Download rajiv gandhi university of health sciences, bangalore, karnataka

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
MS.KASHMEERA.P.S
GAYATHRI COLLEGE OF NURSING
MAGADI MAIN ROAD
KOTTIGEPALAYA
BANGALORE-560091
1. NAME OF THE CANDIDATE AND
ADDRESS(BLOCK LETTERS)
2. NAME OF THE INSTITUTION
GAYATHRI COLLEGE OF NURSING,
KOTTIGEPALAYA
BANGALORE
3. COURSE OF STUDENTS AND SUBJECT IST YEAR M.SC NURSING
MEDICAL-SURGICAL NURSING 2008
4. DATE OF ADMISSION TO COURSE
5.
04-06-2008
A STUDY TO EVALUATE THE
EFFECTIVENESS OF STRUCTURED
TEACHING PROGRAMME (STP)
REGARDING CARDIAC
REHABILITATION IN TERMS OF
KNOWLEDGE AND SKILL AMONG
STAFF NURSES OF SELECTED PRIVATE
CARDIOLOGY HOSPITAL AT
BANGALORE
TITLE OF THE TOPIC
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6. INTRODUCTION
“Building a better life after heart disease”
It is an exercise and education program designed to improve the patient’s quality of life after a
heart attack or another heart problem. It includes a programme of structured exercise is now generally
believed not only to improve morbidity but also reduces mortality in patients who have suffered a
myocardial infarction (MI). Activity and exercise have been shown to play a role in secondary
prevention or reoccurrence of CHD.
Cardiac rehabilitation is becoming an integral part of
comprehensive care of clients who have been diagnosed with CHD. It has been thought for many
years that all patients, regardless of gender, or age, who have ischemic heart disease and or cardiac
failure might benefit from cardiac rehabilitation.
The concept of nursing is changing fast. Nursing is not only caring for the sick but takes care
of prevention of illness, and promotion and maintenance of health. The scope of health promotion
goes beyond the prevention and treatment of disease. Health promotion as outlined in American
journal of health promotion is the science and art of helping people change their life style to move
towards a state of optimal health. Health promotion activities such as routine exercise and good
nutrition help the clients to enhance or maintain their present level of health. Health can be influenced
by individual practices such as poor eating habits, and little or no exercise. It can also be affected by
physical stressors.
Such as poor living environment, exposure to air pollutants and an unsafe
environment. Total health programs are directed at individuals changing their lifestyle by developing
habits that can improve their level of health. Lifestyle choices are important as they can affect a
person’s quality of life.
The primary nursing care of the sick is directed toward promoting,
maintaining and restoring health. Health promotion in chronically ill patients is possible through life
style and behavioural changes by creating awareness. Health education is the major tool of creating
awareness among clients to meet their specific health care needs.
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Health education is an important nursing care because it can determine how well individuals
perform behaviours conductive to optimal self care. People with chronic illness are the most in need
of health education. People with chronic illness need health care information to participate actively in
and assume responsibility for much of their own care. Health education can help these individuals to
adapt to illness, and prevent complications. The goal of health education is to teach people to live life
to its healthiest.
Coronary artery diseases continue to be a major cause of death throughout the world despite
dramatic advances made in the treatment over the last 25 years. As it is growing and people are
affected by it, the nurse has an important role in helping the people to live with the disease and control
it through various preventive and therapeutic measures.
Cardiac rehabilitation teaches the cardiac client how to be more active and make lifestyle
changes that can lead stronger hart and better health.
Nurses are involved in many aspects of cardiac rehabilitation and may assist clients in
developing a program of exercise that fits their needs and level of functioning. Increased physical
activity appears to benefit individuals with myocardial infarction (MI). Angina pectoris or congestive
heart failure as well as clients who have Bypass Graft (LABG) or Percutaneous Transluminal coronary
angioplasty (PTCA).
Clients with CHD benefit from exercise and activity in terms of reduced
mortality and morbidity, improved quality of life, improved left ventricular function, increased
functional capacity and psychological well-being (NIH-1996) Thompson and Bowman (1998)
Konardi Anglin (2001).
Rehabilitation may be defined as the process of helping the patient adjust to a disability by
teaching integration of all resources and concentration more on existing abilities than on permanent
disabilities. Cardiac rehabilitation is the restoration of a person to optimal state of function in 6 areas;
physiologic, Mental, Spiritual, Economic and Vocational.
Many persons recover from an MI
physically, yet they may never attain psychologic well-being because of misconceptions about the
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illness or a need to practice illness behaviours. Returning to work and resuming all activities have
long been out come measures of cardiac rehabilitation and are important in terms of cost-effectiveness
of cardiac care and rehabilitation.
In considering rehabilitation the nurse and patient must recognize that CAD is a chronic
disease. It will not be cured or will it disappear by itself. Therefore basic changes in lifestyle must be
made to promote recovery and health. These changes must frequently be made at a time when a
person is middle aged. The patient must also realize that recovery takes time. Resumption of physical
activity after MI is slow and gradual.
An important nursing goal is patient and family education. The purpose of teaching is to give
the patient and family the tools they need to make informed decisions about attainment of health. It is
important for the nurses in cardiac unit to become familiar with various types of cardiac problems. If
the nurse’s knowledge and skill is improved the patient can get better care and health teaching by
them.
Cardiac rehabilitation may be helpful for the patients with the history of
o Heart attack.
o Coronary artery disease.
o Heart failure.
o Peripheral arterial disease.
o Angina.
o Cardiomyopathy.
o Certain congenital heart disease.
o Coronary arteries bypass surgery.
o Angioplasty and stunts.
o Heart transplant.
o Heart valve replacements.
