey Max
Chochinov. Depression and Ideation of Suicide
in Patients who discontinue the Life Support
Treatment of Dialysis. Psychosomatic Medicine.
2002; 64: 889-96.
3. Tatsuo Akechi, Hitoshi Okamura, Akira Kugaya,
Tomohito Nakano, Tatsuro Nakanishi, Nobuya
Akizuki et al. Suicidal Ideation in Cancer Patients
with Major Depression. Journal of Clinical
Oncology. 2000; 30 (5): 221-24.
4. Latha KS & SM Bhat. Suicidal Behavior among
Terminally Ill Cancer Patients in India. Indian
Journal of Psychiatry. 2005; 47(2): 79-83
5. Fisher BJ, Haythornthwaite JA. Suicidal Intent in
Patients with Chronic Pain. Clinical Journal of
Pain. Jan, 2001; 89 (2-3): 199-206.
6. Ruth Anne Van Loon. Desire to Die in Terminally
Ill People. Health and Social Work. 1999; 24.
7. Kimmel Paul L, Manjula Kurella. Suicide in ESRD
Patients. Journal of American Society of
Nephrology. 2005; 16: 774-81.
8. Kaplan and Sadock’s. Synopsis of Psychiatry. 10th
Edition. Lippincott Williams and Wilkins. 2007.
Fig. 1. Relationship of Depression and Ideation of Suicide among
Terminally Ill Patients
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222 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
Clinical competence develops over time. Benner
identified five stages of competence: novice, advanced
beginner, competent, proficient and expert.1 Stage 3
in this process is the competent nurse, which is typified
by someone who has been on the job in the same or
similar situations for two or three years. Baramee and
Blegen identified three domains in which one may
become competent: cognitive, affective and
psychomotor.2 Baramee and Blegen posed a number
of questions related to the competence of new
graduates, including: (a) whose perception is it that
new graduates lack competence; ( b) on which
standards are new graduates’ competence based; (c)
on which competence components are new graduates
thought to be lacking; (d) why do new graduates lack
competence; and (e) how can this problem be
remedied? Once competence is reached in each
domain, they are integrated and applied in a clinical
situation. The integration and application or clinical
judgment is often referred to as clinical competence.
A Cross-Cultural Comparison of a Clinical Nurse
Competency Path Model
Susan B Sportsman1, Patti Hamilton2, Randall E Schumacker3
1Director, Academic Consulting Group, Elsevier, 2Professor, Texas Woman's University, College of Nursing, 3Professor,
The University of Alabama, Box 870231, 316 Carmichael Hall, Tuscaloosa, AL 35487
ABSTRACT
A path model of clinical nurse competency was proposed in Thailand based on key variables that
impact nursing. The path model was improved by adding a path from perception of student effort to
perception of clinical learning environment. Data from a nursing program in the U.S. was applied to
the improved Thailand path model. Results indicated that the path model was similar between the
two countries. This provided a cross-cultural validation of the clinical competency path model.
Research findings suggest further investigation of the negative relation between GPA and clinical
competence.
Keywords: Clinical Competence, Cross-Cultural Study, Multiple Group Analysis
DOI Number: 10.5958/j.0974-9357.5.2.054
Corresponding author:
Randall E Schumacker
Professor
The University of Alabama, Box 870231, 316
Carmichael Hall, Tuscaloosa, AL 35487
Phone: (205) 348-6062
rschumacker@ua.edu
Tanner defined clinical judgment, or “thinking like a
nurse” as “an interpretation or conclusion about a
patient’s needs, concerns or health problems, and/or
the decision to take action (or not), use or modify
standard approaches, or improvise new ones as
deemed appropriate by the patient response”. 3
Tanner ’s model of clinical judgment involved noticing,
interpreting, responding and reflection (p. 208).
Del Bueno reported that only 35% of new nurse
graduates were able to meet expectations for entry-
level clinical judgment when evaluated by the Problem
Based Development System (PBDS).4 PBDS involves
the assessment of nurses’ clinical judgment using
patient-focused exercises presented by video
simulation. This system, used by more than 350 health
care agencies in 46 states in the U.S., is designed to
evaluate nurses’ critical thinking and interpersonal
skills and abilities in a variety of clinical situations.
The nurses’ responses are compared to validated
criteria for each situation. The resulting evaluation
ranges from unacceptable (unsafe) to expert (exceeds
expectations). Although new graduates are expected
to be at the entry (safe practice) level, analysis of data
collected from 1995 to 2005 found that from 65% to
76% of newly graduated registered nurses do not
achieve this entry point.
Burns and Poster described a similar situation in
the competence of new graduates. 5 They based their
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 223
opinion on comments by a consortium of nursing
schools deans and nurse executives in a metropolitan
area who met to discuss employers’ concerns for the
readiness of new graduates to enter the work force.
These nurse executives reported that new graduates
had difficulty “critically thinking on their feet” or
managing patient situations, especially those requiring
quick, accurate decisions and actions. Similar results
were found by the Advisory Board Company who
implemented a survey on new graduate practice
readiness.6 Frontline nurses were asked to rate their
level of satisfaction with new graduate proficiency on
36 critical competencies identified by the Nursing
Executive Center in cooperation with a cross-section
of nursing administrators and clinical experts. The
survey found that that new graduates met the
performance expectations of over half of their unit
managers on only two competencies: “Utilization of
Information Technologies” and “Rapport with Patients
and Families”. Thus, three years later, the concerns
expressed by Del Bueno as well as Burns and Poster
continue to plague nursing education and practice.
Nursing programs today are using high fidelity
patient simulation in the nursing curriculum to address
clinical competence of nurses. Students are asked to
rate their perception of their clinical competence when
evaluating their patient simulation learning
experience. At least two studies used focus groups to
elicit student perceptions of their clinical competence
before and after participating in high fidelity patient
simulation. 7,8 Lassater reported that: “simulation
served as an integrator of learning, that it brought
together the theoretical bases from their classes and
readings, as well as the psychomotor skills from
laboratory and lessons learned from clinical practice,
requiring them to critically think about what to do.”7
Similarly, Bradshaw and Sportsman noted that:
“Participation in simulation brings everything
together” and “it makes you realize you know more
than you think you do”.8
Research into the clinical competence of nurses has
become an international concern.9,10 The concern about
the competence of new graduates provided the basis
for the Baramee and Blegen study. They explored
variables prior to and during a nursing students’
educational process which influenced the perception
of their clinical competence. They identified key
variables when defining a path model of nursing
competency. The purpose of this study was to compare
the path model proposed by Baramee and Blegen with
a similar path model developed by the authors using
a new sample of data.
METHODS AND PROCEDURES
Participants
Baramee and Blegen did not report the age and
gender of the students from Thailand.
The U.S. nursing data were female with an age
range from 19 to 50 years (63% were between 19-29
and 25% between 30-39). Although age and gender
influences a students’ learning, these variables were
not included in the Baramee and Blegen path model
and therefore not included in the cross cultural path
model comparison.11,12
Instruments
The Clinical Competency Appraisal Scale (CCAS),
a 44 item instrument, was an adaptation of the Clinical
Competency Rating Scale (CCRE) by Sheetz and the
6-DSNP instrument by Schwirian.13,14 The five CCAS
subscales included the Psychomotor Skills Perception
(PSP), Leadership, Teaching/Collaboration, Planning/
Evaluation and Interpersonal Relationships/
Communication. The Cronbach alpha reliability
coefficients for these subscales ranged from 0.82 to
0.95.
The Learning and Study Strategies Inventory was
designed to assess how respondents learn and study.15
Student effort was measured by the concentration, self-
testing, study aids, and time measurement scales.
According to the authors, these scales measured how
students manage or self-regulate and control the entire
learning process, by using their time effectively,
focusing their attention and maintaining their
concentration over time, checking to see if they have
met the learning demands for a class, assignment or a
test, and using study supports such as review sessions,
tutors or special features of a textbook. The Cronbach
Alpha reliability coefficients for these subscales ranged
from 0.73 to 0.89.
The Clinical Learning Environment Scale, a 23- item
survey, assessed student satisfaction with the clinical
experience during their last semester.16 It is composed
of five subscales: (1) staff-student relationships; (2)
nurse manager commitment; (3) patient relationships;
(4) interpersonal relationships; and (5) student
satisfaction. Dunn and Burnett reported that factors
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224 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
within the scales have strong substantive face and
construct validity, as determined by confirmatory
factor analysis.16 The reliability coefficients range from
.63 to .85.
Personal hardiness was measured by a sense of
commitment to a goal, a perception of control over the
environment influencing the goal, and the ability to
view change as a challenge. A person with positive
levels of each of these dimensions is theorized to be
protected against stress, particularly if the stress is
severe and repeated. Hardiness is most protective
during severe stress by altering the perception of stress
and mobilizing effective coping techniques.17 The
Personal View Survey (PVSIII-R) was used to measure
graduates’ level of personal hardiness.18 The PVSIII-
R is an abridged form of the original 50-item Personal
View Survey (PVS). The PVSIII-R correlated .91 with
the original Personal View Survey. Internal consistency
reliability of the PVSIII-R ranged from .70 to .75 for
commitment; .61 to .84 for control; .60 to .71 for
challenge; and .80 to .88 for total scores. The Cronbach
Alpha coefficient was .65 in the Baramee and Blegen
study.
Graduating grade point average (GPA) for all
students participating in the study was collected by
accessing university data bases. Grades for all courses
required for the BSN degree were included in the
calculation of the graduation grade point average.
CORRELATION DATA
The observed variables were ordered in the
correlation matrix as: hardiness, student effort, clinical
learning environment, grade point average, and
clinical competence. The correlation matrix from the
Baramee and Blegen study, n = 453 nurses, was:
1.0
.38 1.0
.19 .25 1.0
.07 .24 .02 1.0
.16 .28 .23 -.08. 1.0
The correlation matrix from the U.S. study, n = 80
nurses, was:
1.0
.509 1.0
.185 .208 1.0
.166 .318 -.181 1.0
.062 -.086 .154 -.222 1.0
The LISREL-SIMPLIS program was used with these
correlation matrices to test the individual path models
and the multiple group analysis for testing a difference
in the path model between the two countries, Thailand
and U.S.19
Path Model
The Baramee and Blegen path model, based upon
Tinto’s theory of student departure and the Pascarella
and Terenini model of assessing change, defined key
variables that influenced the perception of students
regarding their clinical competence at the time of
graduation from a baccalaureate nursing program in
Thailand.2, 20, 21 Baramee and Blegen concluded that
five variables, including perception of nurses own
hardiness, effort in their studies, clinical learning
environment, and student-faculty relationship, as well
as graduating grade point average, produced a path
model to explain students’ perception of their own
clinical competence.
Their path analysis indicated that students’
perception of their own effort, the clinical learning
environment, and the graduation grade point average
had a direct effect on the perception of clinical
competence. Students’ sense of their own hardiness
had an indirect effect on their perception of clinical
competence through its impact on their perception of
their effort, clinical learning environment and the
student-faculty relationship. They questioned their
results which only showed a 12% variance explained
in the outcome variable with a statistically significant
chi-square model fit; which is not an acceptable model
fit. We re-analyzed their path model, adding a path
from perception of student effort to perception of
clinical learning environment, and obtained a R2 = 34%
and a non-significant chi-square statistic indicating a
good data to path model fit (Table 1 [B&B Revised];
Chi-square=1.72, df=3, p=.63).
The U.S. path model used a set of data from 80
nursing students who graduated from a baccalaureate
nursing (BSN) program in a U. S. accredited
university.22 Although Baramee and Blegen identified
faculty-student relationships as one of the variables
influencing students’ sense of clinical competence, the
present study excluded the faculty-student
relationship variable because the researchers were
unable to obtain permission to use the instrument.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 225
RESULTS
The original Baramee and Blegen path model did
not indicate a good fit to the data (Table 1: B&B),
implying that the variance-covariance amongst the
variables was not explained well by this path model
(Chi-square = 19.35, df = 4, p < .001). In structural
equation modeling, we seek a non-significant Chi-
square to signify that there is no statistical difference
between the sample variance-covariance matrix of
observed variables and the model implied variance-
covariance matrix that is generated based on the
model.23
The Baramee and Blegen revised path model,
indicated a better fitting path model (Table 1: B&B
Revised, Chi-square = 1.72, df = 3, p = .63). The
additional path is supported by educators who have
suggested that the greater a student believes their effort
to be, the more positive they view the clinical learning
environment. Baramee and Blegen overlooked an
important relation in their path model. The U.S. path
model indicated a good fit (Table 1: U.S. Path Model,
Chi-square = 6.74; df = 3, p < .08), but differed in a
negative path coefficient from perceived student effort
to clinical competence ( - .06).
Both path models had a negative relation between
grade point average and students’ perception of
clinical competence (-.15 and -.18, respectfully). This
relation implies that a lower grade point average was
associated with higher perceived clinical competence.
Baramee and Blegen suggested a possible reason for
this finding. High academic achievement may
encourage graduates to set unrealistically high goals
for themselves. As students evaluate their clinical
competence, they may be reluctant to rate themselves
as highly competent when compared with more
experienced nurses. In contrast, students with low
self-esteem and low academic achievement may be less
accurate in self-evaluation, because feelings of
insecurity, inefficiency and loss of confidence might
be compensated for by giving themselves a high rating
on clinical competence. Despite the possible
explanation for the association between a lower grade
point average and higher clinical competence, they
noted that this finding in their research should be
interpreted with caution.
Multiple Group Analysis
Our hypothesis was to test whether the path model
was the same or different between the Thailand and
U.S. students. The multiple group comparison of the
path model was conducted in LISREL to test the
hypothesis.19, 23 The resultant non-significant Chi-
square = 20.82, df = 17, p = .23, indicated that the path
model was the same for the Thailand and U.S. nursing
students. The path model is diagramed in Figure 1
with the common path coefficients and the results are
reported in Table 1. The common path model, being
the same for both the U.S. and Thailand nursing
students implied a viable theoretical model to explain
clinical competence in nursing and established validity
of the Baramee and Blegen path model, as revised.
CONCLUSIONS
The re-analysis of the Baramee and Blegen path
model revealed an important relation in the model that
produced a better fitting model. The discrepancy in
the U.S. path model (negative path coefficient) was not
apparent in the multiple group analysis. Both groups
however did have negative path coefficients from
grade point average to perceived clinical competence
in the individual and multiple group path analysis.
This implies that lower grade point averages are
associated with higher clinical competence, which
doesn’t relate well to theory, so further research is
warranted. The multiple group analysis indicated a
common path model with clinical competence
predicted at R2 = .40, therefore they were not different.
This study supported a cross cultural comparison of a
clinical competence path model in nursing and
validated the initial work of Baramee and Blegen.
Our findings validate that students’ sense of their
hardiness indirectly affects their perception of clinical
competence and graduating GPA through its effect on
their perception of their effort and clinical learning
environment. As a result, students who have this
internal characteristic may have an advantage in
coping with the stress inherent in nursing programs.
Perhaps this characteristic, as measured by reliable and
valid scores from an instrument such as the PVS III-R,
should be one of the criteria for admission.
Fig. 1. Common Path Model for Thailand and U.S. Students
Perception of Hardiness
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226 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Table 1: Path Model Results
Paths in Model B&B B&B Revised U.S. PathModel Multiple
GroupModel
Hardiness’!Student Effort .38 .38 .51 .40
Hardiness’!Clinical Learning Environment .19 .11 .11 .11
Student Effort’!GPA .24 .24 .32 .25
Student Effort’!Clinical Competence .28 .28 -.06 .23
Clinical Learning Environment’!Clinical Competence .17 .16 .13 .16
Student Effort’!Clinical Learning Environment .21 .15 .20
GPA’!Clinical Competence -.15 -.15 -.18 -.16
Chi-square (df: p) 19.35(4: .001) 1.72 (3: .63) 6.74 (3: .08) 20.82 (17: .23)
RMSEA .09 0 .13 0
CFI .92 1.0 .89 1.0
R-squared .31 .34 .40 .40
ACKNOWLEDGMENT
High Fidelity Clinical Simulation: A Regional
Collaborative for Increasing Nursing Enrollment and
Accelerating the Orientation of New Graduates.
Nursing Innovation Grant-Category D. Texas Higher
Education Coordinating Board. $1,272,410
Conflict of Interest: There is no conflict of interest in
the research, analysis, and manuscript.
Source of support: Manuscript preparation did not
receive any financial support. Authors contributed in
the writing and preparation of the manuscript.
Ethical Clearance: The Institutional Review Board
(IRB) at the Midwestern State University, 3410 Taft
Boulevard, Wichita Falls, Texas, (940) 397-4352,
approved the research.
REFERENCES
1. Benner, P. From novice to expert: Excellence and
power in clinical nursing practice. Menlo Park:
Addison-Wesley; 1984.
2. Baramee, J. & Blegen, M. New graduate
perception of clinical competence: Testing a
causal model. International Journal of Nursing
Studies. 2003; 40: 489-399.
3. Tanner, C. Thinking like a nurse: A research-
based model of clinical judgment in nursing.
Journal of Nursing Education. 2006 June; 45(6):
204-211.
4. Del Bueno, D. (2005, September/October) A crisis
in critical thinking. Nursing Education
Perspectives. 2005 September/October; 26(5):
278-282.
5. Burns, P. & Poster, E. (2008, February)
Competency development in new registered
nurse Graduates; Closing the gap between
education and practice. The Journal of
Continuing Education in Nursing. 2008 February;
39(2): 67-73.
6. The Advisory Board Company. Capturing the
academic and industry perspectives: Nursing
Executive Center Dual Survey Methodology
[Internet]. 2008. Available from: http://
www.advisory.com/Research/Nursing-
Executive- Center/Studies/2008/Bridging-the-
Preparation-Practice-Gap-Volume-I.
7. Lassater, K. High-fidelity Simulation and the
development of clinical judgment: Students’
experiences. Journal of Nursing Education. 2007
June; 46(6): 269-276.
8. Bradshaw, P. & Sportsman, S. Student Nurses’
Perception of their Clinical Competence. 17th
International Nursing Research Congress
Focusing on Evidence-Based Practice
[conference]. 2006 July 19-22. Sigma Theta Tau
International, Honor Society of Nursing,
Montreal, Quebec, Canada.
9. Ofori, R. & Charlton, J.P. A path model of factors
influencing the academic performance of
nursing students. Journal of Advanced Nursing.
2002; 38(5): 507-515.
10. Blackman, I., Hall, M, & Darmawan, I.G.N.
Undergraduate nurse variables that predict
academic achievement and clinical competence
in nursing. International Education Journal. 2007;
8(2): 222-236.
11. Arnold, J.C. The Influence of student effort,
college environment and selected student
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characteristics on undergraduate students
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metropolitan institutions. [conference]. 1991.
ASHE Annual Meeting Paper Available from:
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339296&ERICExtSearch_Sear chType_ 0=no
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12. Selvarajah, C. Cross-cultural study of Asian and
European student perception: The need to
understand the changing educational
environment in New Zealand. Cross Cultural
Management: An International Journal. 2006;
3(2): 142-155.
13. Sheetz, L. Baccalaureate nursing student
preceptorship programs and the development of
clinical competence. Journal of Nursing
Education. 199; 28: 29-35.
14. Schwirian, P. M. Evaluating the performance of
nurses: a multidimensional approach. Nursing
Research. 1978; 27: 347-351.
15. Weinstein, C., Schulte, A. & Palmer, D. Learning
and study strategies inventory (LASSI) Users
manual (2nd Edition). Clearwater, Florida: H &
H Publishing; 2002.
16. Dunn, S & Burnett, P (1995). The development
of a clinical learning environment scale. Journal
of Advanced Nursing. 1995; 22: 1166-1173.
17. Schwab, L. Individual hardiness and staff
satisfaction. Nursing Economics. 1996 May-June;
14(3): 353-359.
18. Maddi, R. & Khoshaba, D. Personal views survey
(3rd Revision). Newport Beach: Hardiness
Institute Inc.; 2001.
19. Jöreskog, K.G. & Sörbom, D. LISREL 8.8 for
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International; 2006.
20. Tinto, V. Leaving College: Rethinking the causes
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Evaluating the Impact of Scenario- Based High
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23. Schumacker, R. & Lomax, R.G. A Beginner’s
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228 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
“Tuberculosis for which effective interventions exist
remains an orphan and the world should be ashamed”
Kevin Delock
Humanity has probably recognized tuberculosis as
a killer disease since the ice age. It is a debilitating
disease which can prove fatal if left untreated.
Tuberculosis is the single largest infectious cause of
death among young people and adults in the world,
accounting for nearly two million deaths per year.
Tuberculosis was declared a “global emergency” by
WHO in 1993 because of its toll on the health of
individuals and wider social and economic impact on
the overall progress of a country.1
According to the 13th annual tuberculosis report
published by WHO on World Tuberculosis Day; there
were an estimated 9.27 million new cases of
tuberculosis worldwide in 2007. Disturbingly, there
were approximately 500,000 cases of multidrug
resistant tuberculosis in 2007, of these 131,000 were in
India.2
Identify the Impact of Tuberculosis on Health Status and
Coping Strategies Adopted by Tuberculosis Patients
Rashmi1, Shobha Prasad2, Sulakshna Chand3
1Assistant Professor, 2Professor, 3M. M. College of Nursing, Mullana Ambala, Haryana
ABSTRACT
A study to identify the impact of tuberculosis on health status of tuberculosis patients and coping
strategies adopted by tuberculosis patients with a view to develop pamphlet at selected DOTS centers
in Ambala district of Haryana. Sample subjects were drawn by purposive sampling. The sample
comprised of 100 tuberculosis patients attending DOTS centers of Ambala for tuberculosis treatment.