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Wenger (1994) stated that each year in the United States there were almost one million
survival of MI who is the candidates for cardiac rehabilitation. Services in addition to more than 7
million patients with stable angina pectoris of patients following vasulatization with CABG. Survey
of these several million patients with the coronary heart disease only 11% to20% had previously
participated in cardiac rehabilitation with the aging population of US. Coronary rehabilitation care has
been now provided to many elderly patients. He also commented that exercise rehabilitation of elderly
patient with CAD can improve physical work capacity and endurance prolongs an active lifestyle and
retard disability and dependency. Exercise can further favorably affect the psychological status
Singh. Singh and Singh (1999) in their study on cardiovascular disease in elderly stated that
CVD are the commonest cause of morbidity and mortality in elderly. Ischemic heart disease is most
important single cause of death in elderly and 60% of death among elderly in western countries due to
CAD. They also stated that coronary atherosclerosis progresses with advancing age. Severity of
disease in men is leading than in women by approximately in 15 years. The prevalence of severity of
CAD increases so dramatically with that of increasing age that more than 50% of all death is over 65
years are due to CAD and about 3/4th of all deaths from ischemic heart disease occur in elderly.
Jhala and Shah (1999) conducted a study two seventy six patients among the urban population of
Allahabad were surveyed to assess the prevalence rate of Coronary Artery Disease detected by ECG.
The findings revealed the prevalence rate was 29.66% highest incidence was in the age group of 51-60
years. Male and female rate was 3.99% (angina) and 5.39% (MI). Mortality rate was higher in
subjects having 2 or more risk factors and incidence of disease condition below 40 years of age was
found to be low.
Misra (1999) conducted a epidemiological study on prevalence of CAD in Indians. His study
revealed the prevalence of CAD among adults in Kerala to be as 96.7/1000 and 27/1000 in urban and
rural areas respectively. When the rural population of Kerala alone was studied ECG changes showed
coronary artery disease to be present in 3.6% of subjects and possible evidence of CAD was seen in
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7.4%. He also presumed that the factors to be responsible for increased properisity of CAD in Indians
were abdominal obesity, smoking, glucose intolerance and peculiar dynamic profile.
Many other survey studies Batchler Jollis and Friesing (1999), Jojoo (1999), WHO (1999)
also revealed that CHD had accounted for more death and particularly in developing countries. The
major risk factors of heart disease progression were the same for its development e.g.:- lipids,
smoking, HTN, obesity and sedentarily life which have been related to increased mortality status in
post myocardial infarction patients. American college of cardiology in (1999) described cardiac
rehabilitation as “those exercise and counseling services which reduce the symptoms of disease or
improve the cardiac function”. Gerhenson (1999) stated that the current short hospital stay for
uncomplicated MI necessitates early ambulation and an accelerated educational regimen with deferral
of most teaching and counseling to out patient setting
6.1 NEED FOR THE STUDY
Despite efforts to decrease its incidence over the last several decades’ coronary diseases remains the
prime cause of mortality in adults.
Willette EW, Suxxells D, Davis LL, Bush CT, (2007) conducted a study on nurses
knowledge of hart failure self management. This study assessed nurses knowledge of basic principles
of HF self management. The study surveyed 49 nurses who regularly provided care to the patients
with heart failure at a hospital in southeastern United States. The study suggested that the nurses are
not to be adequately prepared to educate patients with HF about self management.
Albert NM, Collers Sumodi V, Wilkinsons Hammel JP, Vopat L, Willis C, Bittel B
conducted a study to determine nurses knowledge of heart failure education principles. The study was
exploratory and descriptive and included a convenience sample. Subjects included 300 nurses who
provided care to patients with Heart Failure. The study revealed the nurses are not properly educated
in Heart Failure self management principles and must be provided with the right information so they
can improve the quality and amount of information they offer to patients. Nurses who are better
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prepared to educate patients with HF may be more likely to carry out this nursing function as a part of
their daily job role.
Enas (2000) in his special article “India Facing Coronary Artery Disease Crisis” wrote that the
risk factor interventions such as anti-smoking campaigns and cholesterol reduction had led to lowering
of CAD rates in the west in past 50 years, where as the rates had doubled in India with no signs of
downturn. The significant reduction could be achieved in India by adopting a strategy of life style
modification early identification and treatment of risk factors.
A study on “Perception of patients on their educational needs in the first 6 months following
discharge after cardiac surgery” was conducted by Good Man (1997) at Royal Brampton Hospital
England, Being a local study it aimed to gain insight regarding the patient perception about
educational needs. Patients were asked to maintain a diary over 6 week period of time and then take
part in an unstructured interview when they returned for their 6 week out patient appointment. A small
sample size of 10 respondents was selected with least prior experience. The analysis of the study
findings revealed patients need in the areas of early discharge, pain relief and sleep promotion,
psychological needs, practical needs, and community support.
The study also made several
recommendations to improve the rehabilitation experience that is including additions to the literature
and patient educational sessions and changes to ensure another transition in to community.
Bairey, Felando and Klien (1996) surveyed the cholesterol management practices among
CHD patient enrolled and not enrolled in Cardiac rehabilitation to find out their cholesterol awareness
and treatment compliance in patient. A total of 379 men and women were surveyed according to their
cholesterol awareness, serum cholesterol level frequency of lipid lowering medication use and
frequency of lipid lowering medication use and frequency of achievement of serum total cholesterol
<5.2mmol/l corresponding the 1987 NCEP ( Natural Cholesterol Education Programme ) guidelines
for CAD patients. Results of the study showed that over all 72% of the patients were aware of their
cholesterol of 5.5+/_ 100 mmol/l. Use of lipid lowering medication was 26%, 43% had a total
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cholesterol <5.2mmol/l patients enrolled in a long term cardiac rehabilitation demonstrated enhanced
cholesterol awareness 78% lowered total cholesterol values 5.2+0.9 mmol/l higher use of lipid
lowering therapy (34%) and more frequent achievement of total serum cholesterol of <5.2mmol/l
(48%) compared to the other group. This study showed that there was a need of efforts to develop
programs to optimize cholesterol management in patients with CAD.