Significant findings of the study were that Fifty subjects had mild impact of tuberculosis on health
status, 45 subjects had moderate impact of tuberculosis on health status and five subjects had severe
impact of tuberculosis on their health status. Maximum impact of tuberculosis was on physical health
followed by mental health, spiritual life and social life. The most frequently adopted coping strategy
was Logical analysis followed by problem solving, emotional discharge, positive reappraisal. A low
negative relationship was established between impact of tuberculosis on health status and coping
strategies adopted by tuberculosis patients. There was no significant association between impact of
tuberculosis on health status of subject and age, gender, educational status, occupation, marital status,
family income, number of rooms in residing house, number of family members place of residence
and category of treatment.
Keywords: Tuberculosis, Tuberculosis Patients, Health Status, Coping Strategies, Pamphlet
DOI Number: 10.5958/j.0974-9357.5.2.054
In 2008, there were approximately 9.4 million new
cases of tuberculosis. India had the largest number of
cases, with an approximate 1.6-2.4 million new cases,
closely followed by China with 1-1.6 million new
cases.3
It is estimated that 40% of the population in India
is infected with the tuberculosis bacilli and about 10%
of them will develop tuberculosis disease during their
lifetime. There are over 8.5 million tuberculosis patients
in India with an incidence of 1.9 million cases annually
including 0.8 million newly infected cases.
Thread that runs through the journey of all the
tuberculosis patients is stigma related to the disease.
Central to the experience of tuberculosis, for both
patients and their households, is anticipated and
enacted stigma. Tuberculosis patients all experience
verbal stigma and social exclusion. Rejection is another
common form of stigma; broken relationships with
spouses or partners during tuberculosis illness are not
uncommon. Fears around tuberculosis transmission
and social and physical exclusion of tuberculosis
patients is very much evident.4
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 229
It was highlighted by Bhatia et al that while looking
at the medical aspects of the disease, one cannot ignore
related social aspects to it. The way people think about
the disease, the economic and social deprivation of the
person suffering from the disease, contribute to the
recovery from the disease.5
It is a well known fact that people respond to their
problems and situations in different manner. Similarly
in stress, people adopt different coping strategies.
Individuals who cope effectively are able to accept a
diagnosis; seek for the information related to problem
solving; talk with the family members and friends,
adopt some positive attitude and actions. Better coping
means stronger determination, less illness and better
health. Thus, use of positive coping strategies means
people are stronger, earn better, take responsibilities
and are more productive.
OBJECTIVES
1. To identify the impact of tuberculosis on health
status of tuberculosis patients.
2. To identify the coping strategies adopted by
tuberculosis patients.
3. To determine the relationship between impact of
tuberculosis on health status and coping strategies
adopted by tuberculosis patients.
4. To determine the association of impact of
tuberculosis on health status with selected
variables of tuberculosis patients.
5. To develop and validate a pamphlet on healthy
coping strategies for tuberculosis patients.
MATERIAL AND METHOD
The present study was conducted at selected DOTS
centers of urban area of Ambala, Haryana; Civil
Hospital, Ambala Cantt; TB Hospital, Ambala City;
Railway Hospital, Ambala Cantt. The target
population for the present study comprised of patients
diagnosed with tuberculosis. 100 patients with
tuberculosis were selected by using purposive
sampling. The study was carried out in the month of
November and December 2011.
Data collection tools were constructed to obtain the
data; Structured interview schedule to identify the
impact of tuberculosis on health status of tuberculosis
patients, Moo’s coping rating scale to identify the
coping strategies adopted by tuberculosis patients.
Section I: 16 items which were designed to obtain
demographic information such as age, gender, religion,
occupation, type of family, marital status, family
income, type of house, number of rooms, number of
family members, place of residence, duration of illness,
number of previous hospitalization due to
tuberculosis, any health education program attended
on anti tubercular treatment, category of treatment for
tuberculosis.
Section II: Structured interview schedule was
developed to identify the impact of tuberculosis on
health status of tuberculosis patients. It comprised of
30 items with the following domains of impact;
Physical impact, Mental impact, Social life impact,
Spiritual life impact.
Section III: Moo’s coping rating scale comprised
of 48 items with the following domains; Logical
Analysis, Positive Reappraisal, Positive Reappraisal,
Selecting Guidance and Support, Problem Solving,
Cognitive Appraisal, Acceptance or Resignation,
Seeking Alternative Rewards, Emotional Discharge.
The validity of the tool was established by
consultation with experts. The reliability for structured
interview schedule was computed by cronbach’s alpha
method and is found to be r = 0.82 and another was
standardize tool of Moo’s coping inventory.
Pilot study was conducted which did not indicate
any major flaws in the feasibility and design of the
study.
Study was conducted in month of December, 2010.
Structured Interview Schedule and Modified Moo’s
Coping rating Scale was administered to collect the
data regarding impact of tuberculosis on health status
and coping strategies by using interview technique.
Five to six tuberculosis patients were interviewed in a
day. On an average it took 50-60 minutes to collect data
from each subject. Data was analysed using inferential
and deferential statistics. Frequency and percentage
distribution, Coefficient of correlation, Chi- square
were used to infer the collected data.
RESULTS
Total 100 patients were enrolled in the study. Forty
five percent of subjects were in age group of 20-30
years. Maximum number of subjects (63%) was male.
All the subjects (100%) were Hindu. Thirty six percent
of subjects had primary education. Forty three percent
of subjects were self employed as educational status.
Maximum number of subjects (53%) were from nuclear
families. Majority of subjects (77%) were married.
Majority of subjects (88%) had income below Rs. 5000/
- per month. All of subjects (100%) were living in pucca
houses. Maximum number of subjects (55%) was
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230 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
having one to two rooms in their residing houses.
Maximum of subjects (53%) were having five to seven
members living in the house. Majority of subjects (84%)
were residing in their own house. All of subjects (100%)
were having disease duration less than 1 year. None
of the subjects were previously hospitalized due to
tuberculosis. None of the subjects had attended any
formal health education program on Anti Tubercular
treatment.
Mean deviation and standard deviation for impact
of tuberculosis is 51.55 and 9.61 respectively. Mean
deviation and standard deviation for coping strategies
adopted by tuberculosis patients is 102.82 and 18.24
respectively. There was no significant association of
impact of tuberculosis on health status of subject with
selected variables.
Table 1 Frequency Percentage distribution of
Tuberculosis Patients in terms of Severity of Impact of
Tuberculosis on Health status N= 100
Range of Score Severity of Impact f%
30-50 Mild 50
51-70 Moderate 45
71-90 Severe 05
Maximum Score: 90
Minimum Score: 30
The data presented in Table 1 reveals that 50%
subjects had mild impact of tuberculosis on health
status whereas 45% subjects had moderate impact of
tuberculosis on health status. Five percent subjects had
severe impact of tuberculosis on health status.
Table 2. Domain wise Mean, Mean Percentage,
Standard Deviation and Rank order of Impact of
Tuberculosis on Health Status of Tuberculosis Patients
N =100
Domains Max possible Mean Mean % SD Rank
Score order
Physical 27 17.62 65.53 3.83 I
Mental 27 15.58 57.70 4.02 II
Social 30 15.19 50.63 4.87 IV
Spiritual 6 3.16 52.66 1.05 III
The data presented in Table 2 shows that highest
mean percentage score in the physical domain with a
mean % of 65.5 ranked as I, followed by mental health
domain at II rank with mean % 57.70. The spiritual
domain was ranked III with a mean % score of 52.66.
The data further suggest that maximum problem were
faced is the physical problems followed by mental,
spiritual and social.
Table 3 Domain wise Mean, Mean Percentage, Standard Deviation and Rank Order of Coping Strategies Adopted
by Tuberculosis Patients N=100
Domains of Coping Strategies Mean Mean % SD Rank order
Logical analysis 14.20 59.16 3.37 1
Positive reappraisal 12.69 52.87 3.27 4
Selecting guidance and support 12.44 51.83 3.23 5
Problem solving 13.88 57.83 2.99 2
Cognitive reappraisal 12.22 50.91 2.80 7
Acceptance or rejection 12.35 51.45 3.55 6
Seeking alternative reward 11.96 49.83 3.11 8
Emotional discharge 13.08 54.5 3.06 3
Maximum possible score for each domain is 24.
The data presented in Table 3 shows that the maximum mean % score was obtain on logical analysis domain
(59.16%) followed by problem solving (57.83%) and emotional discharge (54.5%) domain of coping strategies.
Table 4 Correlation between Health Status and Coping Strategies Adopted by tuberculosis patients N= 100
Variables Mean Standard Pearson
Deviation correlationr
Health status 51.55 9.61 -0.04NS
Coping Strategies Adopted 102.82 18.24
‘r’ (98) e” 0.995
NS not significant at 0.05 level
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 231
The findings in table 4 shows that the coefficient of
correlation computed between health status and
coping strategies was found to be -0.04. This shows
that a low negative relationship exist between health
status and coping strategies adopted by tuberculosis
patients. Thus the null hypothesis H01 was accepted
and research hypothesis H1 was rejected. Concluding
there is no significant relationship between health
status and coping strategies adopted by tuberculosis
patients.
DISCUSSION
The purpose of this study was to identify the Impact
of Tuberculosis on Health Status of Tuberculosis
patients and Coping Strategies Adopted by
Tuberculosis patients.
Findings of the present study revealed that
tuberculosis reflected the overall health of subjects. The
maximum impact was on physical health as followed
by mental heath, spiritual life and social life. These
findings are supported by a study conducted by
Noronha V A (2005) which revealed that majority of
subjects affected by PTB has moderate to severe impact
on the health and life style of subjects.
Findings further showed that subjects used
different coping strategies to overcome the impact of
tuberculosis on health. These findings are also
supported by Noronha V A (2005) which showed that
subject used coping strategies in effective manner to
overcome the impact of tuberculosis on their health.
ACKNOWLEDGEMENT
At very outset, I would like to thank almighty for
his presence. My sincere thanks goes to all participants
of my study. Lastly and most importantly I am grateful
to everybody who was important to successful
realization of thesis.
Ethical Consideration: Ethical approval to conduct the
study was obtained from Institutional Ethical
Committee of M.M University, Mullana, Ambala,
Haryana. Written informed consent was obtained from
the study subjects regarding their willingness to
participate in the research project.
Conflict of Interest: There is no conflict of interest.
Funding Source: Self financed.
REFERENCE
1 WHO report 2006. Global tuberculosis control
2 WHO report 2009. 13th annual tuberculosis
report.nej.org.june4
3 Tuberculosis international health
organization.2011.Available from: http://
ganapserves.who.int/gho/interactive
4 Sullivan C. Impact of tuberculosis. 2009. Available
from: http://www.programs.ifpri.org/renewal/
pdf/zambia SA Final Report.pdf
5 Bhatia AK, Himani AB: Review of behavioral
studies in TB. Technical report series. CHEB: 1983
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232 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
Health is a multidimensional concept and must be
viewed from a broader perspective. Each person has
personal concepts of health and it will vary among
different age-group, race, and culture. Positive health
behaviours are related to attaining, maintaining, or
regaining good health and prevent illness, whereas
negative behaviours actually or potentially harmful
to health and can lead to illness1. Postoperative pain is
the one of the most common therapeutic problem in
hospital. Strategic aimed at reducing postoperative
pain, to increase patient comfort and shorten hospital
stay2.
Pain duration after the surgery is more prolonged
than anticipated. Pain interferes with the daily function
of the patient from first three days to a week. In
majority of patients, postoperative pain is preventable
with adequate analgesics and by appropriate use of
newer techniques3. A number of non-pharmacologic
Effectiveness of Music Therapy vs Foot Reflexology on
Pain among Postoperative Patients in Selected Hospitals
at Mangalore
Reena Baby1, Babu D2,
1M.Sc Nursing II Year, 2Associate Professor, Department of Medical Surgical Nursing, Yenepoya Nursing College
Deralakatte, Mangalore
ABSTRACT
A study to compare the effectiveness of music therapy vs foot reflexology on pain among postoperative
patients in selected hospitals at Mangalore. The main objective of the study was to compare the
effectiveness of music therapy vs foot reflexology among postoperative patients and determine the
association between level of pain and selected demographic variables of post operative patients.
The conceptual framework adopted for the study was based on the framework of King's Goal
Attainment Model. The research design adopted for the present study was two group pre test post
test(pre experimental) design. Purposive sampling technique was used to select the sample. The
main study conducted in Yenepoya Medical College Hospital by applying numerical pain scale
followed by administration of music therapy and foot reflexology twice a day for two days.
The mean of music therapy group was greater than foot reflexology group. Hence Foot reflexology
was more effective than music therapy. There was no significant association found between the level
of pain and age, gender, occupation, history of previous surgery, type of surgery, and marital status
except education status of postoperative patients.
Keywords: Effectiveness, Postoperative Patients, Post Operative Pain, Music Therapy, Foot Reflexology
DOI Number: 10.5958/j.0974-9357.5.2.054
or complementary therapies are used for pain relief.
Reflexology& music therapy has become one of the
most frequently used treatment modalities within
complementary medicine4.
MATERIAL AND METHOD
Two group pre test post test (pre experimental)
design has been adopted to attain the objectives of the
present study.
The investigator selected Yenepoya Medical
College, Deralakatte, Mangalore, to carry out the study
which is a 750 bedded multi specialty hospital with
the strength of 168 staff nurses. The sample size of the
present study consists of 60 patients with in of the age
group of 21-60 years and who undergone for
abdominal surgeries such as elective caesarean,
hysterectomy, hernioplasty, appendicectomy in a
selected hospital at Mangalore.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 233
Numerical rating scale used to assess the severity
of pain. The data collection was done from 19th
November 2012 to 7th December 2012 in Mangalore.
Data collection was done at Yenepoya Medical College
Hospital, Deralakatte. Subjects were selected according
to the selection criteria. The purpose of the study was
explained to the subjects and informed consent was
obtained. Their respondents were assured
confidentiality.
Firstly, the pre-intervention pain intensity was
measured in the music group and foot reflexology
group. An interval of 10 minutes was given, between
the pre-intervention assessment and the
commencement of music therapy and foot reflexology.
Music was administered for 20 minutes in the music
group and foot reflexology was administered 20
minutes in the foot reflexology group. Post-
intervention assessment of pain was performed
immediately after the cessation of the music therapy
and foot reflexology. The process was continued from
the postoperative day II to postoperative day III for
each subject. The intervention was repeated twice a
day, for two consecutive days, once in the morning
from 7 am to 10 am and in the evening between 4 pm
and 7 pm
FINDINGS
Table 1. To compare music therapy vs foot reflexology on
postoperative pain.
Test Group Mean Standard Mean ‘t’ value
score deviation difference
Post-test 1 MT 4.1 1.35 0.77 2.203*
FR 3.33 1.35
Post-test 2 MT 5.8 1.16 1.37 4.745*
FR 4.43 1.07
Post-test 3 MT 4.87 1.14 1.2 4.167*
FR 3.67 1.09
Post-test 4 MT 4.23 1.33 1.56 4.982*
FR 2.67 1.09
It was revealed from the above table the mean pain
score of MT (4.1±1.35) was higher than mean pain score
of FR (3.33±1.35) in post-test 1. The calculated ‘t’ value
(t=2.203) was greater than the table value (t58=1.671)
at 0.05 level of significance in post-test 1. The mean
pain score of MT (5.8±1.16) was higher than mean pain
score of FR (4.43±1.07) in post-test 2. The calculated ‘t’
value (t=4.745) was greater than the table value
(t58=1.671) at 0.05 level of significance in post-test 2.
The mean pain score of MT (4.87±1.14) was higher than
mean pain score of FR (3.67±1.09) in post-test 3. The
calculated ‘t’ value (t=4.167) was greater than the table
value (t58=1.671) at 0.05 level of significance in post-
test 3. The mean pain score of MT (4.23±1.33) was
higher than mean pain score of FR (2.67±1.09) in post-
test 4. The calculated ‘t’ value (t=4.98) was greater than
the table value (t58=1.671) at 0.05 level of significance
in post-test.
Association of pain level and demographic variables
The obtained chi-square values of age, marital
status, gender, occupation, history of previous surgery
and type of surgery (3.83, 0.02, 1.94, 0.347,0.5, 2.2, and
3.88) were lesser than the table values so there was no
significant association between the demographic
variables and the pre-test pain at the level of p<0.05
except education status (17.2).
CONCLUSION
The findings of the present study enabled the
candidate to compare the effectiveness of music
therapy vs foot reflexology on pain among
postoperative patients in selected hospitals at
Mangalore. The findings of the present study have
various implications for nursing practice, education,
administration and research. The use of non-
pharmacological measures like music therapy and foot
reflexology can be easily incorporated in nursing
education along with other complementary therapies.
In order to bring about the holistic health, music
therapy and foot reflexology can be practiced for better
health, to reduce pain.
ACKNOWLEDGEMENTS
I acknowledge my love and gratitude to all those
loving hearts who helped me throughout my
endeavour. With sincere gratitude and humility I
acknowledge the Almighty God for his abundant
grace, love, compassion and immense showers of
blessings on me which gave me strength, courage to
overcome all the difficulties during the study process.
His unseen presence helped me to complete this study
successfully.
Conflict of interest: Nil
Source of Funding: Nil
Ethical clearance: Ethical clearance obtained.
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234 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
REFERENCES
1. Tylor C, Lilllis C, Lemone P. Fundamentals of
nursing the art and science of nursing care. 6th
ed. New York: Lippincott Publications; 2008. P.
1365.
2. Singleton KJ, Sando AS. Primary care.
Philadelphia: Lippincott Publications; 1999.
P. 526.
3. Shorten G, Core BD. Postoperative pain
management: an evidence based guide to
practice. Philadelphia: Saunders Publication;
2006.
4. Kochkrow C. Foundation of nursing. 5th ed.
Missouri: Mosby Publications; 2006.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 235
INTRODUCTION
Pressure ulcers are not a plague of modern man;
they have been known to exist since ancient Egyptian
times. However, despite the increasing expenditure on
pressure ulcer prevention, a pressure ulcer remains a
major health care problem. Although nurses do not
have the sole responsibility for pressure ulcer
prevention, nurses have a unique opportunity to have
a significant impact on this problem.1 Pressure ulcers
are a localized injury to the skin and/or underlying
tissue usually over a bony prominence, as a result of
pressure, or pressure in combination with shear and/
or friction as evident by, redness, warm to touch,
blisters, tissue damage, breakdown of skin integrity.
Nurses' Practice Related to Prevention of Pressure Ulcer
among Patients and Factors Inhibiting and Promoting
These Practices
Rishu Anand1, Vinay kumari2, Rathish Nair3
1Lecturer Ved Nursing College Baroli, Panipat, 2Assistant Professor, 3Professor M. M. College of Nursing, Mullana
Ambala, Haryana
ABSTRACT
Pressure sores have plagued the nursing profession for many years as a major health care problem in
terms of a patient's suffering and financial cost. Current study is aimed to assess nurses' practices
related to prevention of pressure ulcer and identifying factors which inhibit and promote nursing
practices in relation to pressure ulcer prevention. An observational approach was used with descriptive
design on sample of 100 nurses from medical- surgical units of the Maharishi Markandeshwar Institute
of Medical Science and Research, Hospital, Mullana, Ambala selected by convenience sampling
technique.The data was collected by using observational checklist and rating scale. The nurses' practice
observed and showed that majority of nurses (87%) was performing fair practice for prevention of
pressure ulcer and only 2 nurses were doing good practice. There was no significant association of
level of preventive practice with age, gender, year of experience and there was significant association
of level preventive practice with area of work. Factors identified by nurses as promoter for practice
in relation to prevention of pressure ulcer are: Use of risk assessment tool, Use of pressure ulcer
prevention protocol, Teamwork & collaboration, Supervision of bedside practice by ward sisters.
Factors identified by nurses as inhibitor are: Lack of confidence in performing activities, Inadequate
skin care supplies, More involvement of nurses in non patient care activities, Knowledge deficit for
use of equipments and skin care products, Lack of patient co-operation in following commands, lack
of staff training and education. Therefore it is concluded that nurses' practice in relation to prevention
of pressure ulcer are not appropriate.
Keywords: Pressure ulcer, Nurses, Medical- Surgical units, Inhibiting and Promoting factors
DOI Number: 10.5958/j.0974-9357.5.2.054
The most common sites of pressure ulcers are the
sacrum, coccyx, heels, ischium, trochanter, malleolus,
elbow, spine, and occiput. 2
Moreover, pressure ulcers have been described as
one of the most costly and physically debilitating
complications in the 20th century.3 Pressure ulcers are
the third most expensive disorder after cancer and
cardiovascular diseases.44 Health Council of the
Netherlands: Pressure Ulcers. Publication No. 1999/
23. ISBN: 90-5549-302-3.
In addition, about 57–60% of all pressure ulcers
occur within hospitals.5 Up to 13% of patients develop
pressure sores while being treated in an intensive care.6
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236 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Recent studies conducted in Europe, the United States,
Canada and Australia have provided estimates of
pressure ulcer prevalence in hospitals ranging from
8.3% to 25.1%.7,8
Pressure ulcers may not directly cause death, but
the association with mortality may be due to their
occurrence in otherwise frail, sick patients.9
Prevention is the key to the management of
pressure ulcers. Implementation of best practice
guidelines should be utilized for all patients to
maintain skin integrity and prevent tissue breakdown.
A comprehensive multi-disciplinary team approach is
needed to prevent and treat patients with pressure
ulcers, especially high-risk, complex medical patients.10
The prevention of pressure ulcers represents a
marker of quality of care. Pressure ulcers are a major
nurse-sensitive outcome. Hence, nursing care has a
major effect on pressure ulcer development and
prevention. Prevention of pressure ulcers often
involves the use of low technology, but vigilant care is
required to address the most consistently reported risk
factors for development of pressure ulcers.11 Nursing
staff would make a greater commitment to lower the
rate of pressure ulcers provided with accurate, current
information on the costs of pressure ulcer treatment.
Keeping in view the present study was undertaken
to identify the nurses practice related to prevention of
pressure ulcer and factors inhibiting and promoting
the nursing practice. The finding of study will be useful
in reducing the incidence of pressure ulcer by
identifying factors which inhibit good nursing practice
and helpful in taking corrective measures against
identified factors.
OBJECTIVES
1. To assess nurses’ practice related to prevention of
pressure ulcer in medical- surgical units of the
selected hospital.
2. To identify factors inhibiting and promoting the
nurses’ practice in prevention of pressure ulcer
among patients.
3. To determine the association of level of preventive
practice with selected personal variables.
4. To develop and validate guidelines for pressure
ulcer prevention.
MATERIALS AND METHOD
Design, Sample and Tools and Techniques
The study was conducted in Maharishi
Markandeshwar Institute of Medical Sciences and
Research hospital Mullana, Ambala. The research
approach used was non-experimental with descriptive
research design. Hundred nurses working in medical-
surgical units were selected by convenience sampling
technique. Time sampling was used for observing
nurses’ practice. Three nurses were observed
simultaneously for 6 hours.
The tools developed and used for data collection
were observational check list having 19 items for
observing nurses’ practices towards prevention of
pressure ulcer and rating scale having list of 14 factors
were used to identify factors which act as promoter /
inhibitor for nurses’ practices in relation to prevention
of pressure ulcer. The data collection technique used
for assessing nurses’ practice was observation
technique by using observational checklist. Time
sampling was used. Factors inhibiting and promoting
nurses’ practice were identified by paper pencil
technique using Rating scale.
RESULT
Data was entered into Microsoft excel and analysed
using descriptive and inferential statistics. Frequency
and percentage, mean, median, Standard deviation
and mean percentage, chi-square were used to analyse
the nursing practice in relation to prevention of
pressure ulcer. Frequency and percentage used to
analyse the factors which act as promoter / inhibitor
for nursing practice in prevention of pressure ulcer.
The age of nurses enrolled in this study ranged from
20-40 years. Majority of the nurses (97%) belonged to
age group of 20-30 years and most of them were female
(87%). Majority of the nurse’s were single (67%) and
most of them were (68%) Hindus. All the nurses
(100%) had done General Nursing and Midwifery.
Majority (37%) of them had experience between 1-2
years and most of them (32%) were working in surgical
ward.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 237
Table 1. Frequency and Percentage distribution of
nurses according to level of preventive care
N-100
S.No. Level of Preventive Care Percentage
1. Good Practice (>75%) 2
2. Fair Practice (50-75%) 87
3. Poor Practice (<50%) 11
Table 1 depicts that only 2 staff nurses were doing
good practice in relation to pressure ulcer prevention.
Maximum nurses (87%) were performing fair practice
followed by 11% performing poor practices.
Table 2: Mean, Median, Range, Standard deviation of
practice score% of nurses regarding prevention of
pressure ulcer N-100
Mean Median Range S.D
58.36 57.89 41.67-81.82 7.98
NOTE:- Mean is calculated by percentage scores
obtained by nurses on observational checklist for
prevention of pressure ulcer.
Table 2 shows that mean score of nurses’ practice
regarding prevention of pressure ulcer was 58.36 ±
7.98; median was 57.89, ranging from 41.67- 81.82
Table 3. Frequency and percentage distribution of nurses according to identified inhibiting and promoting factors
for prevention of pressure ulcer
N-100
S. No. Factors Promoter% Rank Inhibitor% Rank
1. Use of risk assessment tool(Braden, Norton scale) 96 3 04 12
for assessing pressure ulcer.
2. Use of pressure ulcer prevention protocol. 97 2 03 13
3. Lack of confidence in performing activities for pressure ulcer due 06 12 94 03
to inadequate competences.
4. Teamwork and collaboration in performing activities for 100 01 - -
pressure ulcer prevention.
5. Lack of staff training and education regarding current practice for 33 08 67 07
pressure ulcer prevention and care.
6. Supervision of bedside practice by ward sisters. 82 06 18 09
7. Inadequate skin care supplies and products related to 05 13 95 02
prevention of pressure ulcer.
8. Year of experience (more experience can improve competence) 58 07 42 08
9. Involvement of family members in the preventive activities. 92 04 08 11
10. More involvement of nurses in non patient care activities. 18 09 82 06
11. Communication of patient’s risk of developing pressure ulcer to 90 05 10 10
other staff during change of shift.
12. Knowledge deficit for use of equipments and skin care products 11 10 89 05
related to prevention of pressure ulcer care.
13. Inadequate supplies of equipments & products related to 07 11 93 04
prevention of pressure ulcer.
14. Lack of patient co-operation in:
- Following commands. 01 14 99 01
- preventive care activities
Data present in Table 4 identify factors that act as promotor or inhibiter nurses’ practice in relation to pressure ulcer prevention.
Top 5 promoter factors identified by nurses are:
1. Teamwork and collaboration in performing activities for pressure ulcer prevention.
2. Use of pressure ulcer prevention protocol.
3. Use of risk assessment tool (Braden, Norton scale) for assessing pressure ulcer.
4. Involvement of family members in preventive activities.
5. Communication of risk of developing pressure ulcer to other staff during change of shift.
Top 5 inhibitor factors identified by nurses are:
1. Lack of patient co-operation in: Following commends.
- preventive care activities
2. Inadequate skin care supplies and products related to prevention of pressure ulcer.
3. Lack of confidence in performing activities for pressure ulcer due to inadequate competency.
4. Inadequate supplies of equipments & products related to prevention of pressure ulcer.
5. Knowledge deficit for use of equipments and skin care products related to prevention of pressure ulcer care.
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238 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Table 4. Chi-square showing association of levels of preventive care with selected personal variables
N-100
S. No Personal variables Levels of d.f Table Chi- P value
preventive practice value square
Good Fair Poor
1Age
20-30 2(2.27) 75(85.22) 11(12.5) 5.99 1.002NS 0.006
31-40 12(100) 2
2Gender
Male 1(7.69) 9(69.23) 3(23.07) 5,99 1.508 NS 0.47
Female 1(1.14) 78(89.65) 8(9.19) 2
3Year of Experience
<1 yrs 24(82.7) 5(17.2) 6 12.59 4.173 NS 0.653
1-2yrs 33(89.18) 4(10.81)
3-5yrs 2(9.09) 18(81.81) 2(9.09)
<5yrs 12(100)
4Area of Work
Ortho ward 24(100)
ICU 1(8.33) 11(91.66)
ICCU 14(100) 8 15.5 21.058* 0.007
Surgical ward 1(4.76) 20(95.23)
Medical card 18(62.06) 11(37.93)
Table-5 shows that chi square value computed
between level of preventive care with selected personal
variables age (χ2 =1.002) gender (χ2= 1.508) year of
experience
(χ2=4.173) were found to be statistically not
significant. This reveals that there was no significant
association between level of preventive care with age,
gender and year of experience. The chi-square value
computed between level of preventive care and area
of work (χ2=21.058)* was significant. This shows that
there was significant association between level of
preventive care and area of work.
Preventive activities differ significantly in different
areas of work only 2 nurses did good practice in ICU
& surgical ward. In medical ward11 nurses did poor
practice but none of the nurses in other areas of work
performed poor practice. Performance of nurses was
significantly poor as compared to other areas of work.
DISCUSSION
Pressure ulcers are a serious medical problem that
can affect a patient in any health care setting. Pressure
ulcers typically occur among patients who can’t move
or have lost sensation and result from prolonged
periods of immobility with uninterrupted pressure on
the skin, soft tissue, muscle, or bone.
The present study revealed that most frequent
performed preventive activities by nurses in relation
to prevention of pressure ulcer are: Keeping bed sheet
wrinkle free and dry (99%), assisting, turning, rising,
changing position(99%), using comfort devices(99%)
maintaining personal hygiene(99%).
Similar findings were reported by Walia et.al (2004)
that some of the preventive steps to reduce the
prevalence of pressure ulcers either by staff or
attendants of patients included: change of side or
position (95%), removal of wrinkles from the bed sheet
(60%) and use of cushions or air rings (55%). More than
50% nurses reported ‘care of back’ as a preventive
step.12
Some of the study findings are inconsistent with
Walia et.al like in present study (99%) nurses were
maintaining personal hygiene but Walia et.al reported
that 35% nurses were maintaining cleanliness.11
The present study further revealed that least
frequent performed nursing activities in relation to
pressure ulcer prevention were screening of pressure
ulcer (0%) Inspection of skin of the high risk especially
at bony prominences once per shift (0%) and assists/
encouraging repositioning (19.6%).
The result of the study are consistent with the study
by Amelia Merriman et.al (2000) the findings
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 239
highlighted that nurses generally do not use a risk
assessment tool for identifying pressure ulcer
development & rely on a range of routine practice
procedures.13
In the present study, factors which had been
identified as inhibiting factors by nurses were
inadequate skin care supplies related to prevention of
pressure ulcer (95%), inadequate supplies of
equipments & products related to prevention of
pressure ulcer (93%), more involvement of nurse’s in
non- patient care activities. The result of the study is
consistent with study conducted by Jankowski et.al
(2011) the barriers identified were non-availability of
supplies, Equipment issues, Access to supplies etc.14
The present study concludes that nurses’ practice in
relation to prevention of pressure ulcer was not
appropriate. Nurses do not screen patient for pressure
ulcer neither any tool was used for risk assessment.
Only few nurses (3/100) were changing the position
of high risk patient every 2 hourly though
repositioning is the foremost preventive action in
relation to prevention of pressure ulcers.
ACKNOWLEDGEMENT
At very outset, I would like to thank almighty for
His presence. My sincere thanks to all participants of
my study. I am extremely grateful to everyone who
has whole heartedly co-operated to make my thesis
successful.
Ethical Consideration: Ethical approval to conduct the
study was obtained from Institutional Ethical
Committee of M.M University, Mullana, Ambala, and
Haryana. Written informed consent was obtained from
the study subjects regarding their willingness to
participate in the research project.
Conflict of Interest: There was no conflict of interest.
Funding Source: Self financed.
REFRENCES
1. Maklebust J., Sieggreen M.Y. 2001. Pressure
Ulcers: Guidelines for Prevention and
Management, 3rd ed. Springhouse, PA.
Lippincott Williams & Wilkins.
2. National Pressure Ulcer Advisory Panel. Pressure
ulcer prevention points. The Advisory Panel.
1993. Available From:-http://www.npuap.org/
PDF/preventionpoints.pdf
3. Burdette T, Kass J.Heel ulcers in critical care unit:
a major pressure problem. Critical Care Nursing
2002; 25 (2):41–53.
4. Health Council of the Netherlands: Pressure
Ulcers. Publication No. 1999/23. ISBN: 90-5549-
302-3.
5. Thomas, D.R., 2001. Prevention and treatment of
pressure ulcers: what works? What doesn’t?
Cleveland Clinic Journal of Medicine; 68 (8):
704–722.
6. Hunt, J.Application of a pressure area risk
calculator in an intensive care unit. Intensive and
Critical Care Nursing1993; 9 (4): 226–231
7. Clark M, Bours GJJW, Defloor T Summary report
on the prevalence of pressure ulcers. EPUAP
Review 2002; 4(2):49-57.
8. Whittington KT, Briones R: National Prevalence
and Incidence Study: 6-Year Sequential Acute
Care Data. Advances in Skin & Wound Care 2004;
17(9):490-494.
9. Berlowitz DR, Wilking SVB. The short-term
outcome of pressure sores. American journal of
Geriatriatrics.1990; 38:748–752.
10. Carpico B. Preventing skin breakdown through
education. Pennsylvania pressure ulcer
partnership teleconference. 2009.
11. Courtney H. Lyder, Elizabeth A. Ayello Pressure
Ulcers: A Patient Safety Issue.
12. Vati. Jogindra, Chopra Suksham, Walia, Indarjit
nurses’ role in the management and prevention
of pressure ulcers - a study 2004.
13. Eman SM Shahin et.al. Pressure ulcer prevention
and incidence in intensive care patients a
literature review. Journal of critical care
nursing.2008; 13(2):72-78.
14. Mirjam A Hulsenboom, Gerrie JJW Bours, Ruud
JG Halfens Knowledge of pressure ulcer
prevention: a cross-sectional and comparative
study among nurses. BMC Nursing 2007; 6:2.
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240 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
One of the most wide spread problem in India is
anaemia. Girls and women of child bearing age are
anaemic. Anaemia can have profound negative impact
on psychological, physical development, behaviour,
healing capacity, working performance and
reproductive health which affects the future of an
individual. Adolescent is a period where learning and
adoption of new knowledge and practices take place.
Additionally rural adolescent girls get married at an
Effectiveness of Planned Teaching Programme on
Prevention of Anaemia among School Going Adolescent
Girls
Moreshwar S A1, Naik VA2, Chrostina B C3
1Associate Professor, Department of Community Health Nursing, KLEU's Institute of Nursing Sciences, Belgaum,
2Professor and HOD, Department of Public Health, Jawaharlal Nehru Medical College, Belgaum (Karnataka), India,
3Lecturer, Department of Community Health Nursing, Institute of Nursing Sciences Belgaum, (Karnataka), India
ABSTRACT
Investing in adolescent health will yield large benefits for the generations to come. During adolescent
period, growth spurt and the acquisition of adult phenotypes and biologic rhythms takes place. In
addition to this, iron requirement also increases dramatically as a result of the expansion of the total
blood volume, the increase in lean body mass and the onset of menstruation which contribute to
accentuating the potential risk for anaemia. The global prevalence of anaemia mainly in South East
Asia is 65.5%, in India 56% mainly among adolescent girls as per the NFHS -3 report. The adolescent
girls are future mothers. Thus, the researcher has focused on health education to improve and motivate
them to prevent health problems and conditions in early period due to anaemia. A pre-experimental
study was carried over a period of 6 months on 60 adolescent high school girls between 10-19 years
studying in Handignur high schools, Belgaum, Karnataka. The objectives of the study were, to assess
the knowledge of adolescent girls both before and after planned teaching programme, to administer
teaching program and to associate findings with selected socio demographic variables. Data obtained
were tabulated and analysed in terms of objectives of the study using descriptive and inferential
statistics. Analysis of the data showed that 100% of adolescent girls in pre-test had average knowledge,
whereas in post-test majority 73.33% of the adolescent girls had good knowledge and 26.67 % had
average knowledge, which indicates that the Planned Teaching Programme has impact in prevention
of anaemia.
Keywords: Anaemia, Planned Teaching Programme, Adolescent girls, Effectiveness
DOI Number: 10.5958/j.0974-9357.5.2.054
Corresponding author:
Sangeeta Moreshwar
Asso Prof & HOD
Community Health Nursing, KLE Institute of Nursing
Sciences, Nehrunagar, Belgaum, Karnataka
Email: smoreshwar@yahoo.co.in
early age which leads to early pregnancy, repeated
pregnancy and abortions and are exposed to greater
risk of morbidity and mortality1.A significant
percentage of anaemia among adolescent girls in the
developing countries (27%) is more than in developed
countries (6%) 2. Regional figure which vary by country
within the region suggests that percentage of anaemia
in Africa and Oceania 45%, Latin America and the
Caribbean 12% and Asia 19%3.
Anaemia among adolescent girls reduces work
productivity as it causes impaired physical capabilities
which leads to poor performance in the school.
Physical and mental development should be taken care
in this crucial period so as to prevent later maternal
anaemia. No strategies are appropriate to reduce iron
deficiency among adolescent girls other than creating
awareness in the form of teaching programme4.
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India, in fact, beats even sub- Saharan Africa with
the highest underweight adolescent girl population of
47% in age group of 15 to 19 years. The country has
the world’s largest adolescent girl population (20%)4.
Iron deficiency is one of the most prevalent nutritional
deficiencies in the world, affecting in estimated 2
billion people (Stoltzfus - Dreytuss, 1998).Young
women are most commonly and severely affected
because of the high iron demand for growth.
Although anaemia affects over 2 billion people
worldwide (APC), it is especially prevalent in India,
where more than 90% of adolescent girls (13-19 years)
suffer from anaemia (UNICEF, 2004). Iron deficiency
anaemia is more prevalent among adolescents with
faulty dietary habits, chronic illness, heavy menstrual
blood loss and who are underweight or malnourished.
Regular health education programme needs to be
incorporated in the school for prevention of anaemia5.
Adolescent girls are the future generation mothers
and they need to be taken care in terms of their
balanced nutrition to prevent morbidity and mortality.
However, most of the adolescent girls diet are based
on staple food with little meal intake, which causes
iron deficiency. In Indian context, adolescent girls are
more prone for nutritional disorders due to ignorance
and son preference of parents in the family which
intern limits access to health and leads to nutritional
disorder6.
Treatment of anaemia consists of supplementation
of iron for a period of at least 100 days. This being
long term treatment compliance plays a very important
role. Based on literatures and investigators experience,
investigator felt that there is a strong need of planned
teaching programme regarding prevention of anaemia
and find out its effectiveness to develop healthy life
style among adolescent girls which will help them to
incorporate healthy dietary pattern for prevention of
anaemia and its associated disorders7.
MATERIALS AND METHOD
This was Pre-experimental study carried out in the
high schools at Handignur village, Belgaum for a
period of 6 months. A simple random sampling was
used. The sample area selection comprised of two
zones that is south zone and north zone school. The
study subjects included 60 who were studying in class
VII and VIII. Data from school children was collected
through a structured questionnaire. In process of data
collection, pre-test knowledge questionnaire was
distributed followed by planned teaching programme
and after 7 days post test was conducted. The
maximum score for knowledge was 40.The knowledge
scores was divided into three categories viz; good,
average and poor according to the mean and standard
deviation.
The reliability of the tool was tested by split half
method by using Karl Pearson’s Co-efficient of
correlation formula. The reliability result was r=0.89.
The collected data was analysed by using descriptive
and inferential statistics. The study attempted to
examine the following research hypothesis:
H1: The mean post-test knowledge scores of
adolescent girls exposed to planned teaching
programme will be significantly higher than their
mean pre-test knowledge scores at 0.05 levels.
H2: There will be significant association between
pre-test knowledge scores and selected demographic
variables at 0.05 levels.
As this study pre-test knowledge was obtained
before the intervention and post-test knowledge was
obtained. Pre-experimental one group pre-test-post-
test design was chosen. The measurement used in this
study was the knowledge and test denoted as O1 and
O2 for pre-test and post-test respectively.
O1 X O2
O1 = Pre-test Knowledge scores before introducing the
intervention.
X = Intervention (Planned teaching programme)
O2 = Post-test knowledge after seven days of
introducing the intervention.
OBSERVATION AND RESULT
Association between knowledge on Prevention of
anaemia and selected demographic variables:
Majority of students 76.67% belonged to age group
of 14-16 years, 96.67% were from Hindu religion, 73.3%
of students’ parents had secondary education, 73.33%
were from joint family, 50% of student’s family income
was Rs3001-4000 and 43.33% non-vegetarian and
43.33% were vegetarian.
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242 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
religion, family income, type of family and dietary
pattern has statistically significant association with
knowledge regarding Prevention of anaemia.
Fig. 1 represents that 60 (100%) of adolescent girls
in pre-test had average knowledge, whereas in post-
test majority 44(73.33%) of the adolescent girls had
good knowledge and16 (26.67 %) had average
knowledge.
Fig. 1. Distribution of pre-test and post-test knowledge score
among adolescent girls.
Analysis showed that the selected socio
demographic variables such as education of parents,
Table1: Mean Median, Mode, and Standard Deviation &Range of knowledge score of Adolescent girls. n=60
Area of Analysis Mean Median Mode S.D Range
Pre-test (x) 16.22 16 20 4.17 18
Post-test (y) 25.87 26 28 2.97 13
Difference (y-x) 9.65 10 8 -1.20 -5
Table1 depicts that the mean post- test knowledge scores are higher than the mean pre- test knowledge score.
Table 2: Mean difference (d), Standard Error of difference (SEd) and paired‘t ’values of knowledge score of
Adolescent girl:
Mean Difference (d) Paired 't' Values
Standard Error Calculated Tabulated
Difference (SEd) value value
9.49 0.660 14.6160 2.145
Table 2 revealed that calculated paired‘t’ value
(t=14.6160) is greater than tabulated value (t=2.145).
Hence H1 is accepted. This indicates that the gain in
knowledge score is statistically significant at P<0.05
levels.
DISCUSSION
Analysis showed that the selected socio
demographic variables have statistically significant
association with knowledge regarding Prevention of
anaemia. A study which was conducted in Haryana
on 110 adolescent girls who belonged to low socio-
economic groups, found that anaemia was more
prevalent in girls who were more than 14 years of
age8.Thus, the high prevalence of anaemia among girls
who were more than 14 years of age could be related
to menstrual loss. These findings correlates with those
of the studies which were conducted among adolescent
girls in Chandigarh, Nagpur, UP and Delhi, where it
was revealed that anaemia was high in the lower socio-
economic groups9, 10, 11, 12. The study conducted by
Akramipour R, Lezari M, Rahimi Z. contradicts with
our results that there was no significant difference
between the presence of anaemia and the level of
education of parents10.In the present study overall
improvement in knowledge was found after planned
teaching programme and paired‘t’ value 14.6 at p<0.05
level of significance which proved that the hypothesis
H1 is accepted. Improvement of food practices and
home-fortified food supplementation interventions are
essential. High-risk groups should be targeted and a
long-term health education program that aims to
modify food habits should be implemented.
CONCLUSION
The findings of final study revealed that there was
a significant gain in knowledge scores of the students
after the session of PTP at 0.05 levels. The study
concluded that PTP had a great potential for
accelerating the awareness regarding the prevention
of anaemia.