Jaarsana, Kastumans, Dassesn and Philipsen (1995) conducted a study at the university
hospital; Netherlands to assess the problems of post MI, CABG patients in early recovery 82 patients
were interviewed after 6 months of discharge using a tool that required them to describe problems they
experienced in early recovery and what information they needed. Majority of the problems developed
according to their responses were emotional reactions (59%) deleterious effect of treatment 56% and
convalescence (54%). Most of the patient needed additional to different information on topics like
deleterious effects of treatment (26%) physical condition (24%) risk factor (24%) convalescence
(24%) and knowledge of disease (24%).
Matta (1995) conducted a survey study at Escorts Heart Institute and Research centre, Delhi to
assess cardiac patients need for educational programme. It was found that majority 72% of cardiac
patient said that they wanted to participate with their physicians in decision making about their health
care findings of the study also revealed that patients were most likely to follow suggestions related to
altering lifestyle related to risk factors, when the message is conveyed by personal physician but it is
factual that detailed explanation was not given regarding health matters unless specifically asked
which makes that patient lacks in information about their own healthy aspect.
Plach.Wierenger and Heidrch (1996) studied the effect of a post discharge education class on
CAD knowledge and self reported health promoting behaviors. The study was conducted in mid
western community hospital using descriptive 2 group post-test survey method. Among114 patients
who had experienced a cardiac catheterization of which 53 attended a post discharge coronary artery
disease education class and 61 did not attend the class. The tool used for collection was an interview
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schedule.
The result of the study revealed that knowledge of CAD and its risk factors was
significantly higher among the subjects who attended the post discharge class and they presented with
better health promoting behaviors.
Winslow EH (1976) conducted a study to assess the role of nurse in cardiac patient education.
The evidence cited shows that nurses are not doing effective, consistent patient teaching and are not
perceived by patients. It appears that nurses do not view patient teaching as a priority and that nurses
are not held accountable for patient teaching. Patient teaching seems to be done only if “there is time”.
It is often done on an informal and largely voluntary basis by motivated nurses. Nurses must awaken
to the fact that patient education is not a luxury, but a necessity if patients are to receive maximum
benefit from today’s knowledge of treatment, prevention and control of disease.
From the above findings of literature it is realized that the cardiac patients were rarely provided
with sufficient information related to the health behaviour modification which aids in the secondary
prevention of heart diseases. The researcher in her own view found that the nurses don’t have
sufficient knowledge and practice of cardiac rehabilitation. Patient education programme for cardiac
patients is an essential part of the quality of nursing staff working in cardiac unit only if the nurses
acquire knowledge regarding cardiac rehabilitation they can improve the knowledge and practice of
patient with cardiac problems.
6.2 REVIEW OF LITERATURE
The review of available literature was organized under the following headings
I. Studies related to Role of Cardiac Rehabilitation in preventing cardiac complication.
II. Studies related to Nurses role in Cardiac Rehabilitation i.e. nurse directed approach in
improving patient’s quality of life.
III. Studies related with knowledge and practice of staff nurses regarding cardiac problems
and management.
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I. Studies related to Role of Cardiac Rehabilitation in preventing cardiac complication.
Jiang X, Sit JW, Wong TK (2007) conducted a study to examine the effect of a cardiac
rehabilitation programme on health behaviours and physiological risk parameters in patients with
coronary heart disease in Chengdu, Chine. The result of the study revealed that the patients in the
intervention group demonstrated a significantly better performance in walking, Step II diet adherence,
medication adherence a significantly greater reduction in serum lipids including triglyceride, total
cholesterol, low density lipoprotein and significantly better control of systolic and diastolic blood
pressure at 3 months. The study showed that the cardiac rehabilitation programme led by nurse can
significantly improve the health behaviours and cardiac physiological parameters in coronary heart
disease patients. Nurses can fill the significant treatment gaps in the risk factor management of
patients with coronary heart disease. This study raised attention regarding the important roles nurses
can play in cardiac rehabilitation and the unique way for nurses to meet the rehabilitative care needs
for coronary heart disease patient.
Kjaev T, Gyrd Hansen D, Willaing T (2006) conducted a study to analyze preferences for
activities comprised in comphrensive cardiac rehabilitation programs among former cardiac patients
from 3 different hospitals in Copenhagen, County, Denmark. The program offered participation in
various cardiac rehabilitation program activities: smoking cessation course, physical exercise program,
personal meeting with cardiac nurse, group meeting managed by cardiac nurse and nutritional
counseling guidance. The study found that preferences differed with respect to gender and age and
that the offer of participation cardiac rehabilitation activities was not highly valued by older patients,
in particular among older men. The study provides important information on patient’s preference for
cardiac rehabilitation for health care professionals and decision makers.
Austin J, Williams R, Ross L, Moseley L, Hutchisons (2005) conducted a study to determine
whether a cardiac rehabilitation programme improved on the outcomes of an outpatient heart failure
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clinic (standard care) for patients over 60 years of age with chronic heart failure. The study revealed
significant improvement in health related quality of life.
The experimental group had fewer
admissions and spent fewer days in hospital. The study suggested that cardiac rehabilitation offers an
effective model of care for older patients with heart failure.
Goodwin BA (1999) conducted a study to assess the home cardiac rehabilitation for congestive
heart failure; a nursing case management approach. Cardiac rehabilitation for CHF can improve a
patient’s functional ability, alleviate activity related symptoms, improve quality of life, and social
status. The results of the study revealed that financially, physically and psychologically beneficial for
CHF patients and their families, home cardiac rehabilitation is also cost-effective for society.