ACKNOWLEDGEMENT
We express our thanks to participants and the
authorities who provided permission to conduct the
study.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 243
Conflict of Interest
Improvement in diet, as well as treatment and
prevention of infections along with iron and folic acid
supplementation will definitely improve the
nutritional status of the adolescents from under-
privileged sections of the society, being brought up in
low socioeconomic group. Health education
programmes have to be carried out both, at schools
and in homes along with health authorities, especially
in relation to nutrition, personal and environment
hygiene. Even if consumption of vitamin C-rich foods
improved among adolescent girls, yet greater effort
would be required to promote consumption of iron
rich foods for long-term gains in iron status of the girls.
Source of Funding: Self-Funding
Ethical Clearance: Ethical clearance was taken from
Chairman of Ethical Clearance Committee of KLE
University and Principal, Prof. Sudha A Raddi, Vice
Principal and Secretary, Prof. Milka Madhale, KLEU’S
Institute of Nursing Sciences, Belgaum.
REFERENCES
1. Baral K P, Onta S R, Prevalence of anaemia
amongst adolescents in Nepal, a community
based study in rural and urban areas of Morang
District. Original Article Nepal Med Coll J, 2009;
11(3) page no.179 -182.
2. World Health Organisation. Programming for
adolescent health and development. WHO Tech
Rep Ser No.886, 1996.p.2.
3. Stolzfus R J, Dreyfuss M L. Anaemia among
adolescent and young adult women in Latin
American and the Caribbean.
Availablefrom:URL:http;//unscn.org/layout/
modules/resources/files/AnemiaEngWEB.pdf.
4. Over 50% adolescent girls in India anaemic:
UNICEF ,Feb 28, 2011
5. Paul R. Meier, James Nickerson H, prevention of
Iron deficiency Anaemia in Adolescent and Adult
Pregnancies. January 2003; 1(1): 29-36. Available
From:URL:http://www.ncbi.nlm.nih.gov/pmc/
1069018
6. Anaemia is on rise in India, says NFHS report.
Express India [online] 2008 Jul [cited2009 Oct29];
Available from: URL: http://
www.expressindia.co / latest new / Anaemia-
is-on-the-rise-in-India.
7. Assessment, prevention and control; a guide for
program managers, WHO/NHD 01.3,
Distribution: general.
8. Gupta N, Kochar G. Pervasiveness of anaemia in
adolescent girls of the lower socio-economic
groups of the district of Kurukshetra (Haryana).
The Internet Journal of Nutrition and Wellness
2009[Serial online];[cited 2009 Feb 13];7(1)
Available from :URL:http://www.spub.com/
journal/the_internet_ journal_of_ nutrition_
and_wellness/volume_7_ number_ 1_21/
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adolescent_ girls_of_ low_socio_ economic_g
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haryana.html
9. Basu S, Hazarika R, Parmar V. Prevalence of
anaemia among the school going adolescents of
Chandigarh. Indian Paediatric 2005; 42:593-8.
10. Chaudhary SM, Dhage VR. Study of anaemia
among adolescent females in the urban areas of
Nagpur. Indian J Community Med 2008; 33(4):
245-48.
11. Rawat CMS, Garg SK, Singh JV, Bhatnagar M.
Socio-demographic correlates of anaemia among
adolescent girls in rural areas of the district
Meerut (UP). Indian J Community Med 2001;
26(4):173-75.
12. Kapoor G, Aneja S. Nutritional disorders in
adolescent girls. Indian Paediatric 1992; 29:
969-973.
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244 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
Within the literature on teaching in nursing there
appears to be little attention paid to the use of
microteaching to enhance learning. Its use have been
advocated by a number of authors, but for the novice
teacher there is little advice available on how to plan
or implement a teaching session using this
strategy1.Microteaching, which has for long been
acclaimed as one of the best methods for training
preservice and inservice teachers, is a technique that
can be used for various types and stages of professional
development2.Lack of satisfactory awareness of the use
of microteaching has led to criticisms that
microteaching produces homogenized standard
student teachers, the amount of time for preparing
materials; the difficulty of material production may
also cause unwillingness3. A study investigated the
perceptions of 39 teacher trainees towards the
effectiveness of microteaching subject in preparing for
the teaching practice showed that the teacher trainees
perceived microteaching as effective in preparing them
for teacher practice4.
Perception and Experience of Teachers and Postgraduate
Nursing Students on Microteaching as an effective
Teaching Strategy
Shanthi Ramasubramaniam1, Lakshmi Renganathan2
1Lecturer, Maternal and Child Health Nursing, College of Nursing, Sultan Qaboos University, Muscat, Oman
P. O. Box 66, Alkhod, Muscat, 2Senior Trainer, Oman Nursing Institute, P.O. Box-3720 PC-112
Muscat, Sultanate of Oman
ABSTRACT
Aim: The main purpose of the study was to assess the perception and experience of teachers and
postgraduate nursing students on microteaching at selected College of nursing, India.
Methods: Descriptive survey and interview method was used for the study. A five point likert scale
was used to assess the perception of lecturers and students on microteaching. Experiences of teachers
were assessed using interview method. The study was conducted by obtaining prior permission
from Head of the institution, concerned teachers and postgraduate nursing students.
Findings: the results of the study indicate that teachers and postgraduate nursing students had a
positive perception about microteaching as an effective teaching strategy. Participants also brought
out suggestions to improve the present practice.
Keywords: Microteaching, Effective Teaching Strategy, Microteaching in Nursing Education
DOI Number: 10.5958/j.0974-9357.5.2.054
OBJECTIVES
1. Assessment of perception and experience of
teachers on Microteaching.
2. Assessment of perception and experience of
postgraduate nursing students on Microteaching.
3. To suggest the ways to improve the present
microteaching strategy.
NEED FOR THE STUDY
For teacher educators, the implementation of
microteaching into their courses enables both pre
service teachers and themselves to engage in dialogue
and discussion centered on making connections
between theories of teaching and microteaching
experiences 5,6. In view of the lack of literature and
empirical evidence on the use and benefits of
microteaching we would encourage others to
implement and evaluate its appropriateness in nurse
education1.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 245
Indepth awareness of microteaching, the
motivation of teacher himself/ herself and the ability
of the observer to offer comprehensive feedback may
bring into remarkable improvements in teaching
skills7.Therefore the author wanted to explore the
experience and perception of nursing college lecturers
and prospective students (Masters in nursing students)
on microteaching technique.
Literature Evidence
Microteaching has become a unique method of
investigating technical skills in teaching. It has a great
research potential because of its precision and low
threats and also because it encourages
experimentation. No research exists in the literature
indicating as to what should be the ideal class- size
and the micro-lesson time in the practical class room
setting8.
A study in Nigirian setting investigated, whether
the use of video tape recordings is an effective method
of teacher education prior of full-time teaching. Two
groups of students were used for the study. The first
group was allowed to practice the skills through micro
teaching with the aid of video recording equipment.
The second group practiced their own skills through
micro teaching but without the aid of video recording
equipment. At the end of the study it was discovered
that the group which used the video-recording
equipment has more significant progress in the
mastery of teaching skills2.
Literature describes the use of microteaching as a
beneficial and accepted element of preservice teacher
education. Microteaching experiences provide pre-
service teachers to the realities of teaching. Second it
introduces preservice teachers to their roles as teachers
9,2,10;third it helps them to see the importance of
planning, decision making and implementation of
instruction; fourth, it enables them to develop and
improve teaching skills (Communication, public
presentation etc.)11,10 and finally it helps them build
their confidence for teaching5. Other than bringing
about effective teaching skills, microteaching also
inculcates the value of reflective practice to preservice
teachers who engage in microteaching are more
receptive to feedback10, while others contend that
microteaching encourages self evaluation of self
perceptions and teaching behaviours5.
An exploratory research concluded that
microteaching is regarded as an essential tool in
growing technology. In depth studies in using this
technique in training institutions, availability of
technological labs and participatory role of expert
group emerged as areas for further research14.
METHOD
The study was conducted at a selected college of
nursing, south India which is one of the pioneers
among the private nursing colleges. The participants
in the study consisted of teachers both at graduate and
post graduate level of nursing education and few
students at postgraduate level in nursing. 28
respondents were postgraduate nursing teachers and
16 were graduate level nursing teachers and 6
respondents were students at 2nd year masters in
nursing level.
Descriptive survey method was used for the study.
The data for the study were collected using a self
administered 5 five point likert scale questionnaire
containing perception and practice items concerning
microteaching. The experience was assessed using a
structured interview method and were analysed
descriptively.
Research Instruments
Two instruments were used in the research. A five
point likert scale was used to assess the perception of
lecturers and students on microteaching and a
structured interview was used to find out the
experiences of lecturers and students on microteaching
and suggestions for further improvement in
microteaching strategy.
Development of the Tool
The tool was developed by referring to relevant
literature on microteaching and getting expert opinion.
The tool was given to experts in the field of nursing
education and general education for validity.
Description of the Tool
Part-A consisted of the socio personal variables of
the respondents. It contained questions about the
demographic data like the gender, age, educational
qualification, years of teaching experience and
experience in the use of microteaching as a teaching
skill.
Part: B
Consisted of likert scale questionnaire containing
perception of lecturers on microteaching topic itself,
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246 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
process and preparation for microteaching and lastly
about the outcome of microteaching.
Part : C
Structured interview with open ended questions
on narrating the experiences of the teachers and
postgraduate students on various aspects of
microteaching and Suggestions were asked from the
respondents for further improvement to continue
microteaching as a teaching skill.
RESULTS AND DISCUSSION
Socio demographic data
Among 50 samples 28 respondents were in the
age group of 20-30 years, 20 samples in the age group
between 31-40 and 2 samples between 40-50 years of
age.
Among 50 samples 28 respondents were teachers
in the postgraduate level teaching, 16 were teachers at
the undergraduate level teaching and 6 were students
at the 2nd year msc level of their education.
Among 50 samples only 3 teachers in the
postgraduate level teaching were males and rest of all
the samples including postgraduate students were
females.
Main Findings of the Study: The findings related
to the perception of nursing college teachers and
postgraduate nursing students were assessed using
the five point likert scale and it showed the following
results.
Table 1. Perception Of Nursing College Teachers And Postgraduate Nursing Students
S.No Items Almost never Never Sometimes Frequently Always
1 Do you feel that Microteaching is the most effective 0 0 12% 24% 64%
method of teaching technique
2 Do you think microteaching motivates the teacher 0 0 0 36% 64%
3 Did you feel that microteaching takes a lot of time 0 0 0 56% 44%
and efforts from the teachers side to be prepared
for the process
4 Have you felt that microteaching is most suitable 0 0 0 56% 44%
in clinical learning
5 Do you think that microteaching increases the 0 2% 15% 23% 60%
teachers confidence level
6 Do you feel that microteaching helps the teacher to 0 0 8% 12% 80%
know her strength and weaknesses
7 Have you felt that microteaching helps to maintain 0 0 0 36% 64%
concentration among the students during the session
Table 1. Perception Of Nursing College Teachers And Postgraduate Nursing Students
1. Regarding the statement on “Do you feel that Microteaching is the most effective method of teaching technique”? Majority 64% of them felt it’s
always as most effective method of teaching.
2. Regarding the statement “Do you think microteaching motivates the teacher?” majority 64 % perceived always motivating and 36% frequently
motivating.
3. Regarding the statement “Did you feel that microteaching takes a lot of time and efforts from the teachers’ side to be prepared for the process?”56%
of them felt frequently it takes a lot of time and efforts from the teachers’ side and 44% said always it takes the time and efforts of the teacher.
4. Regarding the statement “Have you felt that microteaching is most suitable in clinical learning?” since it was a clinical oriented course, 56% of them
felt it frequently suits clinical learning and 44% felt it always helps in clinical learning.
5. Regarding the statement “Do you think that microteaching increases the teacher’s confidence level?”Majority 60% felt it always it increases the
confidence level.
6. Regarding the statement “Do you feel that microteaching helps the teacher to know her strength and weaknesses?” almost 80% of them perceived it
always helps the teacher to know her strength and weakness.
7. Regarding the statement “Have you felt that microteaching helps to maintain concentration among the students during the session?” majority 64% of
them felt it always maintain Concentration among the students.
On the whole the study results showed that there
was a positive impact on postgraduate nursing
student’s perception and views on microteaching as a
teaching strategy. The study showed teachers both at
undergraduate and postgraduate level teaching had
positive perception on microteaching as a teaching
strategy. These findings are consistent with studies
providing evidence that microteaching as an effective
means of improving prospective teachers teaching
skills11,1,17. Different models and versions have
appeared in providing the microteaching experience.
Some variables such as the number of students,
teaching learning environments, teacher skills and
behaviors to be practiced have changed, but in all
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versions the principle that certain skills should be
practiced again after evaluation remains the same16.
Experience of teachers and postgraduate nursing
students on microteaching
The lecturer needs to assess the student’s prior
experience and understanding of microteaching before
using this strategy. The students also need to be
advised about the function, aims and value of
microteaching and video recording1.Microteaching is
a scaled down teaching. Its goal is to provide
confidence, guidance, feedback and support to the
prospective teachers. Basically its aim at modifying
teaching behavior provides flexibility, location,
organization and divergent ways of thinking13.
Preparation and Practice Aspects of microteaching:
• Majority of the teachers (71.42%) at the
postgraduate level teaching said that they conduct
Microteaching at least twice in a year.
• Majority of teachers (62.5%) at the undergraduate
teaching level said that Clinical teaching was the
main area where the teachers used Microteaching
as a method of teaching.
• All the postgraduate nursing students (100%) said
that they practice microteaching minimum of 6
sessions per year as a part of their educational
requirement. The students said microteaching
sessions are planned at the beginning of the
semester mainly in their specialty subjects.
• The postgraduate nursing students said they used
both topics including theory and also skills were
demonstrated in the 20 minute microteaching
session.
• Preparation of peers for the msc students
(prospective teachers) was done during their
specialty hours. As well as the group for the
microteaching was between 4-5.the students also
felt it would be better if the group is bigger.
• The participants said Video recording was not
used for their microteaching sessions.
• The multimedia used in the microteaching sessions
were LCD presentations, charts/ posters and
printed materials.
• Majority (62%) of the teachers said it was difficult
to schedule topics and timings for the
microteaching practice at the undergraduate level
because the groups of students were around 40 in
a class.
The findings are supported by an authors view as
microteaching offers the advantages of both realistic
practical experiences and controlled laboratory
environment. It also offers immediate and continuous
feedback; close supervision and objectives that can be
managed according to the needs and abilities of the
individual trainee 15.
Evaluation of microteaching
• 48% 0f the postgraduate level teachers said that
they would give constructive criticisms, and would
give feedback based on observation of teachers
alone.
• Majority (82%) teachers at postgraduate level
teaching said they used to evaluate student teacher
at Postgraduate level.
•· Problems faced by undergraduate level teaching
faculty for not practicing Microteaching were no
time, lack of resources and difficulties in student
preparation.
An exploratory study14 recommended that
microteaching lessons should be conducted in more
flexible environment. Programs should be designed
in such a way that does not leave any gaps in planning
and presentation of lesson. It requires the use of highly
technical information technology devices, so use of
these devices should be made proper as necessary. The
class size should be increased so that large number of
trainee teachers can be given the opportunity of
enhancing their skills. Time allocation should be made
sufficient for microteaching.
Suggestions for future improvements
The teachers and the postgraduate nursing students
suggested few strategies to improve the current
practice of microteaching technique.
• Standardize the process of microteaching at the
Msc Nursing and Bsc nursing level of education.
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248 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
• Make the facilities available (eg video recording),
use of multimedia in the institution.
• Have continuous staff development programmes
on the newer instructional technology including
microteaching and giving effective feedback for
students after the microteaching.
Limitations of the study
The study was done in a single setting and hence
the findings cannot be generalized. The actual
microteaching strategy using videotaping and peer
presentations at the undergraduate level of education
was not practiced.
CONCLUSION
Lack of adequate and in-depth awareness of the
purpose of micro teaching has led to criticisms that
microteaching produces homogenized Standard robots
with set smile procedures. A lot depends on the
motivation of the teachers to improve himself and the
ability of the observer to give a good feedback.
Repeated experiments abroad have shown that over a
period of time microteaching produces remarkable
improvement in teaching skills12. The study results
showed that majority of the lecturers perceived
microteaching to be the effective method, it helped the
lecturer himself/ herself and the prospective teachers
to know their strength weaknesses. They suggested
that they needed resources adequately, and also have
set standardized practice for microteaching skills at
the postgraduate and undergraduate teaching practice
sessions to overcome the practical difficulties to
practice microteaching in the ideal way.
Conflict of Interest: None
Source of Support: There was no funding requested
for this study.
Ethical Clearance: The ethical clearance was obtained
from the institutional research and ethical committee.
ACKNOWLEDGEMENTS
The authors wholeheartedly thank the Principal,
faculty and postgraduate nursing students who
actively took part in the study and helped us to arrive
at conclusions.
REFERENCES
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lecturers and students in the use of microteaching
as a teaching strategy. Nurse Education in
Practice, 3, 220-227, doi:10.1016/s1471-5953(02)
001606-3.
2. Edward K.P. (2001) A study of the effects of video
tape recording in microteaching training. British
journal of Educational Technology: 32(4) 483-86.
3. Cripwell K, Geddes M. (1982). The development
of Organisational skills through microteaching.
ELT Journal 36/4:232-6.
4. Md Saleh, Zanariah and Yahya, Nurfareza. (2011).
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effectiveness of microteaching subject (SPA 2001) in
preparing them for teaching practice. Unspecified.
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5. Brent R, Wheatley E.A, and Thomson W.S. (1996)
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the university to the classroom. The teacher
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7. Ogeyik M.C. (2009) Attitudes of the student
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10. Wilkinson G. (1996) Enhancing microteaching
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13. Abbasi M.H. (2009) Microteaching. Faculty
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(3&4) 16-20.
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250 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
An Intensive Care Unit can be a very intimidating
place for a patient. Shrill alarms, lights flashing from
machines intermittently and unpleasant odors
permeate the air. While ICU nurses feel comfortable
amidst the advanced technology and flashing screens,
patients can make little sense of this strange and
overwhelming environment. Overall, the experience
of being admitted to an ICU is unsettling and
frightening for the patient.1
The Intensive Care Unit has high technology
machines for better monitoring which requires highly
trained nurses .The skillful ICU staff makes the patients
feel safe and comfortable throughout the treatment.
Despite this, the ICU stay is not something, which the
patient looks forward to. This may be because of their
poor condition, the crowded place, the high technology
machines used, invasive procedures carried out, noise
as well as the high cost of treatment. All these
A study to assess the Stressors of the Intensive Care Unit
Patients' and to Compare these with the Nurses'
Perception in Selected Hospitals of Karnataka State
Tsering Paldon1, Elsa Sanatombi Devi2, Flavia Castelino3
1Staff Nurse, Medicity The Medanta, Gurgaon, Haryana, 2Associate Professor, 3Assistant Professor, Manipal College
of Nursing, Manipal
ABSTRACT
An intensive care unit is a specialized unit for monitoring the critically ill patients. However this
environment is unsettling and frightening for the patients. The purpose of this study was to assess
the stressors of the ICU patients and the nurses' perception of these stressors. A descriptive survey
was undertaken and data was collected using structured questionnaires from a sample of 75 ICU
patients and 75 nurses working in ICUs of Kasturba Hospital, Manipal. The top five stressors identified
were: not being able to sleep, financial worries, not able to fulfill family responsibilities, being in
pain, frequently being pricked by needles. The patients ranked the Physical Stressors the most stressful,
followed by Psychological Stressors and Environmental Stressors. The nurses were able to perceive
4 out of top 5 stressors and also the Physical Stressors as the most important stressor of ICU patients.
This shows that the nurses are aware of the fact that ICU is stressful for the patient and the different
stressors affecting the patients. However the nurses' rating of the ICU patients' stressors was higher
than that of the patients' stressors (59.53 vs 41.84). This shows that the nurses overemphasize the
stressors of the ICU patients. The findings from this study provide a set of baseline information to the
health care providers, with which to provide better care for the patients in ICU.
Keywords: Stressors of ICU Patients, Nurses' Perception, Intensive Care Unit
DOI Number: 10.5958/j.0974-9357.5.2.054
contribute to physical, psychological, and
environmental stressors which take a toll on the
patients.3
The frightening experience in Critical Care Units,
whether it be associated with the disease process or
related to the critical care environment, has an
important impact on the clients’ recovery and
rehabilitation. Critical care nurses are therefore in a
strategic position to identify stressors in critical care
units so that appropriate nursing measures can be
directed towards minimizing the controllable stressors
and promoting adaptive coping strategies to
anticipated stressors.7
Research methodology
Descriptive survey design was found used for this
study. The present study was conducted in medical
ICUs, surgical ICU and cardiology ICUs of Kasturba
Hospital, Manipal.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 251
The sample included 75 ICU patients and 75 nurses
working in ICUs of Kasturba Hospital, Manipal.
Purposive sampling was used for the selection of the
samples.
The conceptual model adopted for this study was
developed by the researcher by using the concepts of
Imogene King goal attainment model (1981).
Inclusion criteria
Patients
• Patients aged 20 years and above
• Patients who have been admitted to ICU for a
minimum of 2 days & above.
• Patients who can read & communicate in English,
Hindi or Kannada.
• Patients who are willing to participate in the study
• Patients without any neurological or psychological
disorders.
• Patients who have not been previously admitted
in ICU.
Nurses
Nurses who have worked in ICU for 1 year or more
RESEARCH MATERIALS
Tool 1: Background Proforma of patients and nurses
Tool 2: A Structured Rating Scale on Stressors of the
Intensive Care Unit
The tool was developed to assess the stressors of
ICU patients. It consisted of 35 items. The content areas
covered were Physical stressors, Psychological
stressors and Environmental stressors. Each item was
scored on a four point Likert Scale to indicate the
degree of stressor experienced: Extremely Stressful (3),
Moderately Stressful (2), Mildly Stressful (1) and Not
Stressful (0). The scores were arbitrarily classified as
Mild level of Stressor (1-35), Moderate level of Stressor
(36-70) and Severe level of Stressor (71-105).