Burns KJ, Camaione DN, Froman RD, Clark BA (1998) conducted a study to investigate patient
characteristics related to referral to cardiac rehabilitation and cardiac exercise self efficacy, a salient
predictor of health behaviour change and maintenance. The result of the study revealed that patient
characteristics of having fewer MIs or CABGs having attended CR in the past and being less
physically active during leisure time are related to an increased likelihood of being referred to CR.
Multiple regression analysis indicates that leisure physical activity is a predictor of cardiac exercise
self efficacy. Implications for nurses who recruit patients for cardiac rehabilitation are discussed.
Cavellaro V, Dwyer J, Houser RF, Shores F, Canez I etal conducted a study to describe
variations in nutrition services offered in a nationally representative sample of out patient cardiac
rehabilitation programs by presence of a registered dietitian (RD). Nutrition services offered by
programs polled included distribution of nutrition pamphlets, one -on-one nutrition counseling, group
nutrition classes, guest lectures on nutrition, and cooking demonstrations. Cardiac rehabilitation
programs with an Registered Dietitian offered significantly more nutrition services on average than
programs without a Registered Dietitian. Programs with Registered Dietitians were more likely to
offer one-on-one nutrition counseling than programs with out them and they were also more likely t
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offer cooling demonstrations. More , and a greater, variety of nutrition services are offered in cardiac
rehabilitation programs that have a Registered Dietitians, without a Registered Dietitian, exercise
physiologists and registered nurses often provide some but fewer and different nutrition services.
Cabello Fernandez R, Navajas Rodriguez de Mondelo, Suriano Balnco M, Moreno Zorrero C
conducted a study in improving the quality of life of cardiac clients through cardiac rehabilitation.
Specific goal in CR include preventing the harmful effect of prolonged bed rest, controlling risk
factors, improving the patients knowledge on his/her disease, involving the family in CR, particularly
its last phase, preventing and ore or correlating psychological problems such as anxiety and
depression, increasing the patients self confidence and will to live, improving his or her capacity for
physical effort with a program of aerobic physical exercise, facilitating familiar, occupational and
social reinsertion and finally if we achieve these goals, reducing hospital stay and perhaps morbidity
and mortality as well. The study showed that the increased knowledge of the benefits of CR will make
nurses better prepared and motivated to include this program in Coronary Intensive Care Units.
II. Studies related to Nurses role in Cardiac Rehabilitation i.e. Nurse directed approach in
improving patient’s quality of life: Edwardson SR (2007) conducted a study to assess the patient education in heart failure. The
study suggest that although teaching patients about the care of a chronic condition is necessary, it may
be more effective if supplemented by continuing
re-enforcement
behavioural reinforcement by an interdisciplinary team.
symptom monitoring, and
Nurses have an opportunity and a
responsibility to dissect and test the teaching learning process in heart failure. Evidence that builds on
what is already known about patient education will allow nurses to construct protocols than can be
adopted as standards of practice and included in electronic health rewards.
Kutzleb J, Reinex D (2006) conducted a study to evaluate the impact of a nurse directed
approach to patient education, which focused on life style modification, daily weight management, diet
and medication compliance to improve the quality of life (QOL) and functional capacity in people
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with heart failure. The study included 23 patient comparing a nurse directed care (NC) group (n=13)
which received comprehensive disease management education and weekly telephone follow up and the
routine care (RC) group (n=10) that received protocol driven medical management. The study showed
that nurse directed patient education was effective in improving quality of life (QOL). A nurse
directed treatment strategy significantly improves patient’s role in symptom control and disease self
management.
Astin f, Jones k, Thompson DR (2005) conducted a study to describe the levels of anxiety and
depression reported by patients pre and post elective PTCA, and to determine associations evident
between anxiety and depression and the social-demographic and clinical variables of gender, marital
status, history of acute myocardial infarction, and attendance of cardiac rehabilitation. The study
findings lend support for the closer surveillance of emotional status in the population. Specialist
nurses have the potential to play a greater role in identifying those at risk of developing anxiety and
depression. However this unmet need will remain unmeant until specialist nurses who spend the most
face to face time with patients are equipped with the skills and resources to systematically identify
those “at risk”.
Harkness K, Smith KM, Taraha L, Mackenzie CL, Gunn E, Arthur HM (2005) conducted a
study to examine that effect of a nurse initiated telephone call (NIC) on attendance at a CR intake
appointment. The study showed that patients who received the Nurse initiated telephone call (NIC)
were significantly more likely to attend their Cr intake appointment compared with standard care.
Hierarchic logistic regression analysis revealed the NIC as the strongest predictor of attendance at a
CR intake explaining 56.9% of the total variance. The study findings suggest that pre-appointment
telephone contact by a cardiovascular nurse is a valuable tool to enhance attendance at a CR intake
appointment after CABG.
Child A (2004) conducted a study to assess the cardiac rehabilitation goals, interventions. The
study revealed that many people do not have access to cardiac rehabilitation towards menu driven
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approaches which may suit individual need than a standardized approach. Nurses play a crucial role in
the delivery of cardiac rehabilitation services and hold the necessary skills and expertise so to do.
Future challenges to cardiac rehabilitation include developing increasingly patient focused services
across the boundaries of primary, secondary and social care, and increasing patient and public
involvement in services.
Svendsen A (2003) conducted a study to provide a brief overview of consensus guidelines and
nursing implication developed by American College of Cardiology/American Heart Association, the
Canadian cardiovascular society, the Heart failure society of America, and the European society of
cardiology. Nurse’s implications include careful assessment of volume status, vital signs, monitoring
electrolyte and renal function as well as spacing of medications. The study showed that the nurses
play a key role in assisting patients to identify their lifestyle habits that require modifications,
ultimately improving their quality of life and decreasing hospital readmissions. Education focusing on
self care activities, diet, rest and exercise enables patients to retain a sense of control in their lives.