Tool 3: Rating scale to assess the nurses’ perception of
stressors of ICU patients
The tool was developed to assess the nurses’
perception of ICU patients’ stressors. It consisted of
35 items. The content areas covered were Physical
stressors, Psychological stressors and Environmental
stressors. The nurses were asked to rate their
perception of stressors as experienced by the patients
during their stay in ICU. Each item was scored on a
four point Likert Scale to indicate the degree of
stressors perceived: Extremely Stressful (3),
Moderately Stressful (2), Mildly Stressful (1) and Not
Stressful (0). The scores were arbitrarily classified as
Mild level of Stressor (1-35), Moderate level of Stressor
(36-70) and Severe level of Stressor (71-105).
The validity was established by experts from
different specialties i.e Psychiatry, Medical Surgical
Nursing, Pediatric Nursing and Psychiatric Nursing.
Reliability of the tools was determined by Cronbach’s
alpha.
Data collection procedure
The investigator approached the study subjects,
explained the purpose of the study and obtained their
consent after assuring them of the confidentiality of
the data. Data was collected using the structured
questionnaires. The patients were approached in the
ICU on the day of the transfer to their respective wards
and the nurses working in their respective ICUs were
approached for the study.
DATA ANALYSIS
Descriptive and inferential statistics using SPSS
windows 16.0 version was used to analyze the study
findings.
Findings of the study
Sample characteristics
Patients: Most of the patients (30.7%) belonged to
the age group of 51-60 years; were males (70.7%) and
were married (86.7%). Majority of them (70.7%) were
of Hindu religion, were unskilled worker (41.3%) and
had a family income of Rs 5001-10,000 per month
(58.7%). Only 9.3% of the patients were illiterate. Most
of the patients (44%) were admitted with a diagnosis
of cardiac disease; and majority of the patients (65.3%)
were treated medically. Thirty six percent of the
patients had a hospital stay of 10-13 days.
Nurses: Most of the nurses (41.3%) were of the age
group 26-30 years and were females (65.3%). Most of
them (60%) were from medical ICU and majority of
the nurses (74.7%) had a work experience of 1-5 years.
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252 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Stressors of the patients
The top five stressors of ICU patients were: not
being able to sleep, financial worries, not able to fulfill
family responsibilities, being in pain and frequently
being pricked by needles.
The least five stressful items as perceived by the
ICU patients were: hearing people talk about me and
my condition, frequent examination by the health care
professional, presence of unusual smells, healthcare
professionals more concerned with machines and
health care professionals not introducing themselves
The patients reported a marginally moderate level
of stressor with scores ranging from 20-60, mean 41.84
and SD= 7.23. Majority of the patients (81.3%)
experienced moderate level of stressor, while none of
them reported severe level of stressor.
The mean percentage for the categories of the
stressors was computed, and it was revealed that the
ICU patients were most affected by the Physical
Stressors, followed by the Psychological Stressors and
the Environmental Stressors.
Nurses’ perception of ICU patients’ stressors
The top five stressors of ICU patients as perceived
by the nurses were: fear of death, being in pain not
being able to fulfill family roles and responsibilities,
financial worries and being pricked by needles
frequently.
The five least stressful items as reported by the
nurses were: being in a room that is too cold, health
care workers using words which are not
understandable, not knowing the date/day, not
knowing the time and presence of unusual smells.
The total stressor score of patients as perceived by
nurse ranged from 40-74 with mean- 59.53 and SD-
6.646. Majority of the nurses 72 (96%) perceived the
that patients experience moderate level of stressors and
4 % of the nurses perceived severe level of stressor;
while none of them perceived mild level of stressor.
The nurses were able to perceive the Physical
stressors as the most stressful to the ICU patients,
followed by Psychological stressors and
Environmental stressors.
Comparison of the top five stressors of ICU patients and as perceived by the nurses
Top 5 stressors of ICU patients Rank Top 5 stressors of ICU patients as perceived by nurses
Not being able to sleep 1 Fear of death
Financial worries 2 Being in pain
Not being able to fulfill family responsibilities 3 Not being able to fulfill family responsibilities
Being in pain 4 Financial worries
Being pricked by needles frequently 5 Being pricked by needles frequently
It was found that the nurses were able to perceive
4 out of 5 top stressors of ICU patients. However the
mean total score of nurses’ perception of patients’
stressors was greater than that of the patients’ stressors
(59.53 vs 41.84).
Difference in stressors of ICU patients and stressors
of ICU patients as perceived by the nurses
Independent t-test was used and it was found that
the stressor scores between patients and nurses were
statistically different (t= 15.588, p=0.000),
demonstrating the difference in perceptions of stressors
between the two groups with the nurses
overemphasizing the stressfulness of the ICU
environment.
Association between stressors of ICU patients and
selected patient variables
There was association between stressors of ICU
patients and educational status (f= 2.703, p=0.027) and
gender (t=2.442, p=0.017), but there was no association
with other demographic variables.
Association between nurses’ perception of ICU
patients’ stressors and selected demographic variables
There was significant association between nurses’
perception of ICU patients’ stressors with age
(f=12.314, p=0.000), professional qualification (f=7.494,
p= 0.001) and work experience in ICU (f=10.261,
p=0.000), but there was no association with gender (t=
1.493, p=0.140).
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 253
Limitations
The purposive sampling technique used may limit
the generalization of findings.
The present study was confined to a sample
selected from a single hospital.
CONCLUSION
1. Physical stressors were the most felt by the ICU
patients. This result supports Maslow’s’ hierarchy
of needs in which humans’ primary concern is to
fulfill the physiological needs rather than other
needs.
2. Although the results of this study indicate that
importance is to provide the best possible physical
care, it is equally important to provide adequate
attention to psychological aspects, since they are
interrelated.
3. The study findings reveal that the nurses are aware
of the fact that ICU is stressful for the patient and
the different stressors affecting the patients
4. The nurses’ rating of the ICU patients’ stressors
was higher than that of the patients’ stressors (59.53
vs 41.84). This shows that the nurses
overemphasize the stressors of the ICU patients.
5. Critical care nursing practice occurs at the interface
of the nurse with the patient and family in an
environment that requires humanism and
compassion, despite aggressive technology. The
nurse is in charge of the environment and the
physical and emotional tone in the ICU. Creating
an environment where patients feel secure is a
major goal.
ACKNOWLEDGEMENT
I would like to extend my sincere thanks to all the
Heads of the Departments, nurses, patients, my
teachers and my classmates for their help in
completing my study.
Conflict of Interest: None
Source of Support: Self
Ethical Clearance: Administrative permission was
taken from the Dean, Manipal College of Nursing,
Manipal University.
• Permission was taken from the HODs of
Department of Medicine, Department of Surgery
and Department of Cardiology, Kasturba Hospital,
Manipal.
• Permission was taken from Medical
Superintendent, Kasturba Hospital, Manipal.
• Institutional Ethics Committee approval from
Kasturba Hospital, Manipal.
• Informed consent from the participants.
REFERENCES
1. Joan T. Critical care nursing Clinical Management
through the nursing process. Philadelphia: FA
Davis Company;1999
2. Wong FYK, Arthur DG. Hong Kong patients’
experiences of intensive care after surgery:
nurses’ and patients’ views. Intensive and Critical
Care Nursing. 2000; 16:290–303.
3. Soh KL, Soh KM, Ahmad Z, Raman RA, Japar S.
Perception of Intensive Care Unit stressors by
patients in Malaysian Federal Tertiary Hospitals.
Contemporary Nurse. 2008 Dec; 31(1):86-93.
4. Rosa BA, Rodrigues RCM, Gallani MCBJ, Spana
TM, Pereira CGS. Stressors at the intensive care
unit: the Brazilian version of the Environmental
Stressor Questionnaire. Rev Esc Enferm USP.
2010; 44(3):623-30. Available at www.ee.usp.br/
reeusp
5. Cornock , MA. Stress and the Intensive Care
patient: Perceptions of patients and nurses.
Journal of Advanced Nursing. 1998; 27(3):
518-527.
6. Hweidi IM. Jordanian patient’s perception of
stressors in critical care units: A questionnaire
survey. International Journal of Nursing studies.
2007 Nov; 44: 227-235. Available from URL:http:/
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7. So HM, Chan DS. Perception of stressors by
patients and nurses of critical care units in
HongKong. International Journal of Nursing
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Studies. 2004 May;41:77-84. Available at
URL:http://www.sciencedirect.com.
8. Franck L, Tourtier JP, Libert N, Grasser L and
Auroy Y. How did you sleep in the ICU? Critical
Care. 2011;15:408. Available at URL:http://
www.biomed central.com.
9. Ozer N, Akyil R. The effect of providing
information to patients on their perception of the
intensive care unit. Australian Journal of
Advanced Nursing. 25(4).
10. Efstathiou N, Ompasi M and Galanaki A.
Perception of stressors by patients and nurses
from a critical care unit in Greece. American
Journal of CriticalCare. 1998;4(1):71-76. Available
from URL:http://www.aniarti.it/efccna.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 255
INTRODUCTION
The minimum level of nursing education that
should be required for practice has been a topic of
conversation for several decades. (1) At present, due to
a lack of incentives in pursuing higher education, less
than 20% of practicing Registered Nurses (RN) with
an Associate Degree (AD) continue on to obtain a
Bachelor of Science (BS). (2-4) Once AD nursing
graduates enter the work force, personal challenges
seem to outweigh the benefits of returning to
academia. The National Council of State Board of
Nursing (NCSBN) reported in their most recent
statistics that AD RNs account for 58.4% of the
workforce, while 38.4% hold a BS degree nationally. (5)
Research to date has focused on practicing AD
nurses planning to return to school and pursue a BS
degree. Results of these studies (2,3,6,7) show that there
is a lack of incentives such as salary or title differences.
Furthermore, barriers including work and family
constraints make it even more difficult to continue
education. As opposed to AD nurses in the workforce,
a recent study showed that the majority of nursing
students currently pursuing an AD intend to enter a
transitional educational program (RN-BSN) post-
graduation. (8) This new trend may be due to a shift in
the nursing shortage with fewer jobs available for new
graduates; the need for increased job security, and the
opportunity to obtain advanced nursing education. An
additional factor to consider is the proposed mandate
The Lived Experience of Associate Degree Nursing
Students Intending to Pursue the RN-BSN
Unn Hidle
City University of New York, LaGuardia Community College, 31-10 Thomson Avenue, Queens,
New York, 11101, USA
ABSTRACT
This qualitative phenomenological research study explored the lived experience of ten senior Associate
Degree nursing students intending to continue their education. Findings revealed eight themes and
although most students were motivated to pursue the RN-BSN, it did not take away from the
overwhelming barriers they faced. Based on study findings, there needs to be greater emphasis on
individual student barriers, nursing advisement, and accurate information about the changes within
academia.
Keywords: Education Barriers Advisement
DOI Number: 10.5958/j.0974-9357.5.2.054
“BSN in 10” which will require RNs with an AD to
obtain a BS within 10 years. (9-14)
MATERIAL AND METHOD
A qualitative phenomenological research design
was chosen to describe the lived experience of senior
AD nursing students intending to pursue the RN-BSN.
Using purposive sampling, qualified candidates from
a large Northeastern college were recruited. The
Institutional Review Board (IRB) of the college in
which the study was conducted granted human subject
approval.
Qualified candidates for the study had to be in their
last semester of the AD program with the intent to
pursue the RN-BSN or higher nursing degree post-
graduation. The sample consisted of 10 (n=10) senior
AD nursing students, eight females and two males,
from the same program. The ages for the participants
ranged from 27 to 55 years, with a mean age of 31.
Eight of the participants were first generation
immigrants, and two were born and raised in the
United States. Three of the participants held a High
School Diploma as the highest degree, six had a non-
nursing BS degree, and one had an MS.
Once consent was obtained, data collection
consisted of semi-structured one-on-one interviews
during the Fall 2012 semester. In order to obtain basic
demographic data, each participant completed a brief
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256 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
verbal survey. The interviews were audio-recorded
and ranged from 37 minutes to 66 minutes. Privacy
was maintained. The main question guiding the
interviews was: “What is it like planning to continue
education after your graduation?” with follow-up
“probes” as needed. Once the audio-recordings were
transcribed, bracketing and phenomenological
reduction were used to analyze the data.
FINDINGS
There were many commonalities in the
participants’ experiences and a total of eight themes
were determined from the clusters of meaning (Table
1). The themes are explored in detail using excerpts
from participant interviews.
Theme I: Epiphany: nursing education is the right
path for me. One evident theme was the epiphany
participants experienced since entering the AD nursing
program. The realization they had made the right
educational choice and the appreciation of the nursing
profession, contributed to a desire to pursue the RN-
BSN. Although some participants initially entered
nursing with the goal to achieve job and financial
stability, their intention changed while advancing
through the AD program. One student described her
epiphany:
While on the Labor and Delivery Unit, holding the
hand of a woman in labor and helping her breath, I
got this feeling inside of me I cannot describe. I don’t
have words for it. They [family] really appreciated me
and I knew it [nursing] was what I’d like to do in the
future.
Another student recalled a simple gesture, which
altered his view of nursing
I was going to quit nursing because I thought it
was a misconception. Then, while on a medical floor, I
gave milk to a patient who had been “ignored” due to
a language barrier and she was so grateful. We ended
up talking in my language and I’ve never felt anything
like that before. This one incident, it makes up for
everything, you know.
The stories of life-changing events were rich with
descriptions and emotions. The participants
emphasized how patient experiences impacted on
their personal and professional lives, reinforcing their
intentions to continue nursing education.
Theme II: Motivation: enhanced knowledge.
Viewing nursing as an evolving science motivated
participants, and they equated continued education
to enhanced knowledge. One student stated: “The two
years [AD program] is just the beginning. Increased
knowledge [RN-BSN] means increased security and
comfort level in my performance as a nurse.” Another
student said: “The BS will help improve nursing
expertise, which can be applied in the clinical setting.
It all comes down to evidence based practice.” Several
participants were motivated to pursue the RN-BSN
because it was a gateway to higher accreditation, such
as: “There are no real advantages in terms of skills,
but increased knowledge [BS] will give me the
opportunity to ‘move on’ and obtain a higher degree
[NP].”
Theme III: Value of higher nursing education:
improved patient care. There was a belief by the study
participants that education beyond the AD in nursing
would likely improve patient care. In their last
semester of the AD program, many felt insecure
entering the workforce due to insufficient knowledge
and the necessary skills to perform safe patient care.
Although the participants were aware that their
insecurities would diminish during work orientation
and preceptor ship, many expressed that continued
education would likely make them more
knowledgeable in their nursing role, and thus provide
safer patient care. On student said: “Increased
knowledge through education [RN-BSN] will improve
my patient assessment and critical thinking skill. I will
be able to provide better care because I am more ‘in-
tuned’ with my patients.”
Theme IV: Future vision: job security and
financial stability. One incentive theme for
participants to pursue the RN-BSN was the belief that
it would be easier to secure a job and receive a regular
paycheck. One student expressed her family struggles:
When the recession hit, my husband lost his job
four times in two years. By me going back to school
and continuing education, we envision a lifestyle we
want together with the security of a stable income. I
feel nursing is a field that will always be there, and
there is always a need for us [nurses].
For many AD students, the stress of working
multiple jobs to provide for themselves and sometimes
their families while attending college, took a toll.
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 257
Theme V: Personal achievement: perseverance
and gratification. As students progressed through the
AD nursing program they tended to place greater
emphasis on personal achievement in the pursuit of a
nursing degree and took pride in continuing their
educational path. The majority of participants faced
overwhelming barriers, but the expected successful
completion of the AD in nursing coupled with the
intent to enter the RN-BSN program, gave them
increased confidence. The participants expressed
“determination and perseverance” to overcome the
obstacles standing in their way. Commonly used words
in this theme of personal achievement were: “personal
gratification,” “pride,” “accomplishment,”
“fulfillment,” “self-confidence,” and “self-respect.”
One student stated: “The biggest incentive is to
compete with myself and achieve personal
gratification. Pride motivates me, self-pride; not what
others think of my accomplishments.” Another
participant expressed how nursing completed her as
a person: “Nursing fulfills that ‘other part of me’ where
I am doing something good for people around me, and
contributing to society. I am helping those in need who
can’t do for themselves, and I feel rewarded in the
process.”
Theme VI: Frustration: lack of job opportunities with
an AD in nursing
Although participants were motivated to continue
nursing education, they also expressed frustration with
the process. This held especially true for participants
who had a BS or MS degree in a different field. One
student conveyed her resentment: “I already have a
BS from my own country, but none of the credits will
be accepted. It is not fair! Alternatives such as
accelerated MS programs are costly and I cannot afford
it right now.” Participants were also discouraged about
the limited information they received regarding job
requirements in the hiring process. There was
consensus that obtaining a job with an AD could be
challenging. Participants were concerned they would
be unemployed in nursing while attaining the RN-
BSN. One participant stated: “Originally, I wanted to
get a job immediately after graduation [AD program],
pay some of my dept, and start a family before
returning for the RN-BSN. Now I have to alter my
plans and get a BS in order to get a job.”
Theme VII: Overwhelming barriers: financial burden,
time constraint, age-factor, visa status, and guilt.
Considering the demographics of this sample, the
theme of overwhelming barriers is not surprising. The
majority were first generation immigrants, many
without immediate family in this country. One student
stated: “Being by myself, separated from family in my
own country is a minus. I don’t have the family support
and encouragement. This makes me feel lonely at
times.” Additional challenges such as immigration,
visa status and language barriers were commonly
expressed within this theme. One participant said:
I thought my greatest challenge was to learn
English [ELA classes before nursing], but now I feel
the pressure from having an International Student Visa
with a time-constraint to continue education or work.
My dream would be to get a hospital to sponsor me
[Green Card], but sponsorships are almost non-
existent.
All participants expressed a financial burden and
time constraint to complete the RN-BSN. One student
expressed a constant pressure: “The financial strain is
very difficult. Right now, I am living off my savings
and I am very stressed out since I have no health
insurance. It becomes a daily stress factor.”
Some participants also conveyed guilt, such as: “I
feel guilty towards my husband who has been the sole
provider while I’ve been in this program. I need to
work and contribute to the family while I continue
education.” The concept of aging also surfaced within
the barrier theme. Participants in their thirties as well
as fifties expressed age as a barrier for different reasons,
including the need for starting family and the fear of
age discrimination in the workforce.
Theme VIII: Acceptance of educational pathway:
peaceful process. Regardless of barriers and
frustrations surfacing in the educational process, the
majority of participants accepted the future need for
the RN-BSN with a sense of serenity. One student
stated: “I am not going to stress over things I cannot
control [referring to the proposed mandate ‘BSN in
10’]”. Once they reached full acceptance of educational
needs, students felt more relaxed. One participant
acknowledged her educational intentions:
I just accept it [RN-BSN] and I don’t have any
feelings that it is unfair. I do not stress myself out about
factors that I cannot change; I just go with the flow. BS
is a pre-requisite for what I want, and there is no need
to fight that.
The value of education and love of learning was
also evident: “Attending school is not a chore but a
pleasure. I take it one day at a time, do what I have to
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do, and don’t worry about tomorrow. It brings me
happiness.”
Table 1. Summary of themes
Theme number Theme
I Epiphany: Nursing education is the right
path for me
II Motivation: Enhanced knowledge
III Value of higher nursing education:
Improved patient care
IV Future vision: Job security and financial
stability
V Personal achievement: Perseverance and
gratification
VI Frustration: Lack of job opportunities with
an AD in nursing
VII Overwhelming barriers: Financial burden,
time constraint, age factor, visa status, and
guilt
VIII Acceptance of educational pathway:
Peaceful process
CONCLUSION
Based on study findings, there is no doubt that
participants were motivated to pursue nursing
education post-AD graduation. They were also well
aware of reasons the RN-BSN has nearly become a pre-
requisite to attain a RN position. However, it did not
take away the reality of barriers and frustrations they
experienced. Although these rich and in-depth
qualitative study findings cannot be generalized,
implications for continued nursing education is
evident. There needs to be a greater emphasis on
advisement, accurate information about changes in
academia, and focus on individual student barriers.
In a study by Jacobs, (15) students placed importance
on academic advisement in planning to meet degree
requirements. Furthermore, providing information
about higher education in nursing, or even starting
courses towards a BS in nursing while in the AD
program, was shown to facilitate the process of
continuing education. (15) One participant in this study
articulated the meaning of advisement: “Patient
discharge planning starts during the admission phase
to the hospital, so why not do the same for students?
In-depth advisement should start during the first
semester of nursing and followed up every semester.”
Academic advisement should address transitions to
the RN-BSN, accelerated higher education programs
such as MS, and eventually doctoral degrees to assist
nurses in filling specialty roles and faculty positions.(9)
In-depth assessment of individual students’
situations is necessary to facilitate a smooth transition
to higher nursing education. (16) Multiple studies to date
have shown that the lack of financial aid is a major
barrier to continuing education. (2,17,18) Thus, creative
ways to explore financial resources or alternative ideas
is helpful in motivating AD nursing students to pursue
the RN-BSN. For example, if a hybrid or web-based
nursing program is utilized, the need for childcare
expenses may be reduced.
In conclusion, despite facing significant barriers,
the participants in this study were motivated in their
educational path and realized the benefits of the RN-
BSN. In order for AD students to stay motivated,
faculty need to be supportive and provide advisement
with up-to-date information on academic issues as well
as political changes impacting nursing.
ACKNOWLEDGEMENTS
I am forever grateful to the nursing students who
shared their experiences and spent valuable time
participating in this study.
Conflict of Interest: See attached declaration
Source of Funding: Self
Ethical Clearance: Human subjects were used in this
study. Prior to data collection, institutional IRB
approval and informed consent from the participants
were obtained. Both are indicated in the submitted
article.