Fridlund B (2002) conducted a study to highlight the role of the nurse in cardiac
rehabilitation programmes. The nurse’s multiple roles in cardiac rehabilitation have a ‘Spider in the
web-like’ character and depending on the phase of the patient’s recovery, he/she acts as a container, a
counseller, a coach and an educator. The study showed that to implement a successful cardiac
rehabilitation, the nurse needs to have improved evaluation tools in clinical practice as well as to be
self critical and serve as a good role model. Finally the cardiac rehabilitation nurse has to have a four
fold comprehensive perspective of the cardiac rehabilitation concept, an impact perspective, a timing
perspective a life span perspective and a personal perspective.
Eastwood GM (2001) conducted a study that provided a detail on the rationale and influences
behind the decisions of four male participants to change or not change their lifestyle patterns 3 months
after a Percutaneous Transilluminal Coronary Angioplasty/intra coronary stunt procedure. One of the
Participants made a noticeable life style pattern change in this period. The remaining participants
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failed to exhibit any discernible lifestyle pattern change or had continued with their previous
behaviors. The results of the study suggest a new positive psychological health perspective, family
considerations, return to work issues and a reluctance to participate in cardiac rehabilitation as the
major factors influencing lifestyle pattern change. Because the nurses spend the greatest amount of
time with Percutaneous Transilluminal Coronary Angioplasty/intra coronary stunt patients during
hospitalization, they have the best opportunity to provide up to date and relevant information to
patients that will enable them to then make decisions concerning cardiac healthy lifestyle changes.
Bergman E, Bertero C (2001) conducted a study to gain increased knowledge and
understanding of what it means to be afflicted with coronary artery disease (CAD) and how it affects
the life style of the individual. The findings included three areas (1) The cause of coronary artery
disease describing different factors such as heredity lifestyle and demands. (2) Difficulties in the work
of rehabilitation, which was explained in terms of informants feelings of confusion, uncertainty and
sadness. (3) Successful rehabilitation consisted two factors:- The personality of the individual patient
and external support. The study showed that the Nurses have a significant role in supporting these
patients since they are more accessible than physicians. Nurses also have a responsibility to work
together with patients to empower them in order to make their lifestyle changes and self care activities
manageable.
Davis N (2000) conducted a study to assess the cardiac rehabilitation implications for critical
care nurses. Subjects included 56 careers of cardiac surgery patients. The study findings suggest that
cardiac rehabilitation need to be aimed at careers as well as patients. Investment in targeted career
support could facilitate patient recovery and rehabilitation. Strategies aimed at the career need to
begin early and commence during the acute stage of the patient’s recovery.
Steinke EE, Patterson P (1995) conducted a study to examine the assessment of sexual
concerns and the practice of sexual counseling with myocardial infarction patients in a convenience
sample of 171 cardiac nurses from three hospitals in the Midwest. The study analysis of 17 items on
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the practice index indicated that nurses are not assessing sexual concerns and specific information
relevant to myocardial infarction patients largely is not being taught.
Mayou RA, Thompson DR, Clements A, Davies CH, Goodwin SJ, Normington K, conducted
a study to determine the effectiveness of individualized educational behavioural treatment delivered by
cardiac nurse in hospital compared to usual care for patients following acute myocardial infarction.
One hundred and fourteen consecutive patients were randomized to receive the intervention or usual
care. The result of the study revealed that the intervention groups were more confident about returning
to activities one month after discharge from hospital.
An individualized educational behaviour
treatment delivered by cardiac nurses in hospital may have substantial benefits.
III. Studies related with knowledge and practice of staff nurses regarding cardiac problems and
management
Solman A, Conway J, McMillan M, conducted a study that investigated the experience of nurses
working in a cardiac step down unit of nurses working in a cardiac step down unit (CSDU). The study
was undertaken in order to identify factors that inhibit the smooth running of the unit and impact up on
patient care. The study showed that the nursing care provided in the unit focused on the provision of
technology oriented rather than patient oriented care and that nurses experienced lack of role clarity
about the care they provided. A number of recommendations that emerged from the study have since
been implemented in practice and the effects of these changes are being evaluated in a follow up study.
Conway J, McMillan MA, Solman A (2006) conducted a study that examined the work practice of
nurses in a cardiac step down unit (CSDU). This study show that a need exists for greater alignment
between the practice and the educational preparation of nurses who work in a CSDU. A framework
such as Dorothea Orem’s self care theory of nursing (1995) offers a conflict for nurses to deliver care
appropriate to CSDU patient’s needs. However, there is a need for continuing education for nursing
staff to align the cardiac rehabilitation nursing philosophy and the theories that underpin it (Such as the
self care theory) with nursing practice.
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Wahburn SC, Hornberger CA, Klutman A, Skinner L (2005) conducted a study to describe nurses
knowledge of HF self management education principles. The sample included 14 nurses working in
an intensive care unit and 41 nurses working on a general medical unit all routinely providing care to
patients with HF. The study result suggests that nurses working in a small community hospital may
not be sufficiently knowledgeable in HF management principles.
Additional emphasis on HF
educational principles may improve the quality of patient education. One suggested intervention is to
provide ongoing education for nurses regarding HF management.
Zecchin RP, Chai YY, Roach KA, Speerin R, Lindsay G, Squire J etal conducted study to
examine the incidence of cardio vascular complications and to describe the competency based training
program for the nurses performing the exercise stress test (EST) seventeen thousand, four hundred and
sixty seven patients were included in this study over a 12 year period. This study shows that the nurse
supervised EST of higher risk patients in the hospital based cardiac rehabilitation setting has been a
safe practice from a mortality and morbidity rate perspective.