REFERENCES
1. American Association of Colleges of Nursing
[homepage on the Internet]. Washington D. C.:
The Association; c2013 [cited 2013 Feb 2]. The
Essentials of Baccalaureate Education for
Professional Nursing Practice; [about 2 screens].
Available from: http://www.aacn.nche.edu/
Education/bacessn.htm.
2. Delaney C, Piscopo B. RN-BSN programs:
associate degree and diploma nurses’ perceptions
of the benefits and barriers to returning to school.
J Nurs Staff Dev. 2004;20(4):157-161.
3. Spencer J. Increasing RN-BSN enrollments:
facilitating articulation through curriculum
reform. J Cont Ed Nurs. 2008;39(7):307-13.
4. U.S. Department of Health and Human Services
[homepage on the Internet]. Washington D.C.:
HRSA Data Warehouse; c2013 [updated 2013 Feb
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 259
27; cited 2013 Mar 10]. National Sample Survey
of Registered Nurses [about 2 screens]. Available
from: http://datawarehouse.hrsa.gov/
nursingsurvey.aspx.
5. National Council of State Board of Nursing
(homepage on the Internet]. Chicago: NCSBN;
c2013 [cited 2013 Jan 12]. Nurse Licensure and
NCLEX Examination Statistics; [about 2 screens].
Available from: https://www.ncsbn.org/
1236.htm.
6. Guay F, Ratelle CF, Chanel J. Optimal learning in
optimal contexts: the role of self-determination
in education. Can Psych, 2008;49(3):233-40.
7. Megginson LA. RN-BSN education: 21st century
barriers and incentives. J Nurs Manag, 2008;16:
47-55.
8. Hidle, U. The role of professional values in
motivating associate degree nursing students to
pursue higher nursing education. Int J Nurs
Educ;2011;3(2):132-136.
9. American Association of Colleges of Nursing
[homepage on the Internet]. Washington D. C.:
The Association; c2009 [updated 2012; cited 2013
Jan 7]. Impact of the Economy on the Nursing
Shortage; [about 4 screens]. Available from: http:/
/www.aacn.nche.edu/economy.pdf.
10. American Hospital Association [homepage on
Internet]. Washington D.C.; c2006-2013 [cited
2013 Feb 2]. 2010 Health and Hospital Trends;
[about 3 screens]. Available from: http://
www.aha.org/research/index.shtml
11. Boyd T. New York, New Jersey educators debate
BSN in 10 bills. Nursing Spectrum [serial on the
Internet]. 2010 Feb 22 [cited 2013 Jan 10]; Available
from: http://news.nurse.com/article/20100222/
NJ01/302220003.
12. Frey R. Helping adult learners succeed: tools for
two-year colleges. Counc Adult Exper Learn.
2007:1-11.
13. Gillibrand K. New York’s nursing shortage. The
Huffington Post [serial on the Internet]. 2009 July
8 [cited 2013 Feb 12]: [about 2 screens]. Available
from: http://www.huffingtonpost.com/rep-
kirsten/gillibrand/new-yorks
nursingshortage_b_227154.html.
14. Goulette C. Nursing (job) shortage. Adv Nurs
[serial on the Internet]. 2009 Oct 14 [cited 2010
Feb 9]: [about 3 screens]. Available from: http://
nursing.advanceweb.com/article/nursing-job-
shortage.aspx.
15. Jacobs PM. Streamlining an RN-BSN program for
nurses. Nurs Educ Perspect. 2006;27(3):144-7.
16. Teeley, K. H. Designing hybrid web-based
courses for accelerated nursing students. J Nurs
Educ. 2007:46(9):417-422.
17. Lillibridge J, Fox SD. RN to BSN education. What
do RNs think? Nurs Educ. 2005;30(1), 12-6.
18. Morgenthaler M. Too old for school? Barriers
nurses can overcome when returning to school.
Assoc Perioper Regist Nurs J. 2009;89(2):335-44.
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INTRODUCTION
Mixed methods research is a new approach.
Researchers for many years have collected both
quantitative and qualitative data in the same studies.
However, to put both data together as a distinct
research design or methodology is new. Mixed
methods research involves the collection, analysis and
integration of both qualitative and quantitative data
in a single study. The benefits of mixed method
research approach are particularly evident when
studying new questions or complex initiatives and
interactions. Tashakkori and Teddlie (2003) called
mixed methods research the “third methodological
movement”. It means that in the evolution of research
methodologies, mixed methods now follow
quantitative approaches and then qualitative
approaches.1 Many researchers are interested in mixed
methods research as it has evolved during the last few
decades.
Mixed Methods Research: A New Approach
Vathsala Sadan
Professor & Addl. Deputy Dean, College of Nursing, Christian Medical College, Vellore, South India
ABSTRACT
Mixed methods research is a new approach in which both the qualitative and quantitative research
designs are mixed and are becoming popular in nursing research too. Mixed methods research
involves collecting analysing and mixing quantitative and qualitative data in the single research
process. It is a natural and practical approach. Because of the complexity of health problems, mixed
methods research is needed today in the field of health profession. In this article, the author describes
about mixed methods research, the value of this research approach, the types of mixed methods
research, its design and the various guidelines and steps involved in designing and conducting
mixed methods research. It also outlines the strengths and limitations of the new approach as well as
the challenges ahead in conducting mixed methods research.
Keywords: Mixed Method, Quantitative, Qualitative, Research Design
DOI Number: 10.5958/j.0974-9357.5.2.054
Corresponding author:
P Vadivukkarasi Ramanadin
Asst. Professor
Dept. of OBG
Mata Sahib Kaur College of Nursing, Mohali, Punjab
Mobile No.: 7696732898
Mail Id: krishraghav2010@gmail.com
pvadivuram2010@yahoo.com
Mixed methods research is a research design with
philosophical assumptions as well as methods of
inquiry. As a methodology, it involves philosophical
assumptions that guide the direction of the data
collection and analysis of data and the mixture of
quantitative and qualitative approaches.2 Mixed
method encourages the use of multiple world views
and is a practical and natural approach to research.
Mixed methods research is important today because
of the complexity of problems that need to be
addressed, the rise of interest in qualitative research
and the practical need to gather multiple forms of data
for diverse audiences. A combination of both
quantitative and qualitative data can provide the most
complete analysis of problems.3
DEFINITION
A qualitative phase and a quantitative phase are
included in the overall research study. Mixed
methods research is a design for collecting, analyzing,
and mixing both quantitative and qualitative research
(and data) in a single study or series of studies to
understand a research problem.4
Value of Mixed Methods Research2
The basic principle of mixed research is that the
researcher should use a combination of methods that
has complementary strengths and non-overlapping
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weaknesses. The quantitative and qualitative
researches have their own strengths and weaknesses.
The combination of these two approaches provides a
better understanding of research problems than either
approach. Mixed methods research provides strengths
that bring down the weaknesses of both quantitative
and qualitative research. It provides more
comprehensive evidence for studying a research
problem. Mixed methods help answer questions that
cannot be answered by quantitative or qualitative
research alone. It encourages researchers to collaborate
across the relationship between quantitative and
qualitative researchers.
Mixed methods research is more practical that the
researcher can use all methods possible to investigate
on the research problems. According to Collins et al
(2006),2 the following are the research mixing rationale:
• Participant enrichment (optimizing samples)
• Instrument fidelity (maximizing appropriateness
and utility of instruments)
• Treatment integrity (assess the fidelity of
interventions)
• Significance enhancement (maximize
interpretation of data)
Types of Mixed Methods Research
Research can be viewed in a continuum with mono
method or partially mixed method or as fully mixed
method. The major types of mixed research are mixed
model research and mixed method research. In the
mixed model research, the quantitative and qualitative
research approaches are mixed within or across the
stages of research process. In within-stage mixed
model, the qualitative and quantitative approaches are
mixed within one or more of the stages of research
E.g. use of open ended (qualitative) and closed ended
(quantitative) questions. In across stage mixed model,
the research approaches are mixed across at least two
of the stages of research e.g. collecting qualitative data
by interviews and then quantifying the results.4
In mixed methods research, a qualitative phase and
a quantitative phase are included in the research study.
The mixed methods research designs are classified
based on the time order and the paradigm emphasis.
The designs based on the time order decisions include
the concurrent versus the sequential designs. The
paradigm emphasis designs include equal status
versus dominant status. The mixed method design
matrix is shown on Figure 1. In order to understand
this matrix, we must get oriented to the following
notations used: 4
• QUAL and qual – qualitative research
• QUAN and quan – quantitative research
• Capital letters denote priority
• Lower case letters denote lower priority
• + indicates concurrent data collection
• — indicates a sequential data collection
Fig. 1. Mixed Method Design Matrix 4
We need to ask few questions before we choose the
type of mixed methods research design for a research
study
•Will the quan and qual data be collected?
♦♦
♦♦
♦Timing
– Sequentially? – one builds on the other
– Concurrently? – both are collected at the
same time
♦♦
♦♦
♦Emphasis
– Quan emphasized?
– Qual emphasized?
♦♦
♦♦
♦Mixing
– Merging?
– Connecting?
– Embedding?
The mixing of data is an important aspect of mixed
methods research. The qualitative and quantitative
data need to be mixed together to form a complete
picture of the research problem. There are three ways
by which the data can be mixed.2 they are merging or
converging, connecting and embedding which are
shown in Figure 2.
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Fig. 2. Ways of Mixing Quantitative and Qualitative Data
Mixed Methods Research Designs2
A) Concurrent Mixed Methods Designs
a) Triangulation Design: It is a type of design in
which different but complementary data will be
collected on the same topic. The quantitative
instruments will be used to test the theory that
predicts that the independent variables will
influence the dependent variables .Concurrent
with this data collection qualitative data also will
be collected. The reason for collecting both
qualitative and quantitative data is to bring
together the strengths of both forms of research.
b) Embedded Design: An embedded mixed method
design is a design in which one data set provides
a supportive, secondary role in a study primarily
based on the other data set. The primary purpose
of this study will use quantitative instruments to
test the theory that predicts that independent
variables will influence the dependent variables.
A secondary purpose will be to gather qualitative
data that will explore the central phenomenon. The
reason for collecting the secondary data base is to
address different questions and to provide support
for the primary purpose of the study.
Fig. 3. Concurrent Mixed Methods Design2
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B) Sequential Mixed Methods Design
a) Sequential Explanatory Design: In this design,
during the first phase quantitative research
questions or hypothesis will address the
relationship between the independent and
dependent variables. Information from this phase
will be explored further in a second qualitative
phase. In the second phase, qualitative interviews
or observations will be used to probe significant
quantitative results by exploring the aspects of the
central phenomenon. The reason for following up
with qualitative research in the second phase is to
better understand and explains the quantitative
results.
b) Sequential Exploratory Design: In this design, the
first phase will be a qualitative exploration of a
central phenomenon by collecting qualitative data.
Findings from this qualitative phase will be then
used to test a theory or research question or
hypothesis that relates the independent and
dependent variables. The reason for collecting
qualitative data initially is that the instruments are
not adequate or not available, variables are not
known or there is little theory guiding.
General Guidelines in Developing Mixed Methods
Research Studies
In mixed methods research approach, it is often
difficult to clearly define the research questions and
the hypothesis. Researchers typically do not see
specific questions or hypothesis especially tailored to
mixed methods research. Strong mixed methods study
Fig. 4. Sequential Mixed Methods Designs2
should start with a mixed methods research question
to shape the methods and the overall design of the
study. Mixed methods studies rely on neither
quantitative nor qualitative research alone. The
combination of these two provides the best information
for the research questions and hypothesis. The types
of questions presented and the information needed to
convey the nature of the study are to be considered.
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Both quantitative and qualitative research
questions and hypothesis need to be advanced in a
mixed methods study in order to narrow and focus
the purpose statement. These research questions or
hypothesis can be advanced at the beginning of the
study or emerge during the later phase of the research
Attention to be given to the order of research questions
and hypothesis. There should be separate quantitative
questions or hypothesis and qualitative questions.
Research questions and hypothesis narrow the
purpose statement. Qualitative researchers ask at least
one central question and several sub questions.
Quantitative researchers write either research
questions or hypothesis. Both forms include variables
that are described, related, categorized into groups for
comparison and the independent and dependent
variables are measured separately.
Figure: 4 shows the framework which can be used
in planning and conducting mixed methods research.2
Steps Involved in Mixed Methods Research
There are various steps involved in designing and
analysing mixed methods research studies.4
Step 1: Decide whether a mixed method research
design is appropriate to answer the identified research
question and to give the evidence you want to get from
the research study.
Step 2: Determine the rationale for using the mixed
methods research. The benefits of a mixed methods
approach are particularly evident when studying new
questions and initiatives or complex initiatives and
interactions in natural. Greene, Caracelli and Graham
5 have defined five categories of rationales or purposes
Fig. 4. Framework used for designing and conducting Mixed Methods Research
for the use of mixed methods in research studies. They
are development, complementing, triangulation,
expansion and initiation.
These are not mutually exclusive and may be
combined in any given study.
Development: to inform the development of one
method from another, using the methods sequentially
for the purposes of increasing construct validity
Complementing: to explore areas of overlap and
uniqueness within phenomena through the use of
different methods for the purposes of enhancing,
elaborating, illustrating or clarifying results and to aid
in description or application of research findings
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Triangulation: to crosscheck and corroborate
results by the use of different types of data
Expansion: to increase the range or scope of inquiry
by appropriately matching the methodology to various
components of the question of interest
Initiation: to specifically discover inconsistencies
and new perspectives that may be uncovered as result
of employing both qualitative and quantitative
methods
Step 3: Decide whether the study is quantitative
dominant or qualitative dominant or both. Based on
this select the research design. Plan for resources in
terms of time, material and manpower.
Step 4: Decide on what type of data to be collected
and what are the different methods of data collection
you will adopt. Decide whether quantitative and
qualitative data will be collected concurrently or
sequentially. Identify tools that will integrate both
qualitative and qualitative data collected. The six major
data collection methods which can be used are tests,
questionnaires, interviews, focus groups, observation
and secondary or already existing data. Develop
sampling strategies for data collection Ensure that
adequate power is considered to establish inferences.
Step 5: Choose the quantitative data analysis
techniques. We can use the technique of quantitizing
(converting qualitative data into qualitative data) or
qualitizing (converting quantitative data into
qualitative data).
Step 6: Identify the data validation strategies used
in both quantitative and qualitative research and mix
these in such a way that it helps in the mixed methods
research.
Step 7: The next step is the data interpretation and
it continues throughout the study. The data
interpretation and data validation go side by side. The
two important strategies to be used during data
interpretation are reflexivity and negative-case
sampling. Reflexivity refers to self awareness abs
critical self reflection on potential researcher biases
which may affect the study process and results.
Negative-case sampling is trying to find and examine
cases which disconfirm the study expectations and
explanations.
Step 8: Develop strategies for communicating the
mixed methods research findings. Research report
should reflex mixing and the study findings should
capitalize the strengths of mixed research.
Strengths and Limitations of Mixed Method
Research
The use of mixed methods research approach has
its own advantages and disadvantage. The main
advantage is the idea of triangulation. The validity or
the outcomes of the analysis is credible and valid. This
design also permits use of words, pictures and
narrations during the data collection process.
Quantitative aspects provide precision and qualitative
aspects provide textural aspects of lived experiences.
It can be used to generate and to test a grounded theory.
Because of the availability of rich data, the analysis
provides comprehensive answers to the research
questions and hypothesis. In-depth evidences are
arrived from triangulation of the results. The identified
research problem is examined from multiple
viewpoints which are an added strength of mixed
methods research. It provides stronger evidence and
more complete knowledge to inform theory and
practice. Because of the additional methods used and
added insights, this research approach increases the
generalizability of the study findings. Since the
qualitative and quantitative research approaches are
used together, it yields more complete knowledge
which contributes to nursing theory and practice.
The mixed methods research approach also has its
own limitations. The researcher has to be competent
in both qualitative and quantitative research
approaches, since both are used concurrently If not,
the research design will be used haphazardly. This
research design is costly since more team members are
needed to complete the study as well as it is more time
consuming as well as expensive. It is also a difficult
task for the researcher since some details remain to be
fully worked out by the expert research
methodologists.
Challenges
Various challenges arise while conducting mixed
methods research. First of all there will be difficulties
in relation to the availability of time, money and
manpower with added strengths in both qualitative
and quantitative approaches. Accessibility to tools and
programs to store and arrange data again is a challenge
placed in front while using mixed methods approach.
The amount of data available from mixed methods
research is enormous and so there will be difficulties
in publishing these studies with word limits.6
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CONCLUSION
Both quantitative and qualitative approaches are
needed to expand knowledge and understanding of
educational process and content and of its impacts.
The nurse researchers need to be familiar with mixed
methods approaches. Despite its value, conducting
mixed methods research is not easy. It takes time and
needs resources to collect and analyse the data. It
complicates the procedure of research and requires
clear presentation. The investigators need to be trained.
But the value of mixed methods outweighs the
potential difficulty of this approach.
Acknowledgement: Not applicable
Conflict of Interest: Not applicable
Source of Support: Not applicable
Ethical Clearance : Not applicable
REFERENCES
1. Tashakkori A, Teddlie C., eds. Mixed
Methodology : Combining Qualitative and
Quantitative Approaches.Thousands Oaks. CA:
Sage Publications 1998
2. 2Creswell J. Research design: Qualitative,
Quantitative and Mixed Methods Approaches.
2nd edn. Thousand Oaks,CA: Sage Publications
2003: 208-27.
3. Boswell C, Cannon S . Introduction to Nursing
Research : Incorporating Evidence – Based
Practice , 2011, Sudbury : Jones and Bartlett
publishers
4. Johnson B, Christensen L. Mixed research : Mixed
Method and Mixed Model Research Retrieved
December, 1, 2011 from http://www.
southalabama .edu/coe/bset/Johnson/lectures/
lec14. htm
5. Greene J C, Caracelli V J , Graham W F.Toward a
Conceptual Framework for Mixed Method
Evaluation Designs.Educational Evaluation and
Policy Analysis. 1989.11(3): 255-74.
6. Schifferdecker K E, Reed V A. Using Mixed
Methods Research in Medical Education: basic
guidelines for researchers. 2009. Medical
Education 43: 637-644.
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INTRODUCTION
Nurses are the front line staff in healthcare industry
with significant contribution in delivering effective
patient care as well as in rescuing lives. Crisis in
nursing industry related to shortage of staff, and
medication errors are issues of concern.
Many countries have been experiencing nursing
shortage1. Number of nurses per thousand population
in 2009 was 9.8 in US, 2.9 in Brazil, 1 in China and 1.3
in India and the gap to be filled in nursing occupation
in India is 2,510,250 nurses as mentioned in a report
by ASSOCHAM2.
Another related crisis in the nursing industry is that
of medication errors. Anderson and Twonsend3 found
administration errors by nurses to be 26- 32% of the
total medication errors. Staff shortage has been found
to have a detrimental effect on patient care and
medication errors because of work overload by Bostick
et al4.
Shortage of nurses is not only because of lack of
facilities or recruitment of new nurses but also due to
high turnover of nurses resulting from stress, burnout
Nursing Industry: Where Rescuers Become The Victims
Vijayta Doshi
Organizational Behavior Area, Indian Institute of Management, Ahmedabad, India, Dorm 34, Room 6, IIM, Vastrapur,
Ahmedabad, India
ABSTRACT
The study explores the psychological and social experiences of nursing job. Research gap exists in
the literature in terms of limiting emotional labour in nursing around patients, thereby neglecting
the emotional labour that nurses perform with patients' relatives, doctors and other social actors.
The study aimed to firstly understand the emotional labour performed by nurses with respect to
patients and their relatives, doctors and the organization. Another aim was to investigate the
consequences of emotional labour. The study involved in-depth interviews with nurses in Indian
context. It was found that nurses face emotional dilemmas with patients, patients' relatives and
organizational demands. In some cases, medication errors and turnover were found to be related to
emotional labour. The study enhances the understanding about emotional labour in nursing and is
one of the initial studies in the Indian context.
Keywords: Emotional Labour, Nursing, India
DOI Number: 10.5958/j.0974-9357.5.2.054
and emotional work demands of nursing job as
highlighted by Chang et al5. Similarly, medication
errors are high not only because of the carelessness/
lack of skills but also due to emotional fatigue and
exhaustion of nurses as mentioned by Deans6. There
is a need to view the problems of nurses’ shortage and
medication errors in relation to emotional labour
involved in nursing.
Emotional labour concept given by Hochschild7
comprises of deep felt as well as surface level emotions.
Deep felt emotions are those which a person actually
feels whereas surface level emotions are those which
a person feigns in order to comply with the demands/
expectations.
RESEARCH GAP
Research gap exists in the literature in terms of
conceptualizing emotional labour in nursing around
patients, thereby neglecting the emotional labour that
nurses perform with patients’ relatives, doctors and
other social actors. The study by Liji and Manikandan8
is the most recent and to the researcher’s knowledge
the only empirical study on emotional labour in
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nursing in Indian context. However, they also
conceptualize emotional labour of nursing related to
just patients. Therefore, the current study expands the
conceptualization and understanding of emotional
labour in nursing. Venkatesha and Blaji9 have appealed
in their conceptual paper about the need for empirical
studies on emotional labour in nursing especially in
Indian context.
Nursing as Emotional Labour
Nurses face demands by patients and patients’
relatives, doctors, organization and society.
Patient is the king in healthcare like customer is
for any organization as mentioned by Kertesz10.
Positioning of patient as the king creates a power
difference among patients and nurses who serve them.
Gray11 mentioned that patients demand nurses to
portray the caring image of ‘Florence nightingale’,
caress them to make them feel better and put up with
their aggression.