Wright L, Griffin S, Bradly F (1998) conducted a study to determine the extent to which follow
up care for people discharged from hospital after a myocardial infarction is currently being undertaken
by practice nurses and to assess the factors influencing the provision of such care and the nurses’
attitudes towards this extended role. The subjects included 183 practice nurses working in general
practices in the Southampton and South west Hampshire health district. The study showed that the
nurses are enthusiastic and have some of line necessary experience to provide follow up care for
patients who have experienced a myocardial infarction. Yet few currently provide it.
Linde BJ, Janz NM, (1979) conducted a study to look at the effect of a comprehensive teaching
program or patient knowledge and compliance. Thirty patients who had valve replacement surgery
and 18 patients who had had coronary artery bypass surgery were included in this study. Findings
included significant changes in knowledge score from the preoperative test to the discharge test and
stability in most scores from discharge to both postoperative visits. Compliance percentages were
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significantly higher than those reported for cardiac patients in a previous study. Patients taught by
masters prepared nurses had significantly higher test scores at discharge than did patients taught by
nurses with less than masters preparation.
Albert Nm, Collier S, Sumo V, Wilkinson S, Hammel JP. Nopat L etal conducted a study to
determine nurses knowledge of heart failure (HF) self management education principles. The subjects
included 300 nurses who provide care to patients with HF. The outcome measures included overall
and topic specific perception of basic information important to HF self management. Topics included
diet, Fluids or weight, signs or symptoms of worsening condition, medications and exercise. The
study showed that the nurses may not be properly educated in HF self management principles and
must be provided with the right information so they can improve the quality and amount of
information they offer to patients. Nurses who are better prepared to educate patients with HF may be
more likely to carryout this nursing function as a part of their daily job role.
Tranmer JE, Parry MJ (2004) conducted a study to determine the effectiveness of advanced
practice nursing support on cardiac surgery patients during the first 5 weeks following hospital
discharge. Patients were randomly allocated to two groups (a) an intervention group who received
telephone calls from an advanced practice nurse (APN) familiar with their clinical condition and care
needs, twice during the first week following discharge then weekly thereafter for 4 weeks, and (b) a
usual care group; Measures of health related quality of life (HRQL), symptom distress, satisfaction
with recovery care and unexpected health care contacts were obtained at 5 weeks following discharge.
The study showed that the provision of Advanced Practice Nurse (APN) support via telephone follow
up after cardiac surgery is feasible. However, further randomized trials of single and multicomponent
(APN) interventions are needed to prove effectiveness.
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6.3 STATEMENT OF THE PROBLEM
A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING
PROGRAMME (STP) REGARDING CARDIAC REHABILITATION IN TERMS OF
KNOWLEDGE AND SKILL AMONG STAFF NURSES OF SELECTED PRIVATE
CARDIOLOGY HOSPITALS AT BANGALORE.
6.4 OBJECTIVES
1. To assess the level of knowledge of staff nurses regarding cardiac rehabilitation.
2. To assess the skill of staff nurses regarding cardiac rehabilitation.
3. To find out the effectiveness of structured teaching programme (STP) on cardiac rehabilitation
in terms of knowledge and skill among staff nurses.
4. To find out the relationship between the following
o Pre-test knowledge score and pretest skill scores.
o Post-test knowledge scores and post test skill scores.
5. To determine the association between the following.
o Post-test knowledge score and years of experience of the staff nurses.
o Post-test skill score and years of experience of the staff nurses.
6.5 HYPOTHESIS
All hypothesis will be tested at .05 level of significance.
H1
Mean post test knowledge score of staff nurses who received structured teaching
programme (STP) regarding cardiac rehabilitation will be significantly higher than the mean
pre-test knowledge score.
H2
Mean post test skill score of staff nurses who received structured teaching programme
(STP) regarding cardiac rehabilitation will be higher than the mean pre-test skill score.
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H3
a. There will be a significant relationship between pre-test knowledge score and pre
test skill scores among staff nurses, who received STP regarding cardiac
rehabilitation.
b. There will be a significant relationship between post-test knowledge score and post
Test skill scores among staff nurses who received STP regarding cardiac
Rehabilitation.
H4
a. There will be a significant association between the post-test knowledge score and
Selected demographic variables among staff nurses who received STP regarding
cardiac rehabilitation.
b. There will be a significant association between the post-test skill scores and selected
demographic variables among staff nurses who received cardiac rehabilitation.
6.6 OPERATIONAL DEFINITIONS
STP – Structured Teaching Programme
It refers to well planned teaching material regarding cardiac rehabilitation given through
lecture and discussion. It will be here after referred as STP.
o Cardiac Rehabilitation
Cardiac rehabilitation refers to the lifestyle modification including diet, exercise, behavioural
modification and self management followed by cardiac client after myocardial infarction,
angina pectoris and cardiovascular surgeries.
o Knowledge
It refers to the written responses of staff nurses regarding cardiac rehabilitation as measured by
knowledge questionnaire.
20
o Skill
It refers to the action carried out by the staff nurses regarding selected aspects of cardiac
rehabilitation as measured by observation check list.
o Staff Nurses
In this study it refers to those who have completed diploma in Nursing and Midwifery and who
engaged in direct patient care.
6.7 ASSUMPTIONS
The study is based on the assumption.
1. Knowledge influence behaviour.
2. Negligence leads to complications.
3. Nurses play a vital role in creating awareness, to the patient in health care set up.
6.8 DELIMINATIONS
Study is delimited to
a. Staff nurses who have completed General Nursing and Midwifery.
b. Staff nurses who are engaged in direct patient care.
c. Staff nurses working in private hospitals, at Bangalore.
7. MATERIALS AND METHODS
7.1 SOURCE OF DATA
Staff nurses working in selected private cardiology hospitals at Bangalore.