The expectations from nurses are not limited to
patients. Relatives of patients undergo anxiety, fear and
distress, and demands nurses’ attention. Families of
the patients must also receive adequate support and
care because if families needs are well addressed it has
a positive impact on both family well being and
patient’s recovery as found by Fox-Wasylyshyn et al12.
Nurses have to perform emotional labour to live
up to the expectations and demands of the doctors as
well. Doctors are the dominant party in the doctor-
nurse game13. Timmons & Tanner14 found in their study
based in UK National Health Service hospitals that
nurses were expected to keep the doctors happy, not
upset them, bear with doctors’ aggression and bad
temper. They described it as ‘hostess’ role of providing
food, drink and light conversations.
As far as organizations’ demand is concerned,
Alibini and Labronici15(p299) conducted a study to
understand the experience of being a nurse and the
main theme emerged out to be “exploitation and
alienation of the body of the nurse until its exhaustion”.
The invisible nature of emotional labour makes it
under-appreciated and unvalued by organizations in
economic terms16. Emotional work is considered as a
free gift in the nursing labour said Bolton17.
Society also considers nursing job to be menial,
dirty and ‘others’ work17. Nursing job has taboos of
close contact and physical intimacy with the patients
and doctors17. A number of studies have recorded
nurses’ feeling that the society does not value their
work and that they are considered to be low status16.
RESEARCH QUESTIONS
1. How do nurses in the Indian context perform
emotional labour (with patients, their relative,
doctors and senior nurses)?
2. What are the consequences of emotional labour in
nursing?
METHODOLOGY
Qualitative research approach using semi
structured in-depth interviews was used to explore the
research questions. Snowball sampling method was
employed to identify eighteen nurses from
government organizations and fourteen from private
organizations in Ahmedabad, Delhi and Mumbai. The
demographics of the sample are mentioned in Table1.
Since the aim of qualitative research is not to ‘establish’
and rather is to ‘understand’ a phenomenon with
richness, sample size of thirty two brought theoretical
saturation. Theoretical saturation given by Glaser31 is
that point in data collection when no new idea or
themes emerges from the data. Ethical guidelines
pertaining to informed consent and confidentiality of
participants’ identity were maintained.
Interviews were voice recorded. In cases where
permission for voice recording was not granted, short
hand notes were prepared. Voice recorded interviews
were transcribed. Transcripts and short hand notes
were analyzed using manual coding as suggested by
Charmaz18 and Glaser19 to isolate themes. The nurses
were contacted again when the need to triangulate the
data was felt. It helped in validating meanings thereby
enhancing rigor in the analysis.
FINDINGS
Juggling between detachment: attachment
Nurses shared their experiences of patients
expecting them to feel their feelings when they actually
weren’t empathetic. Nurses found difficulty in dealing
with those situations because of the superficial
behavior involved. They stated that they underwent
depersonalization because of prolonged emotional
exhaustion. After spending some time in job they got
habitual of seeing people crying and dying without
feeling as bad as they felt initially in job.
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“A person becomes emotionally shallow when one
is working in such environment constantly unless
some of your family member is the patient..you
become emotionally empty. Emotions do not come
easily that is if a patient is dying and relatives are
weeping, we don’t weep and just console them that
its’ okay the patient was unwell, don’t cry..that’s it.”
Still some of the nurses shared how sometimes they
got emotionally attached to some patients with whom
they had spent lot of time especially kids.
While patients and the human side of nurses forced
them to be empathetic, their job demanded
suppression of those feelings because they had to be
“stable”, in “control” of their emotions and “poised”
otherwise they would not be able to provide proper
care to the patients. Further, they suppressed their
emotions so that they were able to motivate patients
for their fast recovery rather than making them feel
like ‘patients’.
Emotions could be displaced but not physical pain
Nurses experienced frustrations because of work
load and the emotional demands of work. They often
vent out their work frustration on their family
members.
“Stress is there because of work load. Sometimes
frustration of office gets displaced at home. Sometimes
the frustration gets displaced on the kid or husband
or any other family member.”
They hide negative emotions at workplace as one
was supposed to show “professional etiquettes”.
Nurses could escape from the frustration but they
could not escape from the damage to their physical
and mental well being as some of them mentioned
having psychosomatic disorders such as headache,
back pain and depression.
Irksome behavior of patients’ relatives
Nurses stated that they had to provide emotional
support to console the relatives of the patients. Nurses
felt that patients’ relatives were troublesome many
times. The said some patients’ relatives repeatedly
approached them asking same thing which irritated
them but they could not express their irritation in all
situations.
“Sometimes like if a patient’s relative comes to us
and says that patient is in pain. I say okay we are giving
medicine. Then second patient comes and asks that
still the pain has not gone then I say okay the effect of
medicine will take at least half an hour. The third
relative come, fourth come, followed by fifth. Then in
such situation repeating one thing again and again
results into irritation.”
They felt that there was an inherent power
difference between nurses and patients/ their relatives.
Nurses feared complaints by the patients/ their
relative and followed an implicit “professional” code
of conduct- suppress or displace negative emotions
such as aggression and express positive emotions such
as care and empathy in limits.
No control over job
Nurses experienced overtime in their jobs which
was never accounted for, neither were they given any
compensation/ extra payment or leave. Some of them
mentioned the reasons for Indian nurses migrating to
foreign countries as- stipulated work hours and
payment for overtime unlike India where there is
“exploitation” of labour. Overtime was not just because
of staff shortage but also because of non- punctual staff
and absenteeism. In one of the nurse’s words:
“Overtime happens always.. always. We have six
hours duty from 8 a.m. and it’s not necessary that we
complete six hours and go home. Our overtime is
neither counted, that we worked extra time. If you
calculate our duty hours then don’t know so many
hours will be extra hours overtime but nobody bothers
for that.”
Cooperation by doctors
Nurses mentioned about the skewed doctor nurse
ratio. They however were of the opinion that they
worked as a team with doctors who were cooperative.
This cooperation stemmed from the inter-dependence
of doctors and nurse on each other given the shortage
of staff. It is because of this inter-dependence that
doctors never misbehaved with them in any way.
“In our profession there is lot of cooperation and
we work as a team because everyone needs the other
person. So we can’t misbehave with each other. So,
there is lot of cooperation. When we go on lunch then
doctors manage the ward and work and likewise when
doctors are not there, we manage. It’s kind of a team
work.”
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270 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
Social image
Nurses stated that some people considered them
to be “doctor’s assistant” or “helpers”. They shared
their unhappiness with such opinions. As said by one
of the nurses:
“People think that we are just like that..doctor’s
assistance. They don’t realize that how much effort we
do in the absence of doctor. Like I told you doctors are
mostly not available and at that time we only look after
those patients.”
Addressing the dissonance, one of the nurses
working in a government hospital stated that nurses
were at par with doctors in terms of salary and that
slowly their social status is improving as their salary
is increasing.
“People think that nurses are like helpers for
doctors. Because of increase in salary such perception
is no longer there. Our salary is equivalent to MBBS
doctor’s salary.. now the salary has increased and if
one is financially good then the status symbol
automatically changes.”
However, they believed that society also had people
who valued them. Therefore, nurses were aware about
the mixed societal opinions regarding their job but
were not much affected by their societal image.
Medication errors and turnover
As far as mediation errors were concerned, they
did take place however not very often. They mentioned
that often medication errors were either ignored or not
disclosed because of consideration for workload and
the legal consequences.
“It happened in front of me in ICU. I had a colleague
who overdosed a baby instead of 500 units, she gave
5000 units of anti-heparin injection to the baby. The
child was eight years old.”
“Medication errors if happen due to workload,
nurses are held responsible saying that why they did
not complain in written that there were so less nurses
for so many patients.”
Medication errors was attributed to enhanced
workload due to staff shortage or turnover of nurses.
Nurses mentioned about their colleagues migrating
to foreign countries as a reason for turnover. The
reasons for their migration being less workload and
of course better salary in foreign countries.
CONCLUSION
Nurses experienced dilemma of emotional
attachment and detachment with some patients.
Nurses faced emotional challenges in dealing with
organizational demands such as overtime and they felt
lack of control over their job. In terms of the emotional
challenges with patients’ relatives, nurses considered
their work emotionally demanding. Given the
emotional demands and organizational demands,
nurses experienced stress and burnout which
sometimes led to medication errors and turnover.
Fig. 1. Highlighted boxes indicate the problem areas
Based on the insights discussed above, the following
framework is drawn
Fig. 2. Emotional labour in nursing
Some of the limitations of the study are firstly,
opinions of nurses working in private versus
government institutes have not been distinguished.
This was so because firstly, not much difference was
observed and secondly, there was unequal distribution
of the two categories of nurses in the study. For future
research this may be explored. Secondly, analyses was
not carried out based on the departments in which
nurses served because of insufficient diversity in the
sample which was obtained using snowball sampling
technique. Such analyses may be insightful to explore
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 271
in future since different departments may require
different level of emotional engagement.
The study broadens the understanding that in
nursing, emotional labour is not limited to nurse-
patient interactions. The study is one of the initial
contributions on understanding about the emotional
labour experiences of nurses in the Indian context.
Table 1. Demographics of the sample
Demographics (No. of nurses)
Age 20-30 (13)
31-40 (12)
41-50 (7)
Education B. Sc (14)
General nursing & midwifery (18)
Marital status Married (19)
Unmarried (13)
Work experience 5 years - 22 years
Institution type Government (18)
Private (14)
Job type Permanent (22)
Contract (10)
Working hours/ day 6 -8 hours
Night duty 10-12 hours
Working days/week 6 days
Monthly in-hand salary 14000/- to 50, 000/-
ACKNOWLEDGEMENT
The author would like to thank all the participants
for their time and inputs.
Conflict of Interest: There is no conflict of interest
involved in this study.
Source of Funding: No source of funding was obtained
for the study.
REFERENCES
1. Fawcett J. Nursing qua nursing: The connection
between nursing knowledge and nursing
shortage. Journal of Advanced Nursing. 2007;
59(1): 97–99.
2. ASSOCHAM report. Emerging trends in
healthcare: A journey from bench to bedside; 2011.
Retrieved on July 5, 2012 from http://
www.kpmg.com/IN/en/IssuesAndInsights/
ThoughtLeadership/Emrging_ trends_in_
healthcare.pdf
3. Anderson P, Townsend T. Medication errors:
Don’t let them happen to you. American Nurse
Today. 2010; 5(3).
4. Bostick JE, Rantz MJ, Flesner M K, Riggs C J.
Systematic review of studies of staffing and
quality in nursing homes. Journal of the American
Medical Directors Association. 2006; 7(6): 366-376.
5. Chang E M, Hancock KM, Johnson A, Daly J,
Jackson D. Role stress in nurses: review of related
factors and strategies for moving forward.
Nursing and Health Science. 2005; 7(1): 57-65.
6. Deans C. Medication errors and professional
practice of registered nurses. 2005. Retrieved on
31/7/12 from http://www.ncbi.nlm.nih.gov/
pubmed/16619902
7. Hochschild A. Emotion Work, Feeling Rules, and
Social Structure. American Journal of Sociology.
1979; 85(3): 551-575.
8. Liji PG, Manikandan K. Sex role orientation and
emotional labour among nurses. ACADEMICIA:
An International Multidisciplinary Research
Journal. 2013; 3(3): 65-76.
9. Venkatesh J, Balaji D. The health care initiative
for emotional labors. International Journal of
Education and Research. 2013; 1(1): 1-9.
10. Kertesz L. Patient is king. Studies define
customers’ satisfaction and the means to improve
it. Modern Healthcare. 1996; 26(18): 107-8, 112-4,
116-20.
11. Gray B. Emotional labour, gender and
professional stereotypes of emotional and phycial
contact, and personal perspectives on the
emotional labour of nursing. Journal of Gender
Studies. 2010; 19(4): 349-360.
12. Fox-Wasylyshyn SM, El-Masri MM, Williamson
KM. Family perceptions of nurses’ roles toward
family members of critically ill patients: A
descriptive study. Heart and Lung. 2005; 34(5):
335–344.
13. Gordon S. Nursing against the odds. Cornell
University Press: New York; 2005.
14. Timmons S, Tanner J. Operating theatre nurses:
Emotional labour and the hostess role.
International Journal of Nursing Practice. 2005;
11(2): 85-91.
15. Albini L, Labronici L M. Exploitation and
alienation of the body of the nurse: A
phenomenological study. Acta Paul Enferm. 2007;
20(3): 299- 304.
16. Small E. Valuing the unseen emotional labour of
nursing. Nursing Times. 1995; 91(26): 40.
17. Bolton, S C. Who cares? Offering emotion work
as a ‘gift’ in the nursing labour process. Journal
of Advanced Nursing. 2000; 32(3): 580-586.
18. Charmaz K. The Sage Handbook of Grounded
Theory. Thousand Oaks: Sage Publications, Inc;
2007.
19. Glaser BG. Theoretical sensitivity. Mills Valley,
CA: The Sociology Press; 1978.
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INTRODUCTION
Pregnancy is a normal physiological event and it
links mother and fetus together and is the normal
process for regeneration. The birth of a baby is the
joyous moment if it goes smoothly but for some it is
not, due to the illnesses (anemia, hypertension,
diabetes). Every minute of every day, somewhere in
the world women die as a result of complications
related to pregnancy or child birth.1
It has been recognized that maternal mortality
and morbidity due to high risk pregnacies is a global
problem. The risk of dying from pregnancy or
childbirth in developing countries of the world is up
to 200 times higher than in the developed countries.2
Poor pregnancy outcome are more often observed in
adolescents who have poor nutrition and low socio
economic status. The high incidence of complications
during pregnancy has increased the prenatal mortality.
Literature surveys have shown that the cause of still
birth and early neonatal deaths are poor maternal
weight gain, anemia, PIH, antepartum hemorrhage
and lack of knowledge.3
OBJECTIVES OF THE STUDY
1) To assess the knowledge of college girls regarding
prevention of high risk pregnancy in a selected
college in Mangalore
2) To assess the effectiveness of planned teaching
program in terms of gain in knowledge score
Effectiveness of Planned Teaching Programme on
Prevention of High Risk Pregnancy among College Girls
Wansuklang Lyngdoh1, Rev Angeline (Sr. Aileen) Mathias2
1Lecturer, 2Professor (CNO), Department of Obstetrics and Gynaecological Nursing, Father Muller College of Nursing
Kankanady P.O Mangalore-2
ABSTRACT
The concept of getting pregnant is a remarkable feeling inside the heart so that extra and safe emotional
touch of the beginning of a new life in a near future needs the preventive measures to safeguard from
complication. Reduction of complications and mortality of women has thus been an area of concern
therefore proper education before conception especially to reproductive age group is important as
we care for the future to make it safe and their capacity to communicate and reach the society.
Keywords: Effectiveness; Planned Teaching Programme; High risk pregnancy; College girls
DOI Number: 10.5958/j.0974-9357.5.2.054
3) To find the association between pre-test
knowledge score of the college girls with
selected demographic variables
Hypotheses
The hypothesis will be tested at 0.05 level of
significance
H1: The mean post-test knowledge score of college
girls will be significantly higher than the mean pre-
test knowledge score.
H2: There will be a significant relationship between
the pre-test knowledge score and selected
demographic variables.
MATERIALS AND METHOD
Design and sample: An evaluatory approach with
one group pre-test and post-test design was used for
this study. The sample comprised of 100 college girls
students in the final year degree who met the
inclusion criteria and the sample was selected using
convenience sampling technique.
Tools: The tools used were baseline proforma and
structured knowledge questionnaire.
Intervention: In this study planned teaching
programme related to prevention of high risk
pregnancy was given for the college girls after pretest.
It is systematically developed and organized and
teaching aids (power points) designed for the group
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 273
to enhance their knowledge regarding prevention of
high risk pregnancy.
Data collection: Pre-test was administered by using
structured knowledge questionnaire and Planned
Teaching Programme was given after pre-test. On the
eight day post-test was conducted using the same tool.
The data collected were analyzed using descriptive and
inferential statistics, i.e., Paired‘t’ test, Chi-square test
and Fisher’s Exact test
FINDINGS
In the study most of the college girls did not have any source of information (68%).
Table 1: Baseline characteristics. N=100
Sl. No. Variables Frequency (f) Percentage (%)
1Age (in years)
19-20 35 35
20-21 65 65
2Religion
Hindu 22
Muslim 18 18
Christian 78 78
3Family
Nuclear 66 66
Joint 34 34
4Dietary pattern
Vegetarian 17 17
Non vegetarian 69 69
Mixed 14 14
5Family history
Hypertension 17 17
Asthma 13 13
No history 70 70
6Source
Newspaper 14 14
Friends 18 18
No information 68 68
Table 2: Frequency, percentage distribution and grading of college girls according to pre-test and post-test
knowledge score on prevention of high risk pregnancy. N=100
Range of knowledge score Range of percentage Grade Pre-test Post-test
f%f %
0-10 0-33% Poor 26 26 - -
10-20 68-100% Average 73 73 - -
20-30 68-100% Good 1 1 100 100
Maximum score=30
Data in Table 2depicts that in the pre-test majority
of the subjects (73%)were average in their knowledge
score and (26%) were poor in their knowledge score.
In the post-test it is proved that majority of the subjects
(100%) were with good knowledge score.
Table 3: Range, Mean and Standard Deviation of pre-
test and post-test knowledge score of college girls.
N=100
Knowledge level Range Median Mean ± SD Mean%
Pre-test 5-21 11 10.96 ± 2.28 36.53%
Post-test 21-29 23 23.26±1.53 77.53%
Maximum score=30
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Data in Table 3 shows that range of post-test
knowledge score was 21-29 and that of pre-test
knowledge score was 5-21. It is evident from the table
that the mean post-test knowledge score( = 23.26 +
1.53) is higher tahn the mean pre-test knowledge score
(=10.96 + 2.28).
Table 4: Mean difference, paired ‘t’ test value and p
value between pre-test and post-test knowledge score
of girls regarding prevention of high risk pregnancy.
N=100
Group Mean difference of ‘t’value p value
Pre and Post test
College girls 12..3 41* 0.0001*
t(99) at 0.05 level = 1.66, p< 0.05, df=99 mSignificant
The data in Table 4 shows that the mean difference
was 12.3. it is evident that calculated ‘t’value (t(99)=41)
was greater than table value (t(99) at 0.05 level= 1.66).
Hence the null hypothesis was rejected and the
research hypothesis was accepted. The mean difference
between pre-test and post-test knowledge score was a
true difference and not a chance. This indicate that PTP
was significnatly effective in increasing the knowledge
of college girls.
Association between pre-test knowledge and
selected variables
Chi-square is used in order to find out the
significance association between pre-test knowledge
score and selected variables. The p value obtained were
not significant at 0.05 level. Thus it is interpreted that
there is no significant association between knowledge
and selected variables.
CONCLUSION
The findings of the study have shown that the
knowledge scores of college girls were poor before the
administration of Planned Teaching Programme. The
Planned Teaching Programme facilitated them to learn
regarding the prevention of high risk pregnancy which
was evident in post-test knowledge score, post-test
measures showed significant increase in the
knowledge score of the college girls. Hence Planned
Teaching Programme was an effective method in
improving the knowledge of college girls which was
well appreciated and accepted by them.
ACKNOWLEDGEMENTS
My heartfelt gratitude to Rev. Sr. Winnifred
D’Souza, M.Sc (N), Prinicpal, for her encouragement,
inspiration , support as well as for providing all
facilities for successful completion of the study. To the
college students who participated in the study and the
authorities who provided permission to conduct the
study.
Conflict of Interest: Nil
Source of Funding: Self
Ethical clearance: To conduct the research study,
ethical committee clearance was obtained from the
Institution. Administrative permission from the
Principal of different colleges was taken. Informed
consent were prepared and informed consent from
college girls was taken.
REFERENCES
1. Vijay M, Sarode. Does literacy influence
pregnancy complications among women in
slums. IJSA 2010 May;2 (5):82-94.
2. Marge B, Ravindran TK. Safe Motherhood
Initiatives: Critical Issues. London: Blackwell
Science; 2000.
3. WHO. Trends in Maternal Mortality: 1990 to 2008.
Population and Development Review 2011
Mar;37 (1):211-214.
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INTRODUCTION
Colostomy formation is a very common procedure
which is performed every day in health care setups.
However, it brings a major change in patient’s life. Post
colostomy, patient usually reports poor quality of life
1because they are unaware about the outcomes of the
procedure. Post colostomy patients’ and their families’
life will majorly affect physically and psychologically
because they have no knowledge about the
modification in the elimination pattern after the
procedure. This shocking situation makes patient
difficult to cope with their ostomy and live life with
this modification. However, prior discussion with
patient regarding their major changes in their quality
of life after colostomy procedure will help them to
manage their lives with the colostomy1, 2. This prior
discussion also prepares patient after the procedure,
to deal with the problem of stoma, decreases the rate
of complication and enhances their adjustment with
colostomy and improves quality of life.
CASE SCENARIO
Ms X, 25 years old Afghani girl, engaged with her
cousin, diagnosed with Cancer of colon, admitted for
laparotomy and formation of permanent colostomy.
Colostomy Care: Management Beyond Hospitalization
Case Report
Zulekha Saleem1, Lubna Ghazal2
1Instructor, 2Senior Instructor, School of Nursing and Midwifery, Aga Khan University, Stadium Road, PO Box 3500,
Karachi 74800, Pakistan
ABSTRACT
Colostomy formation brings lot of changes in patients' physical, social, spiritual, sexual and
psychosocial health. The modified elimination pattern, after the permanent colostomy may deteriorate
patients' quality of life. Lack of patient preparation for the procedure may lead to impair the domains
of patient quality of life. The prior education, patient involvement and continuous facilitation of
patient in his recovery period may enhance patients' ability to cope with changes in their life after
permanent colostomy and enhanced their quality of life after the modified elimination pattern.
Keywords: Colostomy, Quality of Life After Colostomy and Colostomy Care
DOI Number: 10.5958/j.0974-9357.5.2.054
A night before the procedure, a resident assigned to
this patient came and asked for an ink pad to take
patient’s thumb impression on the consent form. The
resident requested assigned nurse to accompany him
to witness the informed consent.
As this patient had language barrier therefore, the
nurse tried to arrange an interpreter. The resident was
in a rush; he took patient’s thumb impression on the
consent form and asked the nurse to sign as witness.
However, he did not explain the procedure, risk benefit
ratio and outcomes of this surgery on her quality of
life. The assigned nurse refused to sign as a witness
and she requested the resident to wait for the
interpreter and provide complete information
regarding the procedure. The resident disagreed and
said this procedure is in the benefit of the patient so it
does not matter if she understands it or not. However,
after his discussion with the nurse, he assigned one of
his interns to provide the needful information to the
patient in the presence interpreter. The intern with his
limited capacity could not provide the satisfactory
information to the patient, which left patient
unsatisfied and with increased anxiety. After the
procedure, when she met with reality she went in shock
and did not accepted herself. Due to that, she took long
time in the adjustment with colostomy.
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DISCUSSION
It is true that colostomy procedure reduce patient
suffering and pain, but due to the not enough
preparedness prior and after the procedure ends up
the patient in distress2. They are feel depressed and
frustrated in adopting with the change that occurred
in their body. This leads to patients’ late recovery from
the procedure and later adjustment with the
colostomies2, 3. In the scenario, the patient was very
young, and engaged. Her family wanted her to get
married after the treatment. Therefore, it was
important that she should know about the procedure
and outcomes of permanent colostomy, which would
bring expected change in her quality of life particularly
after her marriage. Moreover, this patient was with
language barrier; therefore, more efforts were required
to arrange a translator for her to make sure that she
receives complete information regarding her
procedure (prior and after) because in future it will
impact her physical, psychological, social, sexual and
spiritual aspects of her life3,4
Physical aspect
Sabbir et al reported5 that ignorance about the
education aspect of informed consent make difficult
for the patient to manage their colostomies, which
increased the rate of complications among these
patients. This was expected after the surgery, initially
after 24-72 hours patient may experience severe to
moderate pain this might also affect her sleep and rest
pattern. Moreover, due to her prolong nothing per
oral status might reduce her energy level. Therefore,
it was important that for initial 48 hours she should be
kept pain free, hydrated well and assisted for activities.
In addition, patient should be prepared to deal with
her stoma and colostomy pouch. Furthermore, the
physical presence of the stoma on her abdomen might
make her feel uncomfortable during her mobility and
to perform activities of daily living. It is important
(prior surgery and post procedure) that patients should
understand that the size and color of her fresh stoma
will change with care and passage of time. Therefore,
it is very vital that patient should be involve in stoma
care as soon she copes with her pain so that when she
goes home she should be able to manage her colostomy
independently.
Social aspect
Patient might face more problems with the social
aspects after her permanent colostomy3, 4 .The presence
of her stoma refrain her from social interaction with
her family and friends. The fear of leakage, gas
formation in the bag and bad smell might make her
uncomfortable and embarrassed among the family /
friends or social gatherings. So, it is important to
emphasize that these are the expected changes after
colostomy. In this regard, health care professionals
should educate patient and families about the
adjustment and coping strategies, like modification in
diet, clothing and hygiene practices. This would not
only make patient comfortable by reducing infections,
and skin irritations. Moreover, these strategies will help
them to manage their everyday life and enhance social
interactions.
Spiritual aspect
Patient might face spiritual distress for not been
clean and perform religious rituals as hygiene is
considered to be half faith in Islam4 The physical
cleansing is also emphasized by the Prophet who
recommended his followers to perform prayers and
be physically clean and smell fresh before they stand
and pray in front of God6. The prophet has listed
conditions in which hygiene or ablution is not
maintained such as: presences of feces, urine, vomiting,
full of mouth, flatulence, menstruation, and men’s
nocturnal discharge (Bukhari fil-wazu, hadith no 211;
Tirmizi, fil-tihara hadith no 65). However, having
colostomy makes it difficult to fulfill these
requirements to perform religious practices for a
Muslim. The patient should be well informed that
according to the Islamic catechism (Fatwa) of the
Department of Religious Affairs on this matter,
“provisions are provided for disabled people regarding
the factors that invalidate ablution” Moreover, to
promote patient prolong prayer time, Fatwa for
Ostomities, as cited in Karadag & Baykara, 4 stated that
‘Department of Religious Affairs of Turkey states gas
or feces excretion to pouch during praying does not
disrupt worship’p.1189. Health care professional could
teach the client colostomy irrigation technique. The
patient in one of the study mentioned that after
learning colostomy irrigation, he is able to manage his
prayer at mosque with minimal gas discharge and
smell4.
Sexual aspect
In this scenario, the client was engaged and her
family wanted her to get married after the treatment.
However, it is needed that patient and family should
be educated by the length of recovery after the
procedure. It is also important that her wound is healed
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 277
completely and she is competent enough to manage
her colostomy before she enters to new relationship.
Moreover, her husband should know about this
permanent change of her wife’s body. One of the study
identified that women’s’ after the colostomy procedure
mostly worried about their sexual life and
relationships with her husbands2. Hence, this is
important to emphasis the patient that having
permanent colostomy does not change the desire for
intimate relationship. However, the couple should be
counsel regarding the caution and alternative method
to satisfy their sexual needs after marriage. For that,
proper referral to counselor and continuous
assessment of patients’ sexual health should be
considered by health care professionals. Moreover, the
married couple should also be informed about having
a baby with the consultation of their physician.
Psychological aspect
The patients with colostomy usually have low self-
esteem and altered body image due to their stoma9.
The researchers have identified following factors that
mainly affect patients’ mental health these include:
impaired body image, fear of incontinence, fear of odor,
impaired social interaction, and impaired sexual
function2-4. In a cross sectional study conducted by
group of Iranian physician10, highlighted higher rates
of psychiatric illnesses (body image disturbance, lower
self-esteem) among stoma patient especially among
young women. Therefore, it is very important to aware
patients and their families about these factors and their
effects on mental health. As a health care professional
it is essential to closely observe the symptoms of
anxiety and depression among this patient in the given
scenario.
CONCLUSION
In conclusion, the presence of permanent colostomy
impact patient’s physical, psychological, sexual, social
and spiritual domain of their life. Therefore, health
care professional should be vigilant to assess untold
needs of the patients and provide them with
appropriate education to enhance their quality of life
with modified elimination pattern.
ACKNOWLEDGEMENTS
The authors are pleased to acknowledge Aga Khan
School of Nursing and Midwifery.
Conflict of Interest: We do not have any Conflict of
interest
Source of Funding: Not required
Ethical Clearance: Not required
REFERENCES
1. White, C. A., & Hunt, J. C. Psychological factors
in postoperative adjustment to stoma surgery.
Annals of the Royal College of Surgeons of
England 1997; 79(1): 3.
2. Dabirian, A., Yaghmaei, F., Rassouli, M., &
Tafreshi, M.Z. Quality of life in ostomy patients:
A Qualitative Study. Patient Preferences and
Adherence 2010; 20(11):1-5
3. Hassan, I., & Cima, R. R. Quality of life after rectal
resection and multimodality therapy. Journal of
Surgical Oncology, 2007; 96 (8): 684-692.
4. Karadag, A., & Baykara, Z. G. Clostomy
Irrigation: An important issue for Muslim
Individuale. Asian Pacific Journal of Cancer
Prevention,2009; 10(6):1189-90.
5. Shabbir, M. N., Memon, Z. A. L. I., Nizami, M., &
Khanzada, R. Colostomy related complications.
Pakistan Journal of surgery. 2008; 24 (2): 102-104.
6. Salman, K. & Zoucha, R. Considering Faith within
Culture When Caring for the Terminally Ill
Muslim Patient and Family, Journal of Hospice
and Palliative Nursing, 2010; 12(3): 156-163.
7. Bukari fil Wazu
8. Trimizi fil ilhaa
9. Martinez, L. Self-Care for stoma surgery:
mastering independent stoma self-care skills in
an elderly woman. Nursing Science Quarterly,
2005; 18(1): 66-69.
10. Mahjoubi, B., Mohammadsadeghi, H.,
Mohammadipour, M., Mirzaei, R., & Moini, R.
Evaluation of psychiatric illness in Iranian stoma
patients. Journal of Psychosomatic Research,
2009; 66(3): 249-253.
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278 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1
INTRODUCTION
Childhood mortality continues to be a major
problem faced by India. Many National programmes
have been implemented to improve child survival. The
Child mortality report (2011) of the UNICEF shows
that India (22 percent) and Nigeria (11percent) together,
account for one third of under the five deaths
worldwide. The under five mortality rate (U5MR),
infant mortality rate (IMR), Neonatal mortality rate
(NMR) in India was reported to be 63, 48 and 32
respectively.1
Studies from developing countries suggest that ARI
and diarrhea are still the leading morbidities among
children and malnutrition adds to the burden. 2-3 Delay
in seeking appropriate care and not seeking care
contribute to the large number of child death. Health
seeking behaviour and utilization of public health care
services is poor in countries of India, Pakistan, and
Morbidity and Health Seeking Behaviour of Families for
Childhood Illnesses - Experiences from Coastal Kerala
Accamma Oommen1, Manju Vatsa2
1Associate Professor, Sree Gokulam Nursing College, Trivandrum, Kerala, 2Principal, College of Nursing, All India
Institute of Medical Sciences, NewDelhi
ABSTRACT
Health seeking behaviours influence child morbidity and mortality. The present study was undertaken
to identify the common morbidities among under-five children and pattern of health-seeking by
families, and the factors influencing the health seeking behaviours, in a selected coastal area of Kerala.
This descriptive cross sectional survey was conducted among primary care givers (PCGs) of 138
children, with history of morbidity, recruited by total enumeration from coastal regions of Kerala,
India. Interviews were conducted with PCGs during household survey using a structured interview
schedule and nutritional status of children was assessed. The data were analysed using SPSS.
Results showed that average age of children was 2 years, 30% children had mild to severe malnutrition,
8.7% were not immunized for age and 26.1% were found sick during the survey. Over the counter
use of drugs was common in families (67.4%) before seeking professional help. Care was sought
from trained providers by 87.7% of children, allopathy (84%) being the preferred modality and 44%
children were taken to government hospitals. Medical treatment was availed within 24 hours for 52
(37.7%) children only. Management of the child's illness was influenced by severity, duration and
type of symptoms as cited by PCGs (87.7%).The study concluded that care seeking for childhood
illnesses was appropriate but not prompt and self treatment was common.
Keywords: Childhood Morbidities, Health Seeking Behaviours
DOI Number: 10.5958/j.0974-9357.5.2.054
Bangladesh which is a strong reason for the slow
decline of childhood mortality rates 4-7
Integrated Management of Neonatal and
Childhood Illnesses (IMNCI) envisions that
improvement in family practices, especially health
care-seeking behaviours, reduce child morbidity and
mortality.8-9 Recent studies from India suggest that
perceived severity of illness, educational and
occupational status of parents, gender, birth order,
accessibility and availability of health services,
tradition influence the health seeking behaviour of
families for their sick children.10-13 Effective early
management at the home level and health care-seeking
on the appearance of danger signs are key strategies
to prevent occurrence of severe and life-threatening
childhood illnesses. Understanding the health seeking-
behaviour of families, help in planning interventions
for reducing childhood morbidity and mortality.12
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Though India has high child mortality indicators,
indicators of Kerala are very much different, and
similar to developed countries. The U5MR and IMR
in Kerala were reported to be 14 and 12
respectively.14Studies related to health seeking
behaviours for childhood illnesses from states having
higher childhood mortality rates, have been reported
in the published literature from India. Only a few
studies are available from areas with good indicators
like Kerala. Lessons from areas with good indicators
can enlighten the policymakers regarding the strategies
for improvement of child survival. Also the coastal
areas of Kerala reports higher malnutrition and
morbidities. Hence we conducted the present study
to identify the common morbidities among under five
children, pattern of health-seeking by families, and the
factors influencing the health seeking behaviours, in a
selected coastal area of Kerala.
MATERIAL AND METHOD
This descriptive cross sectional survey was
conducted in two coastal wards out of four wards
catered by a sub centre in Alapuzha district in Kerala,
India. One sub centre (SMC) was selected from all the
subcenteres catering to coastal population in Alapuzha
District, Kerala by random sampling. Two wards (ward
13 and 14) which were exclusively coastal, out of four
wards, under the SMC sub centre were selected
purposively. The sub centre was about four to five
kilometers away from Medical College Hospital,
Alapuzha.
The selected wards comprised of 834 dwelling
houses, 3727 population with 212 under five children.
All the households having under-five children in both
the wards were surveyed by household visit along
with the Accredited Social Health Activists (ASHA
workers). Total enumeration was used to recruit the
sample, by including the Primary Care Givers (PCG)
of all children (n=138) having a history of morbidity/
mortality in the previous three months.
A semi structured interview schedule was
developed and validated by experts with complete
agreement. Test- retest reliability was established
(r=0.96). Ethical clearance was obtained from ethics
committee of Sree Gokulam Medical College and
Research Foundation, Trivandrum. Permission to
collect the data was obtained from the ward members
of the selected wards. After obtaining informed written
consent, face to face interview was conducted with the
PCG of the child at their homes. The interview
included questions regarding the latest illness of the
child and the way in which it was managed using a
pretested interview schedule. The mid upper arm
circumference of child was measured to identify the
nutritional status. Immunisation cards were also
verified to assess immunisation coverage. The data
were analysed using SPSS.
FINDINGS
Out of 212 under five children surveyed 138 (65.1
%) had a history of morbidity/ mortality in the
previous three months. The sample consisted of equal
number of boys and girls (69 each). The median age
of the children was 26.5 months (range: 2-57 months).
Majority (61.6%) of the children was first born, and
mothers (93.5%) were their PCGs. Grandfathers
headed 53.6% of the families, and 71% families were
joint type.
More than half of the mothers (53.6%) and fathers
(61.6%) were educated to high school level but 77.5%
mothers were house wives. Majority of the fathers
(81.9%) did fishing and mending of fishing nets, while
7.2% fathers did skilled jobs like driving and masonry.
Hinduism was followed by 63.8% families in the
locality. Medical College Hospital, Alapuzha, was the
nearest (with in 5 km) health facility available for the
treatment of childhood illnesses.
Malnutrition among children was computed using
mid upper arm circumference (MUAC) based on the
WHO Criteria. The average MUAC was 14.5 + 1.53
cm (range: 10-19cm). Out of 110 children above 6
months, 77 (70%) children were adequately nourished
(MUAC>13.5cm), 25 (22.7%) had mild malnutrition
(MUAC of 12.5-13.5cm), 6 (5.5%) had moderate acute
malnutrition (MUAC: 11.5-12.5 cm), and 2(1.8%)
children had severe acute malnutrition (MUAC < 11.5
cm). It was found that 12 (8.7 %) children were not
immunized for their age.
Out of 138 children who had a history of illness, 36
(26.1%) were ill at the time of survey, 85 (61.6%) within
one month, 15(10.9%) within two months, 2(1.4%
within three months of survey. Report by the PCGs
shows that fever (41.4%) was the most common illness
among children, followed by respiratory tract
infections (29.8%), rhinitis (9.4%), diarrhea (7.2%) and
dysentery (1.4%). Urinary tract infections(4),
pyoderma(3), ear infections(2), epididymitis(1), insect
bite(2), poisoning(1), falls(1), and drowning (1)
constituted to10.8% (others) of illness among children.
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A large majority of primary care givers (n=113, 81.2%)
cited that fever was the first indication of illness in
children.
On evaluating the family behaviours during illness,
it was found that, management of illness started soon
after the onset of illness in 60 (43.5%) children, and
with increasing severity in 46 (33.3%) children (Table
1). No medical treatment was availed by 15 (10.9%)
children and only 52 (37.7%) children were taken to
health facility within 24 hours of onset of illness.
Management was not prompt in other children who
received medical treatment after 24 hours (19.6%), 48
hours (21.7%) and 72 hours (10.1%) of onset of illness.
Table 1: Distribution of children according to the time
of initial management after the onset of illness N=138
Time of initial management Frequency (f) Percentage (%)
Not treated 5 3.6
Soon after onset of illness 60 43.5
With increasing severity of illness 46 33.3
On the next day 27 19.6
Total 138 100
Over the counter use of drugs was very common
among the families, as 93 (67.4%) of the PCGs, reported
that, they administered medicine by self, as soon as
the illness was identified in the child. Mother usually
administered the drug dose, previously prescribed for
the child during an illness or about 5 ml each time.
The drugs which were used commonly for self
treatment were Syp. Paracetamol, Syp. Asthalin, Syp.
Indominic, Syp. Salvent, Syp. Phenargan, Colicaid
drops, saline nasal drops. PCGs cited that they opted
for self treatment because the illness was mild, but
common in children and that they knew that same
treatment will be given even if they approach a
provider. PCGs who self-treated fever with Syp.
Paracetamol cited that, they feared that the child would
develop febrile convulsions if fever is not managed
appropriately.
Only twenty (14.5%) children were taken to health
care providers with the onset of illness. Mothers
(60.9%) were the decision makers regarding the
management of child’s illnesses in majority of the
cases, followed by fathers (32.6%) and decisions were
based on the severity, duration and type of symptoms
as cited by all PCGs (87.7%) who sought health care.
Allopathy was the treatment modality opted for 116
(84%) children followed by ayurveda and homeopathy
for two children each, and siddha for one child and
seventeen (12.3%) children were not treated outside
home.
Out of 121 children who were treated outside, 44%
of the children approached government hospital (with
in 5 km), followed by doctors residence (31%), and
private hospitals/clinics (25%). (Figure 1). The family
responses showed that the reasons for opting a
particular facility or provider were because it was near
(36%) or to ensure the consistent treatment (22%) for
the child. (Figure 2). Some PCGs found private clinics
to be more convenient though expensive, as they could
even approach in the evenings/any time without
compromising their day’s work/income. There was
no significant association between health seeking
behaviour and selected socio-demographic variables.
Fig. 1. Graph showing choice of health facility for childhood
illnesses
Fig. 2. Graph showing reason cited for choice of health provider
All the families approached doctors for treatment,
but 33% of the children who sought treatment were
given partial treatment by the families. The drugs,
including antibiotics, were stopped when the
symptoms subsided and only 20% of the families went
for follow up after the treatment. Three children who
were partially treated, developed complications and
required hospitalization.
Almost all the families (90%) were satisfied with
the care they received, others cited regarding bad
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International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 281
attitude of the care givers. Sixteen (13.2%) children
required hospital admission for the illnesses during
the study period. Majority of the families cited that
they did not face any problem during the child’s illness,
and 12.3% cited delayed recovery from illness.
DISCUSSION
The average age of children was two years,
consisted of equal number of boys and girls, and thirty
percent were malnourished. Illness was noted in 26.1%
children during the survey. Fever (41.3%) was the most
common illness among children, followed by
respiratory tract infections (29.7%). Previous studies
report 14%, 10% and 14.6% children to be sick during
survey, and fever was the common illness
observed. 7,10,13
Over the counter use of drugs was very common
among the families (67.4%). Yadav SP et al reported
that mother opted self treatment for febrile children
up to about 72 hours due to poverty and lack of
transport, in Rajasthan. 16 Mothers took decision about
the management in 60% of the children in this study,
whereas Jain M reported that elderly males were
involved with decision making regarding health
related issues in Agra. 17 Allopathy was the preferred
treatment (84%) similar to findings of Levesque (83%)
and Pillai et al (88%) in Kerala11-12.
Less than half of the children (44%) were taken to
the government hospital for treatment of illness. Azhar
GS etal 19 reported a preference for government
facilities in Aligarh where as contradictory findings
were reported by Larson CP from Bangladesh who
cited that 90% of people approached private
providers.18
Neither gender differences in care seeking and
management of illness, nor differences based on birth
order of the child was noted during the study, which
was consistent with the findings by Sudarshan MB et
al from Puducherry.13 But studies by Jain M et al from
Agra17 and Willis et al20 from UP highlights regarding
male preference during care seeking for childhood
illnesses.
Care was sought almost universally from trained
providers, from different systems of medicine. Present
study found that 87.7%children sought care outside
home, during illness, consistent with the findings of
Deshmukh PR et al from Wardha (87.5%)2 and Pokhrel
S et al from Nepal (69%)7.
CONCLUSION
The present study concluded that ailments (fever,
respiratory infections and diarrhoea) were high among
children residing in coastal areas but health seeking
behaviour was good, as all children approached
trained providers though, not much promptly. Over
the counter use of drugs was common among mothers
before the care was sought. Increasing severity and
duration of symptoms prompted families to seek care
for children during illness.
The finding of the study is limited to the verbal
reports of the PCGs, as no effort was made to observe
the actual practices. The study included only two
randomly selected wards, in the coastal region of
Kerala, limiting the generalizability of the findings. The
selected area was close to a Government medical
college hospital/PHC, which might have influenced
the care seeking behaviour of the families.
The study enlightens regarding the need of frequent
surveillance of childhood illness in the coastal areas,
plan and execute interventions for promoting prompt
care seeking for sick children, reduce over the counter
use of drugs in children and facilitate optimum use of
government hospitals.
ACKNOWLEDGEMENTS
We express sincere thanks to experts who validated
our tools, ward members, Junior Public Health Nurse
(JPHN), ASHA workers of SMC sub centre in Alapuzha
, and all the participants of our study.
Conflict of Interest: None
Source of Funding: Self
Ethical Clearance : Ethical committee of Sree Gokulam
Medical College and Research Foundation
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14. Gupta N, Jain SK, Ratnesh, Chawla U, Hossain
S, Venkatesh S. An evaluation of diarrheal
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