7.2 METHODS OF COLLECTION OF DATA
o Research method
:
Quasi experimental approach
o Research design
:
One group pretest post test design.
o Sampling technique
:
Sample Random technique
o Sample size
:
40 staff nurses.
o Setting of the study
:
Study will be conducted at cardiac unit of selected private
Hospitals at Bangalore.
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7.2.1 CRITERIA
Samples will be selected based on the following inclusion and exclusion criteria.
INCLUSION CRITERIA: 1. Staff nurses who completed General Nursing and Midwifery.
2. Staff nurses of both sexes.
3. Staff nurses between 21-40 years.
4. Staff nurses who are willing to participate in the research study.
EXCLUSION CRITERIA: 1. Staff nurses who are engaged in administrative work.
2. Staff nurses who are working other than cardiac unit.
3. Staff nurses who are not willing to participate.
7.2.2 DATA COLLECTION TOOL
Tool I: - A structured knowledge questionnaire will be prepared to assess the knowledge of staff
nurses regarding cardiac rehabilitation.
Tool II: - An observation check list will be prepared to observe the skill of staff nurses in health
education to cardiac clients regarding cardiac rehabilitation.
7.2.3 DATA ANALYSIS METHOD
Descriptive and statistical anlysis will be done for data analyses procedure
7. 3 . DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR INTERVENTIONS TO BE
CONDUCTED ON PATIENTS OR OTHER HUMAN OR ANIMALS?
YES
The study requires intervention in the form of structured teaching programme, no other
interventions which cause any physical harm will not be done for the subject.
22
8. BIBLIOGRAPHY
1. Potter and Perry, “Fundamentals of Nursing” 6th edition, Missouri Mosby 2005 Page 954.
2. Lewis Heitkemper “Medical Surgical Nursing” 6th edition, Missouri Mosby 2004 Page 830.
3. Joyce M Black “Medical Surgical Nursing” 7th Edition Missouri Squnders 2005 Page mo 1627-1648.
4. Brunner and Suddarth’s “Text book of medical Surgical Nursing” 10th edition Philadelphia
Lippincot Page 728.
5. Barbara Kozier “ Fundamentals of Nursing” 7th edition India Page no 124.
6. Lippincott “Manual of Nursing Practice” 8th edition, India, Lippincot page 1745.
7. Donna D Ignatavicius “ Medical Surgical Nursing 2nd edition, WB Saunders company page No
1011-1014.
8. Payne Ja “Group learning for adults with disabilities or chronic disease” Rehabilitation Nursing
20(5), 1995 Page No 268-272.
9. Basavanthappa Bt Nursing Administration Ist edition Jaypee Brothers publications (2000) Page
No. 323.
10. Polit DF Hungler BP “Nursing Research Principles and Methods” Philadelphia JB Lippin cott
company (1999), Page no.146.
11. Best W.John, Kann.V. James , “Research in education” New Delhi prentice Hall of India(1995)
12. Wenger N.S “Circulatory function and cardiac Rehabilitation Nursing process and Application”
IInd edition Mosby’s publication (1996).
13. Jhala Shah 1999, “ Patterns of Cardiac disorder and epidemiology of CAD in urban population in
Ahmedabadd” Journals of internal Medicine Vol 2(1) Page No: 230-232.
14. Misra A 1999, “Atherosclerosis in Indians” Journal of Association of physicians of India 47(3),
Page no 313-315.
15. Singh,Singh and Singh (1999), “Cardiovascular disease in Elderly” Journal of internal Medicine of
India Vol 2(3) Page No 234-235.
23
16. Dumville JC, MacPherson H, Griffith K, Miles JNV & Lewin RJ. Non-cardiac chest pain: a
retrospective cohort study of patients who attended a Rapid Access Chest Pain Clinic. Family
Practice. 2007 (In Press)
17. Bethell HJN, Evans JA, Turner SC, Lewin RJP. The rise & fall of cardiac rehabilitation in the
United Kingdom since 1998. Journal of Public Health (Oxf). 2006 Dec 22, [Epub ahead of
print].
18. Pattenden J, Roberts H, Lewin R. Living with heart failure: patient & carer
perspectives.European Journal of Cardiovascular Nursing (In Press)
19. Ali, N, Atkin K, and Neal R The role of culture in the general practice onsultation process Ethn
Health. 2006 Nov;11(4):389-408.
20. Neal R, Ali, N, Atkin, K, Allgar V.L, Ali S, and Coleman T. Communication between South
Asian patients and GPs: Comparative study using the Roter Interactional Analysis System.
British Journal of General Practice. 2006 Nov;56(532):869-75.
21. Ismail H, Wright J, Rhodes P, and Scally A, 'Outcomes of quality of care in diabetes for a
patient cohort-attending routine primary care clinics compared with those attending GP
specialist clinics', Diabetic Medicine, (2006) 23, 851-856
22. Macran S, Birks Y, Lewin R, Parsons J, Sloper P, Hardman G, Kind P, Van Doorne C,
Thompson D. The development of a new measure of quality of life for children with congenital
heart disease (ConQol). Cardiology in the Young. 2006 Apr;16(2):165-172.
23. Orrell AJ, Eves FF, Masters RS. Motor learning of a dynamic balancing task after stroke:
implicit implications for stroke rehabilitation. Physical Therapy. 2006 Mar;86(3):369-80.
24. Birks Y, Sloper P, Lewin R, Parsons J. Exploring health-related experiences of children &
young people with congenital heart disease. Health Expectations. 2006.
25. Orrell, A.J., Eves, F.F., Masters, R.S.W., & MacMahon, K.M. Implicit Learning Processes in
Stroke. /Neuropsychological Rehabilitation /(in press).
26. Neal R, Ali N, Allgar V, Phil H, Leese B, Stage at diagnosis, survival and diagnostic delays for
lung, colorectal, prostate and ovarian cancer: comparison between patients referred urgently
from primary care and patients diagnosed through other routes. British Journal of General
Practice. 2006 (In Press)
24
27. Frizelle DJ, Lewin B, Kaye G, & Moniz-Cook ED. Development of a measure of the concerns
held by people with implanted cardioverter defibrillators: The ICDC. The British Journal of
Health Psychology 2006 May,11(Pt2):293-301.
28. Orrell AJ, Eves FF, Masters RS. Implicit motor learning of a balancing task. Gait Posture. 2006
Jan;23(1):9-16.
29. Kendall L, Parsons JM, Sloper P & Lewin RJP. Determining knowledge of appropriate activity
levels & risk behaviour in young people with congenital cardiac conditions: a simple screening
method for clinics. Cardiology in the Young (in press).
30. Furze G, Lewin R, Murberg TA, Bull P, Thompson D. Does it matter what patients think? The
relationship between changes in patients' beliefs about angina and their psychological and
functional status. Journal of Psychosomatic Research 2005;59:323-329.
31. Ismail H, Wright J, Rhodes P, and Small N, 'Religious beliefs about causes and treatment of
epilepsy', British Journal of General Practice, (2005) 55, 26-31.
32. French DP, Lewin RJP, Watson N, Thompson DR. Do illness perceptions predict attendance at
cardiac rehabilitation and quality of life following myocardial infarction? Journal of
Psychosomatic Research 2005;59:315-322.
33. Newell R, Ziegler L, Stafford N, Lewin RJ. The information needs of head and neck cancer
patients prior to surgery. Annals of the Royal College of Surgeons of England 2004;86:407410
34. Frizelle DJ, Lewin B, Kaye G, Moniz-Cook E. Development of a new tool for assessing
automatic implanted cardioverter defibrillator patient concerns: the ICD-TCQ. The British
Journal of Health Psychology (in press).
35. Dunderdale K, Thompson DR, Miles J, Beer S, Furze G. Quality of life in chronic heart failure:
Do we take account of the patient perspective? European Journal of Heart Failure (in press).
36. Lewin RJP, Thompson DR, Roebuck A. Development of the BACR/BHF minimum dataset for
cardiac rehabilitation. British Journal of Cardiology 2004;11:300-301.
37. Murberg T, Furze G. Depressive symptoms and mortality in patients with congestive heart
failure: a six-year follow-up study. Medical Science Monitor 2004;10:643-8.
38. Murberg T, Furze G, Bru E. Avoidance Coping Styles Predict Mortality among Patients with
Congestive Heart Failure: A Six-year Follow-up Study. Personality and Individual Differences
2004;36:757-766.
25
39. Frizelle DJ, Lewin RJP, Kaye GC. Provision of rehabilitation services to patients with
implanted cardioverter defibrillators: a survey of UK implantation centres. British Journal of
Cardiology 2004;11:302-305.
40. Frizelle DJ, Lewin RJP, Kaye G, Hargreaves C, Hasney K, Beaumont N, Moniz-Cook E.
Cognitive-behavioural rehabilitation programme for patients with an implanted cardioverter
defibrillator: a pilot study. British Journal of Health Psychology 2004;9:381-392.
41. Kainth A, Hewitt A, Pattenden J, Sowden A, Duffy S, Watt I, Thompson D, Lewin R
Systematic review of interventions to reduce delay in patients with suspected heart attack.
Extract. British Medical Journal 2004;90:1161.
42. Kainth A, Hewitt A, Pattenden J, Sowden A, Duffy S, Watt I, Thompson D, Lewin R
Systematic review of interventions to reduce delay in patients with suspected heart attack.
Emergency Medicine Journal 2004;21:506-508.
43. Neal RD, Ali N, Allgar V, Coleman T. Consent rates for video-recording general practice
consultations: effect of ethnicity and other factors. Family Practice. 2004 21: 213-218.
44. Furze G, Bull P, Lewin RJP, Thompson DR. Development of the York Angina Beliefs
Questionnaire. Journal of Health Psychology 2003;8:307-316.
45. Martin CR, Lewin RJP, Thompson DR. A confirmatory factor analysis of the hospital anxiety
and depression scale in coronary care patients following acute myocardial infarction.
Psychiatry Research 2003 Aug 30;120:85-94.
46. Lewin RJ Cardiac rehabilitation and primary care. The Practitioner 2003 March;247:2202,224.
47. Lewin RJP, Furze G, Robinson J, Griffith K, Pye M, Boyle R. A simple self-help treatment
manual can reduce angina and improve health related quality of life. Geriatric Medicine 2003
Jan:45-48.
48. Kendall L, Sloper P, Lewin RJP, Parsons JM. The views of young people with congenital
cardiac disease on designing the services for their treatment. Cardiology in the Young 2003
Feb;13:11-9.
49. Kendall L, Sloper P, Lewin RJP, Parsons JM. The views of parents concerning the planning of
services for rehabilitation of families of children with congenital cardiac disease. Cardiology in
the Young 2003 Feb;13:20-7.
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ELECTRONIC MEDIA
1. www.google.com.
2. www.pubmed.com.
3. www.nursingtimes.com.
4. www.oxfordjournal.com.
5. www.indiadaily.com.
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9
SIGNATURE OF THE CANDIDATE : Kashmeera P S
10
REMARKS OF GUIDE : Good
11
NAME & DESIGNATION :
11.1 GUIDE : Mrs. Vanmathi T, Prof
11.2 SIGNATURE :
11.3 CO- GUIDE :
11.4 SIGNATURE :
11.5 HEAD OF THE DEPARTMENT : Mrs. Vanmathi T,
11.6 SIGNATURE OF H O D
12
12.1 REMARKS OF PRINCIPAL:Good
12.2 SIGNATURE OF PRINCIPAL:
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